Care Of Clients With Life-Threatening Conditions PDF

Care of Clients with Life Threatening Conditions, Acutely Ill/Multi – organ Problems, High Acuity and Emergency Situation (Acute and Chronic) NCM 118 - LECTURE Prof. Paz Dominique C. Dehing NURSING CARE MANAGEMENT 118 II. NURSING CARE OF CLIENTS...

Care of Clients with Life Threatening Conditions, Acutely Ill/Multi – organ Problems, High Acuity and Emergency Situation (Acute and Chronic) NCM 118 - LECTURE Prof. Paz Dominique C. Dehing NURSING CARE MANAGEMENT 118 II. NURSING CARE OF CLIENTS WITH ALTERED VENTILATORY FUNCTION This course deals with concepts, principles, theories and  Acute and Chronic Obstructive Pulmonary techniques of Nursing Care of Sick Adult Clients with Life Disease Threatening Conditions, Acutely Ill/Multi-Organ Problems, High  Pulmonary Embolism Acuity and Emergency Situation toward Health Promotion,  Acute Respiratory Syndrome/Acute Lung Injury Disease Prevention, Restoration and Maintenance, and  Respiratory Failure Rehabilitation. The Learners are expected to provide safe and  Pneumonia (Community or Ventilator Acquired) appropriate and holistic Nursing Care to groups of Clients with  Respiratory Pandemics Health Problems and Special Needs utilizing the Nursing  Pulmonary Hypertension Process.  Pneumothorax (Assessment and Managements) 1. Apply knowledge of physical, social, natural and III. NURSING CARE OF CLIENTS WITH ALTERED health sciences and humanities in the care of group of TISSUE PERFUSION clients with life-threatening conditions, acutely ill/multi-  Acute Ischemic Heart Disease organ problems, high acuity and emergency situation.  Heart Failure 2. Provide safe, appropriate and holistic nursing care of  Cardiogenic Shock group of clients with life-threatening conditions,  Coronary Arterial Disease acutely ill/multi-organ problems, high acuity and  Hypertensive Crisis emergency situation utilizing the nursing process.  Cardiomyopathy 3. Apply guidelines and principles of evidence-based  Arrhythmias (Assessment and Managements) practice in the care of clients with life threatening conditions, acutely ill/multiorgan problems, high acuity IV. NURSING CARE OF CLIENTS WITH ALTERED and emergency situation. METABOLIC GI, LIVER FUNCTION and 4. Practice nursing in accordance with existing laws, ELIMINATION legal, ethical and moral principles in the care of group A. NURSING CARE OF CLIENTS WITH ALTERED of clients with life-threatening conditions, acutely ill METABOLIC GI, LIVER FUNCTION /multi-organ problems, high acuity and emergency  Acute GI Bleeding situation.  Intra-abdominal Hypertension and 5. Document to include reporting up-to-date client care Abdominal accurately and comprehensively in nursing care of  Compartment Syndrome group of clients with life-threatening conditions,  Liver Failure acutely ill / multi-organ problems, high acuity and  Acute Pancreatitis emergency situation.  Bariatric 6. Practice beginning management and leadership skills  DKA (Assessment and Managements) in the care of group of clients with life-threatening B. NURSING CARE OF CLIENTS WITH ALTERED conditions, acutely ill / multi-organ problems, high ELIMINATION acuity and emergency situation.  Renal Failure (Acute and Chronic) 7. Apply techno-intelligent care systems and processes o Criteria for Diagnosis of ARF. The Risk, in care of group of clients with life-threatening Injury and Failure conditions, acutely ill / multi-organ problems, high o Criteria with Outcomes of Loss and acuity and emergency situation. ESRD (RIFLE) (Assessment and Managements) I. CRITICAL CARE NURSING  Critical Care Nursing Concepts V. NURSING CARE OF CLIENTS WITH ALTERED  Hemodynamic Monitoring Devices PERCEPTION  Circulatory Assist Devices  Traumatic Brain Injury  Artificial Airways  Acute Ischemic Stroke  Mechanical Ventilation  Traumatic Spinal Cord Injury (Assessment and  Acute/Critically Ill Patients in Hemodynamic Managements) Monitoring (Assessment and Managements) VI. NURSING CARE OF CLIENTS WITH MULTISYSTEM PROBLEMS  Shock  Systemic Inflammatory Response Syndrome (SIRS)  Multiple Organ Dysfunction Syndrome (MODS) (Assessment and Managements) VII. NURSING CARE OF CLIENTS IN EMERGENCY SITUATION MEDICAL EMERGENCIES  ABC  DISABILITY  ENVIRONMENTAL EMERGENCY (Assessment and Managements)  CRITICAL CARE NURSING:  Level 3 – advanced respiratory support, multiorgan CONCEPTS failure INTRODUCTION TO CRITICAL CARE NURSING DEFINITIONS CRITICAL CRITICAL CARE UNIT  Crucial o As the unit in which comprehensive care of a critically  Crisis ill patient which is deemed to recoverable is carried  Emergency out.  Serious  Requiring immediate action TYPES OF ICU  Thorough and constant intervention General  Totally dependent  Medical Intensive Care Unit (MICU)  Surgical Intensive Care Unit CRITICAL CARE NURSING  Medical Surgical Intensive Care Unit (MSICU)  The care of seriously ill clients from point of injury or Specialized illness until discharge from intensive care  Neonatal Intensive Care Unit (NICU)  Deals with human responses to life threatening  Special Care Nursery (SCN) problems  Pediatric Intensive Care Unit (PICU)  Coronary Care Unit (CCU)  Cardiac Surgery Intensive Care Unit (CSICU) DEFINITIONS  Neuro Surgery Intensive Care Unit (NSICU)  Burn Intensive Care Unit (BICU) CRITICAL CARE NURSING  Trauma Intensive care Unit (TICU) o Refers to those comprehensive, specialized, individualized nursing care services which are AN IDEAL ICU rendered to patients with life threatening conditions and their families.  Care of clients who are very ill  Provide direct one to one care  Responsible for making life and death decision  At high risk of injury or illness from possible exposure to infections  Communication skill is of optimal importance CRITICAL CONDITIONS CRITICALLY ILL CLIENTS  At high risk for actual or potential life-threatening Multidisciplinary and Collaborative health problems Approach to ICU Care  More ill  Requires more intensive and careful nursing care MEDICAL AND NURSING DIRECTORS: co-responsibility for ICU management CONDITIONS CONSIDERED AS CRITICAL  A team approach: 1. ANY PERSONS WITH LIFE-THREATENING nurses, doctors, R/T, pharmacists CONDITIONS  Use of standard, protocol, guideline 2. PATIENTS WITH: consistent approach to all issues  Acute Resp Failure  Dedication to coordination and communication for all  AMI aspects of ICU management  CARDIAC TAMPONADE  Emphasis on research, education, ethical issues,  SEVERE SHOCK patient advocacy  Heart Block  Acute Renal Failure TEAM DYNAMICS  Poly Trauma, Multiple Organ o A multidisciplinary team to effectively attain specified Failure and Organ objective.  