Comprehensive Care for Critically Ill Patients

Comprehensive Care for Critically Ill Patients

• Requires a systems-based approach and integration of complex information to provide consistent high standard of care.
• Involves input from many specialties, including Microbiology, Physiotherapy, Radiology, Nutrition, Pharmacy, and Speech and Language teams.
• Implementing care bundles has been shown to improve patient outcomes.

Essential Care Components

• Monitoring of intakes and outputs, including:
  • Patient intake: fluids, I.V. fluids, blood products, and liquid diets.
  • Outputs: urine, faeces, vomitus, and fluid loss through body cavities.
  • Comparing ins and outs to prevent overload or dehydration.
• Nutritional support:
  • Recording food intake in Kcal rather than cans or jars.
  • Assessing patient's energy requirements through nutritional history.
  • Identifying signs of poor nutritional status, such as acute loss of lean body mass, fat, muscle wasting, or oedema.
• Meeting comfort needs:
  • Assessing for pain.
  • Keeping the patient clean and dry.
  • Preventing urine scald and skin breakdown.

Prevention of Nosocomial Infections

• Factors that predispose patients to nosocomial infections:
  • Age (geriatric and neonates).
  • Immuno-compressed patients.
  • Diagnostic and invasive procedures.
  • Antimicrobials therapy.
  • Long-term hospitalization.
• Common causes of nosocomial infections:
  • Escherichia coli.
  • Klebsiella.
  • Salmonella.
  • Canine.
• Nursing goals:
  • Minimizing the risk of nosocomial infection through:
    • Diligent hand washing.
    • Swabbing injection ports with alcohol.
    • Using disposable thermometer sheaths.
    • Disinfecting patient care equipment.
    • Disinfecting environmental surfaces.
  • Observing aseptic techniques in catheter placement and care.
  • Treating patients with nosocomial infection last during ward rounds.

Bandage and Wound Care

• Placing bandages to protect lacerations and surgical incisions.
• Performing catheter care.

Care of the Dying Patient

• Physical care is crucial for ensuring comfort, including effective pain management, maintaining hygiene, and addressing nutrition and hydration needs.
• Providing emotional support is vital throughout the dying process to address existential concerns and facilitate open communication.

Psychological Support

• Psychological support includes addressing spiritual needs for both patients and their families through spiritual counseling, religious practices, and rituals.

Social Support

• Social support is crucial for both the patient and their loved ones, involving a multidisciplinary approach with social workers, counselors, and volunteers.
• A supportive environment should be created to address practical needs and offer emotional companionship.

Ethical Considerations

• Ethical dilemmas often arise in end-of-life care, requiring consideration of autonomy, beneficence, non-maleficence, and justice principles.
• Respecting patient autonomy in treatment decisions and ensuring care aligns with their values and wishes is essential.

Kubler-Ross's Stages of Dying

• The five stages of dying are:
  • Denial: refusing to accept the diagnosis or impending death
  • Anger: expressing frustration, resentment, or rage towards oneself, loved ones, healthcare providers, or a higher power
  • Bargaining: attempting to negotiate with oneself, others, or a higher power to delay or avoid death
  • Depression: experiencing profound sadness, grief, and feelings of hopelessness
  • Acceptance: coming to terms with mortality and accepting the reality of one's situation

Pathophysiology of the Dying Patient

Cardiovascular System

• Blood pressure may decrease as cardiac output diminishes
• Peripheral circulation may be compromised, leading to cool extremities and mottling of the skin
• Irregular heart rhythms, such as atrial fibrillation or bradycardia, may develop

Respiratory System

• Respiratory rate may increase or decrease, and breathing patterns may become irregular
• Secretions may accumulate in the airways, leading to "death rattle"
• Hypoxia and respiratory distress may occur as the body's ability to oxygenate tissues diminishes

Neurological System

• Neurological changes are prominent as the body approaches death
• Consciousness may fluctuate, with periods of confusion or agitation