Dysfunction o Physician team leader and critical care nurse  SEVERE BURNS manager CLASSIFICATION OF CRITICAL CARE PATIENTS CRITICAL CARE PRACTICE PATTERN  Level 0 – normal ward care o Open  Level 1 – at risk of deteriorating, needs support from o Closed critical care team o Transitional  Level 2 – more observation or intervention, single failing organ or post-operative care OPEN UNITS  o Any attending physician with hospital admitting - the prognosis of the patient depends on the early privileges can be the physician of record and direct detection of variation, prompt and appropriate ICU care. (All other physicians are consultants) action to prevent or combat complication. Disadvantages: 3. COLLABORATIVE PRACTICE:  Lack of cohesive plan - critical care which has originated as technical  Inconsistent night coverage sub-specialized body of knowledge has evolved  Duplication of services into a comprehensive discipline requiring a very specialized body of knowledge for the physicians CLOSED UNITS and nurses working in the critical care unit fosters Any intensivist is the physician of record for ICU patients (other a partnership for decision making and ensures physicians are consultants). All orders and procedures carried quality and compassionate patient care. out by ICU staff. 4. COMMUNICATION: Advantages: - Intra professional, inter departmental and inter  Improved efficiency personal communication has a significant  Standardized protocol for care importance in the smooth running of unit. Disadvantages: Collaborative practice of communication model.  Potential to lock out private physicians 5. PREVENTION OF INFECTION:  Increase physician conflict - Nosocomial infection cost a lot in the health care services. TRANSITIONAL UNITS 6. CRISIS INTERVENTION AND STRESS o Intensives are locally present shared co-managed REDUCTION: care between ICU staff and private physician. ICU - partnerships are formulated during crisis. Bonds staff is a common pathway for orders and procedures between nurses, patients and families are Advantages: stronger during hospitalization.  Reduce physician conflict, standard policies and procedures usually present " primum non nocere “ Disadvantages:  Confusion and conflict regarding final authority and “It may seem a strange principle to enunciate responsibilities for patient care decision. (articulate) as the very first requirement in a ICU MODEL CARE hospital that it should do the sick no harm.” (1859) Full-time Intensivist Model: o Patient care is provided by an intensivist GOALS OF CRITICAL CARE NURSING Consultant Intensivist Model:  To promote optimal delivery of safe and quality o An intensivist consults to another physician to care to the critically ill patients and their families coordinate or assist in critical care but does not have by providing highly individualized care so that the primary responsibility for care physiological dysfunction as well as the psychological Multiple Consultant Model: stress in the ICU are under control o Multiple specialists are involved in the patient care  To care for the critically ill patients with a holistic (esp. R/T doctors for ventilators), but none is approach, considering the patient's biological, designated especially as the consultant intensivist psychological, cultural and spiritual dimensions Single Physician Model: regardless of diagnosis or clinical setting. o Primary physician provides all ICU Care  To use appropriate and up-to-date knowledge, caring attitude and clinical skills, supported by A GOOD ICU advanced technology for prevention, early  A well-organized, trust-coordinated care detection and treatment of complications in order o Full-time intensivist makes daily rounds to facilitate recovery. o Protocol and policies are followed (eg. D/C  To provide palliative care to the critically ill patients elective operation when he is not available) in situations where their health status is o Bedside nurses (Master’s Degree and or post progressing to unavoidable death, and to help the grad) patients and families to go through the painful o No intern sufferings.  A TEAM: doctors, nurses, R/T, pharmacists o lead by full-time intensivists, critical care trained, On the whole, critical care nursing should be patient- available in a timely fashion (24hours/day), no centered, safe, effective, and efficient. The nursing competing clinical responsibilities during duty interventions are expected to be delivered in a timely and o Closed units, if resources allow equitable manner. PRINCIPLES OF CRITICAL CARE Special Skill of Critical Care Nurse 1. ANTICIPATION:  Critical thinking skills – Using nursing process as - One has to recognize the high-risk patients and guide for problem solving anticipate the requirements, complications and  Collaborative skills be prepared to meet any emergency.  Delegation skills 2. EARLY DETECTION AND PROMP ACTION: - Clinical model: use AUP  - Nonclinical model: AUP perform non-nursing  Serves as a consultant during research tasks study implementation  Computer skill  Reads current nursing literature  Applies information in practice Changing Role of the Critical Care  Collects data  Conducts research studies Nurse  Serves as a consultant during research 1. staff nurses, study implementation  Makes independent assessments  Plans and implements patient care o Advance practice role  Provides direct nursing care - Acute Care Nurse Practitioner (ACNP)  Makes clinical observations and executes - Case manager interventions - Outcome manager  Administers medications and treatments  Promotes activities of daily living Issues Related to Critical Care 2. nurse-educators,  Advance directives and End-of-life decisions  Assesses patients’ and families’ learning  Resuscitation needs plans and implements teaching  Informed consent strategies to meet those needs  Brain death  Evaluates effectiveness of teaching - Whole-brain death “the permanent,  Educates peers and colleagues irreversible cessation of functioning of all of  Possesses excellent interpersonal skills brain areas” 3. nurse-managers,  Complete loss of consciousness  Acts as an administrative representative of  Absent corneal, oculovestibular, the unit oropharyngeal, ventilatory reflexes  Ensures that effective and quality nursing  Organ donation care is provided in a timely and fiscally - Heart & lungs sound environment - Kidneys 4. case-managers, - Liver  Manages comprehensive care of an - Corneas individual patient  Encompasses the patient’s entire illness “The more compromised the client, the more episode, crosses all care settings, and severe or complex are their needs”. involves the collaboration of all personnel who provide care  Is involved in discharge planning and making referrals  Identifies community and personal resources  Arranges for equipment and supplies needed by the patient on discharge 5. clinical nurse specialists,  Participates in education and direct patient care  Consults with patients and family members  Collaborates with other nurses and health care team members to deliver high-quality care 6. nurse practitioners, and  Provides primary health care to patients and families; can function independently  May obtain histories and conduct physical examinations  Orders laboratory and diagnostic tests and interprets results  Diagnoses disorders  Treats patients  Counsels and educates patients and families 7. nurse researchers.  Reads current nursing literature  Applies information in practice  Collects data  Conducts research studies  HEMODYNAMIC MONITORING DEVICES Hemodynamics  Hemodynamics are the forces that circulate blood through the body. Specifically, hemodynamics is the term used to describe the intravascular pressure and flow that occurs when the heart muscle contracts and pumps blood throughout the body. Hemodynamic Monitoring  Heart function is the main focus of hemodynamic studies.  measurement of pressure, flow, and oxygenation of blood within the cardiovascular system  using invasive technology to provide quantitative information about vascular capacity, blood volume, pump effectiveness, and tissue perfusion Methods of Hemodynamic Monitoring  the measurement and interpretation of biological 1. ARTERIAL BLOOD PRESSURE systems that describes the performance of the a. Non-Invasive cardiovascular system. - With manual or automated devices Method of measurement o Oscillometry (most common) Purposes of Hemodynamic Monitoring  MAP most accurate, DP least accurate  Early detection, identification, and treatment of o Auscultatory (Korotkoff sounds) life-threatening conditions such as heart failure and o Combination cardiac tamponade.  Evaluate the patient’s immediate response to b. Intra-arterial blood pressure measurement treatment such as drugs and mechanical support  Evaluate the effectiveness of cardiovascular function such as cardiac output and index Indications of Hemodynamic Monitoring  Any deficits or loss of cardiac function; such as myocardial infarction, congestive heart failure, cardiomyopathy  All types of shock; cardiogenic shock, neurogenic shock or anaphylactic shock  Decreased urine output from dehydration, hemorrhage, G.I. bleed, burns or surgery. Specialized Equipment Needed for Invasive Monitoring  A CVP, pulmonary arterial catheter  A flush system composed of an intravenous solution, tubing stop cocks, and a flush deviser which provides Complications for continuous and manual flushing of the system.  Local destruction with distal ischemia  A pressure bag is placed around the flush solution  External hemorrhage that is maintained at 300mmHg pressure; the  Massive ecchymosis pressurized flush system delivers 3-5ml of solution  Dissection per hour through the catheter to prevent clotting and  Air embolism backflow of blood into the pressure monitoring system.  Blood loss  A transducer to convert the pressure coming from the  Pain artery or heart chamber into an electrical signal  Arteriospasm  An amplifier or monitor which increases the size of  Infection electrical signal for display on an oscilloscope 2. CENTRAL VENOUS PRESSURE  The CVP, the pressure in the vena cava or right atrium, is used to assess the right ventricular function and venous blood return to the right side  of the heart. The CVP can be continuously measured by connecting either a catheter positioned in the vena cava or the proximal port of a pulmonary artery catheter to a pressure monitoring system. CVP with a Water Manometer System 3. PULMONARY ARTERY CATHETER PRESSURE MONITORING  important tool used in critical care for assessing left ventricular function, diagnosing the etiology of shock, and evaluating the patient’s response to medical interventions (e.g. fluid administration, vasoactive medications). - is achieved by using a pulmonary artery catheter and pressure monitoring system. PULMONARY ARTERY CATHETER PRESSURE MONITORING  4. CO measurements are adjusted to patient size by calculating the cardiac index (CI), CI equals CO divided by body surface area (BSA); BSA is determined through standard charts on individual height and weight. Normal CI 2.5 to 4L/min/m2 Assessment of Cardiac Output Signs of low CO include:  changes in mental status  an increase in HR  shortness of breath (SOB)  cyanosis or duskiness of buccal mucosa, nailbeds, and earlobes  falling of BP  low urine output  cool, moist skin Measures:  CVP or right atrial pressure Central Venous Pressure Monitoring  pulmonary artery systolic and diastolic pressure  refers to the measurement of right atrial pressure of  mean pulmonary artery pressure, and the great veins within the thorax  pulmonary artery wedge pressure (normal range: 5 to 10 cm H2O or 2 to 8mm Hg) Hemodynamic Monitoring Purposes of CVP catheter and monitoring include: Normal Results a. Serve as a guide for fluid replacement  Normal pulmonary artery pressure (PAP) is 25/9 b. To monitor pressures in the right atrium and central mmHg with a mean pressure of 15mmHg veins  Pulmonary Capillary Wedge Pressure (PCWP) is a c. To administer blood products, total parenteral nutrition mean pressure and is normally 4.5 to 13mmHg (TPN) and drug therapy contraindicated for peripheral infusion  d. To obtain venous access when peripheral vein sites Complications are inadequate  Infection e. To obtain central venous blood samples  Pulmonary artery rupture  Pulmonary thromboembolism  Pulmonary infarction Pulmonary Artery Pressure Monitoring  Catheter kinking Purposes  Dysrhythmias, and 1. To monitor pressures in the right atrium (CVP), right  Air embolism ventricle, pulmonary artery, and distal branches of the pulmonary artery (pulmonary capillary wedge  pressure/PCWP). The latter reflects the level of the Hemodynamic Monitoring pressure in the left atrium (or filling pressure in the left  is the assessment of the patient’s circulatory status; ventricle); thus, pressures on the left side of the heart it includes measurements of the heart rate (HR), are inferred from pressure measurements obtained on intra-arterial pressure, CO, central venous the right side of the circulation. pressure (CVP), PAP, pulmonary artery wedge 2. To obtain blood or central venous oxygen saturation. pressure and blood volume. Underlying Concepts 1. CO is determined by stroke volume (SV) and HR. Thus CO = SV x HR. CO must be maintained to adequately oxygenate the body. 2. The body alters CO through increases or decreases in one or both of these parameters. CO is maintained if the HR falls in an increase in SV. Likewise, a decrease in SV produces a compensatory rise in HR to keep the CO normal. 3. CO will decrease if either of the determinants cannot inversely compensate for the other  HEMODYNAMIC MONITORING (the heart spends twice as much time in diastole as it By: VERNEL IAM P. SENDRIJAS, RN, MAN does in systole). MAP can be used as an approximation of organ perfusion pressure. Hemodynamic Monitoring  Severely elevated BP, especially if acute, is  refers to the process of measuring the blood flow associated with increased vascular resistance and and pressure within the cardiovascular system, may be associated with inadequate tissue perfusion, particularly within the heart and blood vessels. It is for example hypertensive encephalopathy or acute crucial for assessing the efficiency of the heart's renal failure. pumping ability and the circulation of blood throughout the body.  Blood pressure  Hemodynamic monitoring is a mainstay in the care of  Blood Pressure Categories critically ill patients and remains a valuable adjunct  According to guidelines from organizations like the to physical examination and diagnostics in the American Heart Association (AHA), blood pressure is assessment, diagnosis, and management of shock categorized as follows: (Rali et al., 2022).  Normal:  It involves using invasive and non-invasive o Systolic: Less than 120 mmHg methods to provide information about pump o Diastolic: Less than 80 mmHg effectiveness, vascular capacity, blood volume, and o Example Reading: 115/75 mmHg tissue perfusion.  Blood Pressure Categories  Elevated: Non-invasive Monitoring o Systolic: 120-129 mmHg  Electrocardiogram (ECG) o Diastolic: Less than 80 mmHg  Non-Invasive Blood pressure (NiBP) o Example Reading: 125/78 mmHg  Pulse oximetry (SpO2)  Hypertension Stage 1:  Echocardiography o Systolic: 130-139 mmHg  Fluid responsiveness o Diastolic: 80-89 mmHg o Example Reading: 135/85 mmHg Invasive Monitoring  Blood Pressure Categories  Intra-arterial blood pressure (ABP)  Hypertension Stage 2:  Central venous pressure (CVP) o Systolic: 140 mmHg or higher o Diastolic: 90 mmHg or higher  Pulmonary artery pressure (PAP) o Example Reading: 145/92 mmHg  Mixed venous oxygen saturation (SvO2)  Hypertensive Crisis: o Systolic: Higher than 180 mmHg o Diastolic: Higher than 120 mmHg NON-INVASIVE MONITORING o Example Reading: 185/125 mmHg o Action: Requires immediate medical Electrocardiogram (ECG) attention.  Heart rate is an important determinant of cardiac output (CO) (CO = HR X SV).  Mean arterial blood pressure (MAP)  A 12-lead ECG confirms cardiac rhythm and provides baseline information on ST segments and T waves.  Continuous monitoring of heart rate, cardiac rhythm, and ST segments allow for early recognition of hypovolemia and myocardial ischemia.  Tachyarrhythmias are a common finding in certain shock states. Bradycardia and/or heart block may indicate cardiogenic shock. Non-Invasive Blood pressure (NiBP)  The definition of hypotension (low blood pressure) is patient-specific and interpreted in the context of the patient’s usual BP.  Hypotension is a common feature of most shock states.  Blood pressure typically shows the pressures in the systemic vasculature during left ventricular systole (SBP) and diastole (DBP). It is shown in the format SBP/DBP.  Mean arterial blood pressure (MAP) is an average  Mean arterial blood pressure (MAP) of the systolic and two times the diastolic pressures  A 65-year-old male patient is admitted to the Intensive measure SpO2 is itself an indicator of abnormal Care Unit (ICU) after undergoing emergency surgery peripheral perfusion. for a ruptured abdominal aortic aneurysm. Post- operatively, the patient is being monitored closely due to the risk of hypovolemic shock. The patient is Echocardiography connected to a cardiac monitor, and his blood  An echocardiogram provides visualization of the pressure is being continuously recorded. cardiac chambers, valves, pericardium, and overall  Current Vital Signs: cardiac function.  Systolic Blood Pressure (SBP): 100 mmHg  It allows for measurement of left ventricular ejection  Diastolic Blood Pressure (DBP): 60 mmHg fraction (LVEF) and estimation of SV and CO based  Heart Rate: 110 beats per minute on measurement of LV outflow tract (LVOT), LVOT  Respiratory Rate: 24 breaths per minute velocity, and heart rate.  Oxygen Saturation: 92% on supplemental oxygen  Normal Range:70 to 100 mmHg is considered the INVASIVE MONITORING normal range for MAP in most adults.  Interpretation: A MAP within this range generally Intra-arterial blood pressure (ABP) indicates that the body is maintaining adequate  Arterial cannulation (usually the radial artery) allows perfusion pressure to vital organs, including the brain, for accurate continuous blood pressure measurement. heart, and kidneys. Arterial line BP monitoring is the standard of care for  No immediate intervention is typically required if the patients on vasopressor/inotrope infusions. MAP is within this normal range, but the context of the  Arterial lines facilitate frequent blood draws for blood patient's overall condition should be considered. gases or other lab studies.  Low MAP (Hypotension) Central venous pressure (CVP)  MAP < 65 mmHg o Interpretation:  The nurse is caring for a patient in the ICU who is  A MAP below 65 mmHg is generally being monitored with a central venous pressure considered too low to ensure (CVP) catheter. The nurse records the patient's CVP adequate organ perfusion, as 8 mm Hg. The nurse understands that this finding particularly to vital organs like the indicates the patient is experiencing which of the brain and kidneys. This can lead to following? tissue hypoxia and organ a. Hypervolemia dysfunction. b. Excessive blood loss  Persistent low MAP can result in c. Left-sided heart failure (HF) conditions such as acute kidney d. Overdiuresis injury, cerebral hypoperfusion  Which of the following statements is incorrect about (leading to confusion or central venous pressure (CVP)? unconsciousness), and myocardial a. It increases in cases of hypovolemia. ischemia. b. It increases in cases of hypervolemia. c. It increases in patients with right ventricular  High MAP (Hypertension) failure. d. It is a measure of right-sided preload.  MAP > 100 mmHg o Interpretation:  Description: A central venous catheter (CVC) is the  A MAP above 100 mmHg can most common device used for CVP monitoring. It is indicate excessive pressure within inserted into a large central vein, such as the internal the arteries, which may strain the jugular vein, subclavian vein, or femoral vein. heart and damage blood vessels  Purpose: Provides direct measurement of CVP by over time. It can also be a sign of measuring the pressure in the central veins, underlying hypertension or other particularly the right atrium. cardiovascular issues.  Measurement: CVP is typically measured using a  Chronic high MAP is associated manometer or a pressure transducer connected to the with an increased risk of CVC. cardiovascular events like stroke,  The CVP is the blood pressure in the vena cava/right heart attack, and heart failure. atrium; normal range is 2-6 mm Hg.  The CVP reflects venous return to right side of heart, or right ventricular preload, which is a key component Pulse oximetry (SpO2) of RV function.  Continuous SpO2 monitoring enables detection of a  CVP is measured via a catheter positioned in the reduction in arterial oxygen saturation, which is an vena cava. integral part of oxygen delivery.  The SpO2 signal is often inaccurate in the presence of decreased peripheral perfusion. The inability to Pulmonary artery pressure (PAP)   PAP is the blood pressure in pulmonary artery. (filling) Normal systolic PAP range is 15-30 mm Hg and End systolic Volume of blood Normal is about normal diastolic PAP is 5-15 mm Hg. volume (ESV) in the RV or LV at 50 mL  PAP may be measured during right heart the end of systole catheterization or via introduction of a catheter into (contraction) the pulmonary artery (i.e., Swan Ganz Catheter). Preload The amount of Also known as the ventricular stretch left ventricular  PAP also reflects right side function of the heart. at the end of end-diastolic  Clinical Significance: Elevated PAP may indicate diastole pressure pulmonary hypertension, left heart failure, or lung (LVEDP) diseases. It helps in assessing the right ventricular Afterload The amount of Also known as the function and pulmonary circulation. resistance the systemic vascular heart must resistance (SVR) overcome to open the aortic valve and push the blood volume out into the systemic circulation Contractility The ability of the heart to contract and generate force and blood flow Hemodynamic Values Pulmonary Capillary Wedge Pressure (PCWP): Hemodynamic Values  Definition: PCWP is measured by inserting a catheter Definition Calculations & into a branch of the pulmonary artery and inflating a Normal Range balloon at the tip. This pressure reflects the left atrial Cardiac output The volume of Normal range is pressure. (CO) blood pumped 4-8 L/minute.  Indication: PCWP is an indirect measure of left through the heart ventricular end-diastolic pressure (LVEDP), which per minute Calculation helps assess left ventricular function and left heart (L/min) CO = Stroke Volume (SV) X pressures. Heart Rate (HR)  Normal Range: 4-12 mmHg. Clinical Cardiac index CO adjusted for Normal range is  Significance: Elevated PCWP may indicate left (CI) body surface area 2.8-4.2 L/min/m2 ventricular failure, mitral valve disease, or fluid (BSA) overload. It is used to assess pulmonary edema and Calculation guide fluid management. CI = CO/BSA Central venous The blood Normal range is pressure (CVP) pressure in the 2-6 mm Hg. Key Definitions vena cava and right atrial diastolic Key Definitions pressure; used to Definition Clinical assess preload Considerations and volume Stroke volume The volume of Normal range is status (SV) blood pumped out 60-90 mL Mean arterial Systolic blood Normal range is of the left blood pressure + (2 x 70-105 mm Hg. ventricle with Calculation pressure (MAP) diastolic blood each contraction SV = End-diastolic pressure)/3 volume (EDV) – Right atrial Reflects venous Normal range is end-systolic pressure (RA) return to the right 0-7 mm Hg. volume (ESV) atrium and right End diastolic Volume of blood Normal is about ventricular end- volume in the right 120 mL diastolic pressure (EDV) ventricle (RV) or Right ventricular Measured during Normal RV LV at the end of pressure (RV) catheter insertion systolic pressure diastole (filling). is 15-25 mm Hg. Pulmonary Used to diagnose Normal PA LV at the end of artery pressure pulmonary artery systolic pressure diastole (PA) hypertension is 15-25 mm Hg.  Normal mean PA pressure is 10-20 mm Hg. Pulmonary Reflects left atrial Normal range is capillary pressure and left 6-15 mm Hg. wedge pressure ventricular end- (PCWP) diastolic pressure (left ventricular preload) Systemic The amount of Normal range is vascular resistance the 800-1200 dynes- resistance (SVR) heart must sec/cm-5 overcome to open the aortic valve and push the blood volume out into the systemic circulation Pulmonary Reflects the Normal is less vascular resistance the than 250 dynes- resistance (PVR) blood must sec/cm-5 overcome to pass into the pulmonary vasculature  CIRCULATORY ASSIST DEVICES Circulatory Assist Devices - used to decrease cardiac work and improve organ perfusion in patients with heart failure when conventional drug therapy is no longer adequate. : CAD - IABP : VAD - The type of device used depends on the extent and nature of the heart problem. CADs provide interim support in three types of situations: 1. left, right, or both ventricles require support while recovering from acute injury (e.g. post cardiotomy); 2. the patient must be stabilized before surgical repair of the heart (e.g. a ruptured septum); and 3. the heart has failed, and the patient is awaiting Contraindication of IABP cardiac transplantation 1. Aortic aneurysm 2. Peripheral vascular disease All CADs decrease cardiac workload, increase myocardial 3. Terminal illness perfusion, and augment circulation. 4. Coagulopathy Intra-Aortic Balloon Pump (IABP) Complications of IABP - IABP therapy is known as Counter Pulsation, a 1. Vascular injuries that may occur from IABP are: method of assisting the failing heart and circulation by 2. Peripheral nerve damage mechanical support when the myocardium is unable 3. Impairment of cerebral circulation to generate adequate CO. 4. Infection at the insertion site and septicemia 5. Thrombocytopenia 6. Hemorrhage due to anticoagulation IABP Indications  postcardiotomy support Nursing Diagnosis  cardiogenic shock/ left-sided heart failure after MI,  Anxiety related to an invasive procedure, critical myocarditis, cardiomyopathy, and myocardial illness, and environment contusion  Decreased cardiac output related to myocardial  postinfarction ventricular septal defects or mitral ischemia and/or mechanical intervention insufficiency resulting in shock  Impaired tissue perfusion related to foreign body in  emergency support following PTCA or cardiac aorta catheterization  Hemodynamic deterioration in patients awaiting heart transplant Nursing Interventions  Relieving Anxiety 1. Explain IABP therapy to patient and family IABP geared to their level of understanding a. Review the purpose of therapy and how the IABP functions b. Reinforce mobility restrictions: supine position with the head of the bed elevated 15 to 30 degrees, no movement or flexing of the leg with IABP catheter c. Explain the need for frequent monitoring of V/S, rhythm, affected extremity, and pulses d. Discuss the sounds associated with functioning external console: balloon inflation and deflation and alarms 2. Encourage family members to participate in the patient’s care. a. Allow family to visit patient frequently b. Solicit family members’ assistance in reinforcing mobility restrictions to patients  and notifying nursing staff of patient comfort needs c. Encourage family members to ask questions 3. Allow the patient to verbalize fears regarding therapy and illness 4. Make sure that informed consent is obtained 5. Administer anxiolytic medications as prescribed and indicated 6. Keep the family informed of changes in the patient’s condition 7. Encourage realistic hope based on the patient’s condition, and discuss the patient’s progress with the family 8. Determine the family’s previous coping mechanism to stressful situations.  ARTIFICIAL AIRWAY MANAGEMENT Artificial Airways  Airway management may be indicated in patients with loss of consciousness, facial or oral trauma, aspiration, tumor, infection, copious respiratory secretions.  Patients in the ICU often need mechanical assistance 3. Laryngeal mask airway to maintain airway patency. Inserting a tube into the  It is composed of a tube with a cuffed masklike trachea, bypassing the upper airway and laryngeal projection at the distal end; inserted through the structures, creates an artificial airway. mouth into the pharynx; seals the larynx and leaves a distal opening of the tube just above the Types of Airways glottis. 1. Oropharyngeal airway a. Easier placement than ET because A curved plastic device is inserted through the mouth and visualization of vocal cords is not necessary. positioned in the posterior pharynx to move the tongue away b. Provides ventilation and oxygenation from the palate and open the airway. comparable to that achieved with an ET tube a. Usually for short-term use in the unconscious c. Cannot prevent aspiration because it does patient or may be used along with an oral ET not separate the GI tract from the respiratory tube tract b. Not used if recent oral trauma, surgery, or if loose d. May cause laryngospasm and teeth are present bronchospasm c. Does not protect against aspiration Position patient on the side and suction oral cavity frequently to prevent aspiration of oral secretions or vomitus when an oral airway is in place. Oral pharyngeal airway (OPA), also known as Oropharyngeal airway, semicircular or tube-like plastic device. It is inserted over the back of the tongue into the lower posterior pharynx. An indication is when the patient is breathing spontaneously but is unconscious. It prevents the tongue from falling back against the posterior pharynx and allows to suction secretions. 2. Nasopharyngeal airway (nasal trumpet)  A soft rubber or plastic tube is inserted through the nose into the posterior pharynx. a. Facilitates frequent nasopharyngeal suctioning 4. Combitube b. Use extreme caution with patients on  A double tube with a pharyngeal lumen and anticoagulants or bleeding disorders tracheoesophageal lumen; pharyngeal lumen has c. Select size that is slightly smaller than the blocked distal end and perforations at pharyngeal diameter of the nostril and slightly longer level; tracheoesophageal lumen has open upper than the distance from nose to earlobe and lower end; large oropharyngeal balloon d. Check nasal mucosa for irritation or serves to seal mouth and nose; distal cuff seals ulceration and clean the airway with the esophagus or trachea. hydrogen peroxide and water If the patient is outside the hospital and cannot be intubated in Nasopharyngeal airways may obstruct sinus drainage and the field, the emergency medical personnel may insert a produce acute sinusitis. Be alert to fever and facial pain. Combitube. The tube rapidly provides pharyngeal ventilation It is a soft plastic or rubber tube designed to pass just inferior and it functions like an ET tube. of the base of the tongue. Measure from the tip of the ear and  One of the two balloons around the tube can be always look at diameter of nostril before insertion. inflated. One balloon is large (100ml) and  occludes the oropharynx. The smaller balloon is inflated with 15ml of air and can effectively occlude the trachea if placed there. Breath sounds are auscultated to make sure that the oropharyngeal cuff does not obstruct the glottis. Patients can be ventilated through either port of the tube, depending on its placement. 6. Tracheostomy tube  A firm, curved artificial airway inserted directly into the trachea at the level of the second or third tracheal ring through a surgically made incision a. Permits mechanical ventilation and facilitates secretion removal b. Can be for long term use c. Bypasses upper airway defenses, increasing susceptibility to infection d. Allows the patient to eat and swallow 5. Endotracheal Tube  A flexible tube inserted through the mouth or nose and into the trachea beyond the vocal cord that acts as an artificial airway a. Maintains a patent airway b. Allows for deep tracheal suction and removal of secretions c. Permits mechanical ventilation d. Inflated balloon seals off trachea so aspiration from the GIT cannot occur e. Generally easy to insert in an emergency, but maintaining placement is more difficult so this is not for long term use Nursing Care for Patients with Artificial Airways 1. Ensure adequate ventilation and oxygenation through the use of supplemental oxygen or mechanical ventilation 2. Assess breath sounds every 2 hours. Note evidence of ineffective secretion clearance (rhonchi, crackles), which suggests the need for suctioning 3. Provide adequate humidity when the natural humidifying pathway of the oropharynx is bypassed 4. Provide adequate suctioning of oral secretions to prevent aspiration and decrease oral microbial colonization 5. Use a clean technique when inserting an oral or nasopharyngeal airway, take it out and clean it with hydrogen peroxide and rinse with water at least every 8 hours 6. Perform frequent oral care with soft toothbrushes or swabs and antiseptic mouthwash or hydrogen peroxide diluted with water, frequent oral care will aid in the prevention of ventilator-associated pneumonia. The patient’s lips should be kept moisturized with petroleum jelly to prevent them from becoming sore and cracked. 7. Ensure that aseptic technique is maintained when inserting ET or tracheostomy tube. The artificial airway bypasses the upper airway, and the lower airways are sterile below the level of the vocal cords 8. Elevate the patient to a semi-Fowler’s or sitting position, when possible; these positions result in improved lung compliance. The patient’s position, however, should be changed at least every 2 hours to ensure ventilation of all lung segments and prevent secretion stagnation and atelectasis. Position change is also necessary to avoid skin breakdown. 9. If an oral or nasopharyngeal airway is used, turn patient’s head to the side to reduce the risk of aspiration (because there is no cuff to seal off the lower airway).  MECHANICAL VENTILATION 2. CO2 elimination is controlled by VT, rate, and dead space. 3. Oxygen tension is controlled by oxygen concentration and PEEP (also by rate and VT). 4. In most cases, the duration of inspiration should not exceed exhalation. 5. The inspired gas must be warmed and humidified to prevent the thickening of secretions and a decrease in body temperature. Sterile or distilled water is warmed and humidified by way of a heated humidifier. Parts of Mechanical Ventilator MECHANICAL VENTILATION  Mechanical ventilator device functions as a substitute for the bellows action of the thoracic cage and diaphragm. The mechanical ventilator can maintain ventilation automatically for prolonged periods. It is indicated when the patient is unable to maintain safe levels of oxygen or CO2 by spontaneous breathing even with the assistance of other oxygen delivery 1. Support arm devices. 2. Inspiratory port with filter 3. Active humidifier 4. Inspiratory line with water trap Clinical Indications 5. Y piece Mechanical Failure of Ventilation 6. Expiratory line with water trap 1. Neuromuscular disease 7. Expiratory port 2. CNS disease 8. Flexible connector 3. CNS depression (drug intoxication, respiratory 9. Proximal flow-pressure sensor depressants, cardiac arrest) 10. Nebulizer 4. Inefficiency of thoracic cage in generating pressure gradients necessary for ventilation (chest injury, thoracic malformation) Types of Ventilators 5. When ventilatory support is needed postoperatively Negative Pressure Ventilators Disorders of Pulmonary Gas Exchange 1. Applies negative pressure around the chest wall. This 1. Acute respiratory Failure causes intraairway pressure to become negative, thus 2. Chronic respiratory failure drawing air into the lungs through the patient’s nose 3. Left-sided heart failure and mouth. 4. Acute lung injury 2. No artificial airway is necessary. 3. Indicated for selected patients with respiratory neuromuscular problems, or as an adjunct to weaning Underlying Principles from positive pressure ventilation. 1. Variables that control ventilation and oxygenation 4. Examples are the iron lung and cuirass (shell unit) include: ventilator. a. Ventilator rate – adjusted by rate setting b. VT – volume of gas required for one breath Positive Pressure Ventilators (ml/kg) During mechanical inspiration, the air is actively delivered to c. Fraction of inspired oxygen concentration (FiO2) the patient’s lungs under positive pressure. Exhalation is – set on ventilator and measured with an oxygen passive. Requires use of a cuffed artificial airway. analyzer. 1. Pressure cycled. d. Ventilator dead space – circuitry (tubing) common a. Delivers selected gas pressure during the to inhalation and exhalation; tubing is calibrated inspiratory phase e. PEEP – set within the ventilator or with the use of b. The volume delivered depends on lung external PEEP devices; measured at the proximal compliance and resistance. airway  4. Pressure support may be used independently as a Modes of Operation ventilatory mode or used in conjunction with CPAP or Controlled Ventilation synchronized intermittent mandatory ventilation. 1. Patient receives a set number and volume of breaths/minute. 2. Provides a fixed level of ventilation, but will not Positive Pressure Ventilation Techniques cycle or have gas available in circuitry to respond Positive End-Expiratory Pressure (PEEP) to the patient’s own inspiratory efforts. This 1. Maneuver by which pressure during mechanical typically increases the work of breathing for ventilation is maintained above atmospheric at end of patients attempting to breathe spontaneously. exhalation, resulting in an increased functional 3. Generally used for patients who are unable to residual capacity. Airway pressure is therefore positive initiate spontaneous breaths. throughout the entire ventilatory cycle. 2. Purpose is to increase functional residual capacity (or Assist/Control the amount of air left in the lungs at the end of 1. Inspiratory cycle of the ventilator is activated by the expiration). This aids in: patient’s voluntary inspiratory effort and delivers a a. Increasing the surface area of gas exchange preset full volume. b. Preventing collapse of alveolar units and 2. Ventilator also cycles at a rate predetermined by the development of atelectasis. operator. c. Decreasing intrapulmonary shunt. 3. Indicated for patients who are breathing d. Improving lung compliance spontaneously, but who have the potential to lose e. Improving oxygenation their respiratory drive or muscular control of f. Recruiting alveolar units that are totally or ventilation. In this mode, the patient’s work of partially collapsed. breathing is greatly reduced. 3. Benefits a. Because a greater surface area for diffusion is Intermittent Mandatory Ventilation (IMV) available and shunting is reduced, it is often 1. Allows patients to breathe at their own rate and possible to use a lower FiO2 than otherwise volume spontaneously through ventilator circuitry. would be required to obtain adequate arterial 2. Periodically, at a preselected rate and volume or oxygen levels. This reduces the risk of oxygen pressure, cycles to give a “mandated” ventilator toxicity in conditions such as acute respiratory breath. distress syndrome (ARDS) 3. Ensures that a predetermined number of breaths at a b. Positive intra-airway pressure may be helpful in selected tidal volume are delivered each minute. reducing the transudation of fluid from the 4. Gas provided for spontaneous breaths usually flows pulmonary capillaries in situations where capillary continuously through the ventilator. pressure is increased (i.e., left-sided heart 5. Indicated for patients who are breathing failure). spontaneously, but at a VT and /or rate less than c. Increased lung compliance resulting in decreased adequate for their needs. Allows the patient to do work of breathing some of the work of breathing, 4. Hazards: a. Because the intrathoracic pressure is increased Synchronized Intermittent Mandatory Ventilation (SIMV) by PEEP, venous return is impeded. This may 1. Allows patients to breathe at their own rate and result in: volume spontaneously through the ventilator circuitry. i. Decreased cardiac output and decreased 2. Periodically, at a preselected time, a partial oxygen delivery to the tissues (especially mechanical breath assistance is delivered. The noted in hypovolemic patients) mandatory breaths are synchronized with the patient’s ii. Decreased renal perfusion inspiratory effort. iii. ICP 3. Gas provided for spontaneous breaths usually flows iv. Hepatic congestion continuously through the ventilator. b. The decreased venous return may cause 4. Ensures that a predetermined number of breaths at a antidiuretic hormone formation to be stimulated, selected VT are delivered each minute. resulting in decreased urine output. 5. Indicated for patients who are breathing 5. Precautions: spontaneously, but at a VT and /or rate less than a. Monitor frequently for signs and symptoms of adequate for their needs. Allows the patient to do respiratory distress – shortness of breath, some of the work of breathing, dyspnea, tachycardia, chest pain. b. monitor frequently for signs and symptoms of Pressure Support pneumothorax, (increased PAP, increased size of 1. Augments inspiration to a spontaneously breathing hemothorax, uneven chest wall movement, patient. hyperresonant percussion, distant or absent 2. Maintains a set positive pressure during spontaneous breath sounds). inspiration. c. Monitor for signs and symptoms of decreased 3. The patient ventilates spontaneously, establishing his venous return (decreased BP, decreased cardiac own rate, VT, and inspiratory time. output, decreased urine output, peripheral edema).  d. Abrupt discontinuance of PEEP is not 5. Successful with infant respiratory distress syndrome, recommended. The patient should not be without much less successful with adult pulmonary PEEP for longer than 15 seconds. The manual complications. resuscitation bag used for ventilation during the suction procedure or patient transport should be equipped with a PEEP device. In-line suctioning Nursing Assessment and Interventions may also be used so that PEEP can be 1. Monitor for complications: maintained. a. Airway aspiration, decreased clearance of e. intrapulmonary blood vessel pressure may secretions, ventilatoracquired pneumonia, increase with compression of the vessels by tracheal damage, laryngeal edema. increased intra-airway pressure. Therefore, b. Impaired gas exchange central venous pressure (CVP), PAP, and PCWP c. Ineffective breathing pattern may be increased. The clinician must bear this in d. ET tube kinking, cuff failure, mainstem intubation mind when determining the clinical significance of e. Sinusitis these pressures. f. Pulmonary infection g. Barotrauma (pneumothorax, tension pneumothorax, subcutaneous emphysema, Newer Modes of Ventilation pneumomediastinum) Inverse Ration Ventilation h. Decreased cardiac output 1. I:E ratio is greater than 1, in which inspiration is i. Atelectasis longer than expiration. j. Alteration in GI function (stress ulcers, gastric 2. Potentially used in patients who are in acute distention, paralytic ileus) severe hypoxemic respiratory failure. k. Alteration in renal function Oxygenation is thought to be improved. l. Alteration in cognitive-perceptual habits 3. Very uncomfortable for patients; need to be 2. Suction the patient as indicated. heavily sedated. a. When secretions can be seen or sounds resulting 4. Pressure-controlled inverse ratio ventilation used from secretions are heard with or without the use in ARDS and acute lung injury. of a stethoscope b. After chest physiotherapy (CPT) Airway Pressure Release Ventilation c. After bronchodilator treatments 1. Ventilator cycles between uses a longer inspiratory 3. Provide routine care for patient on mechanical time. ventilator. Provide regular oral care to prevent 2. Uses a short expiratory time. ventilator-associated pneumonia. Provide humidity 3. Used in severe ARDS/acute lung injury and repositioning to mobilize secretions. 4. Assist with the weaning process, when indicated Non-invasive Positive Pressure Ventilation (patient gradually assumes responsibility for 1. Uses a nasal or face mask, or nasal pillows. Delivers regulating and performing own ventilations. air through a volume or pressure-controlled ventilator a. Patient must have acceptable ABG values, no 2. Used primarily in the past for patients with chronic evidence of acute pulmonary pathology, and must respiratory failure associated with neuromuscular be hemodynamically stable. disease. Now is being used successfully during acute b. Obtain serial ABGs and/or oximetry readings, as exacerbations. Some patients are able to avoid indicated. invasive intubation. Other indications include acute or c. Monitor very closely for change in pulse and BP, chronic respiratory distress, acute pulmonary edema, anxiety, and increased rate of respiration. pneumonia, COPD exacerbation, weaning, and post- d. The patient is awake and cooperative and extubation respiratory decompensation. displays optimal respiratory drive. 3. Can be used in the home setting. Equipment is 5. Once weaning is successful, extubate and provide portable and relatively easy to use. alternate means of oxygen. 4. Eliminates the need for intubation, preserves normal 6. Extubation will be considered when the pulmonary swallowing, speech, and the cough mechanism. function parameters of VT, VC and negative 5. The system has a rate setting as well as inspiratory inspiratory pressure are adequate, indicating strong and expiratory pressure setting respiratory muscle function. High Frequency Ventilation 1. Uses very small VT (dead space ventilation) and high Community and Home Care Considerations frequency (rates greater than 100/min). 1. Candidates for home ventilation are those patients 2. Gas exchange occurs through various mechanisms, who are unable to wean from mechanical ventilation, not the same as conventional ventilation (convection) and/or have a disease progression requiring ventilator 3. Types include: support. a. High-frequency oscillatory ventilation. b. High-frequency jet ventilation. Candidates for home mechanical ventilator support: 4. Theory is that there is decreased barotrauma by a. Have a secure artificial airway (tracheostomy tube). having small VT and that oxygenation is improved by b. Have FiO2 requirement 40% constant flow of gases. c. Are medically stable  d. Are able to maintain adequate ventilation on standard ventilator settings. 2. Patients may choose not to receive home ventilation. Examples of inappropriate candidates for home ventilation include patients who: a. Have FiO2 40% b. Use PEEP 10cmH2o c. Require continuous invasive monitoring d. Lack of a mature tracheostomy e. Lack of able, willing, appropriate caregivers, and/or caregiver respite f. Lack of adequate financial physical facilities: i. Inadequate heat, electricity, sanitation ii. Presence of fire, health, or safety hazards 3. For patients on mechanical ventilation in the home, a contract and relationship with a home medical equipment company must be developed to provide: a. Care of ventilator-dependent patients. b. Provision and maintenance of equipment c. Timely provision of disposable supplies d. Ongoing monitoring of patient and equipment e. Training of patients, caregivers, and clinical staff on proper management of ventilated patients and use and troubleshooting of equipment. 4. Equipment required: a. Appropriate ventilator with alarms (disconnect and high pressure) b. Power source c. Humidification system d. Manual resuscitation bag with tracheostomy adapter e. Replacement tracheostomy tube f. Supplemental oxygen, as medically indicated g. Communication method of patient h. Backup charged battery to run ventilator during power failures 5. Lay caregiver training and return demonstration must include: a. Proper setup, use, troubleshooting, maintenance, and cleaning and infection control of equipment and supplies b. Appropriate patient assessment and management of abnormalities, including cardiopulmonary resuscitation (CPR), response to emergencies, power and equipment failure 6. Potential complications include: a. Patient deterioration, need for emergency services b. Equipment failure, malfunction c. Psychosocial complications, including depression, anxiety, and/or loss of resources (caregiver, financial, detrimental change in family structure or coping capacity) 7. Communication is essential with local emergency medical services (fire, police, rescue) and utility (telephone, electric) companies from whom the patient would need immediate and additional assistance in the event of an emergency (e.g. power failure, fire)