Learning Objectives Condensed Acute & Critical Illness Nursing (NURS403) Notes PDF

**[DISCLAIMER:]** As much as I make my notes publicly available, my notes are not intended as a replacement for studying \-- Just reading my notes won't facilitate you learning the information any better than reading the lecture slides will and you should find the studying method that works for you....

**[DISCLAIMER:]** As much as I make my notes publicly available, my notes are not intended as a replacement for studying \-- Just reading my notes won't facilitate you learning the information any better than reading the lecture slides will and you should find the studying method that works for you. Personally, what I do is reread other people's notes for reference while rewriting my own notes to see what information is pertinent (or if I missed anything important) while also keeping the lecture slides open, and I word things in a way that makes sense to me and use examples that make sense to me \-- if there are any abbreviations or examples that don't make sense to you, it's cuz that's how I pictured it in my head. I did try to make my notes as simple and clear as possible, however. *The ICU is controlled chaos.* ***[Concepts of Acute & Critical Illness]*** ***[WEEK 1: FLUID AND ELECTROLYTE BALANCE + ARTERIAL BLOOD GASES]*** **Critical Care:** ICU, CICU, Step Down ICU\... environments where patients need more supervision - STRESSFUL - nurses need to be very confident and know their limitations - Nurses need to know the basic functioning of every machine in there - Patients are VERY unstable - treat the patient, not the number; looking too much at screens - Patients can and will crash/code in front of you which can be unsettling - Not a FULL critical care course - just a taste. *Review Homeostasis, Fluid Balance, Hormones, and Electrolytes* ***CONCEPTS OF FLUID BALANCE*** **HOMEOSTASIS:** A state of inner balance and stability in the body - calm - ***Kidneys*** play the largest role in maintaining homeostasis by regulating what's in the blood - In critical care, the body is so weakened that it cannot physically regulate fluid balance **How Does Homeostasis Happen?** - BALANCE in all regards - volume, concentration, body fluids, electrolytes - ***Oxygen:*** Bodies really need O2 to function - ICU takes life-sustaining measures - Meds that squeeze BP to get any remaining blood to tissues - 100% O2 to get any remaining blood oxygenated - ***Water*** - ***Nutrients/Glucose*** - ***Electrolytes***: Controlled [in ranges]; needs intake, storage, and excess elimination - DYSFUNCTION occurs ***without*** balance - symptoms manifest and disease process starts - Things begin to shut down, arrhythmias, contractility, etc. **Clinical Presentation of Fluid Imbalance:** - ***Deficit:*** Skin turgor decreases, thirst, low urine, low BP, no sweat, temp changes HR increases - Can invasively measure fluids - hourly urine, art line for BP, continuous BP monitor - ***Excess:*** Edema/Third spacing (pitting), SoB, decreased LoC/neuro changes, weight gain, pounding or distended pulses, cough **Body Water:** 60% of our body weight is WATER - ***Intracellular Fluid:*** 40% of our body weight (2/3) is fluid ***in*** body cells - ***Extracellular Fluid:*** 20% of our body weight (1/3) is fluid **outside** of cells - *[Intravascular:]* 5% of body weight (1/4) is inside of *blood vessels as plasma* - *[Interstitial:]* 15% of body weight (3/4) is fluid in tissue spaces between cells\... - All of the "stuff" between capillaries and cells that separates the cells from the circulatory system; electrolytes et al. diffuse through interstitial fluid to reach the capillaries from the cells and vice versa - A conduit - e.g., O2 diffuses from RBC -\> interstitial fluid -\> cells - Includes things like lymph fluid et al. - Has ***dissolved components*** like sugar, hormones, fat, O2, water, salt, CO2 **Forces Affecting Capillary Fluid Movement:** - ***Osmotic Pressure:*** "Water Pulling" forces; particles dissolved in a solution are attracted to water and therefore pull it in - keeps fluid in the capillaries - E.g., proteins, electrolytes, charged particles - ***Hydrostatic Pressure:*** "Water Pushing" forces; water does not compress and instead exerts a force on its container (the capillaries) - pushes fluid out of the capillaries - Together these generate blood pressure; higher in the arteries **How do Particles Cross Membranes?** - ***Active Transport:*** Energy is used in the process of moving particles - *[ATP/Carrier Molecules:]* E.g., Na/K Pump - *[Osmolality:]* The thickness of a solution - how many particles are dissolved in solution - *[Osmotic Pressure:]* Pressure derived from the amount of particles in a solution that pull - *[Hydrostatic Pressure:]* Pressure of water pressure from a high to low concentration across a membrane - ***Passive Transport:*** No energy is used in the process of moving particles - *[Diffusion:]* Particles move from high to low concentration areas - *[Facilitated Diffusion:]* E.g., insulin allows for glucose to be moved into cells - *[Osmosis:]* Passive movement of water due to different concentrations (hypo/hypertonic) **HORMONES AND FLUID BALANCE:** **Hormones:** When conceptualizing hormones, think of them as MESSENGERS 1. What stimulus causes its release? 2. Where does the hormone go? 3. What message is the hormone taking to its target location? (What will it tell the location to do) **Antidiuretic Hormone (ADH)/*Vasopressin*:** Primary controller of amounts of ***extracellular fluid*** 1. Release is stimulated by an *increase in osmotic pressure* (++ solutes or \--water) 2. Osmolarity increases -\> Posterior Pituitary releases ADH -\> Kidney nephrons 3. Tells the kidney nephrons to ***hold onto water*** -\> reabsorbs water -\> body has more water to dilute the solutes or loses less water a. Body water osmolality *decreases* (keep water, decrease concentration) b. Urine water osmolality *increases* (less water is lost; solutes remain; increase \[\]) i. You get yellow pee **Aldosterone:** Conserves ***Na+*** and ***H2O*** by wasting ***K+;*** Secreted due to RAAS 1. Release is stimulated by a *decrease in Na+ or increase in K+* - the two need to be balanced 2. *Adrenal Cortex in Suprarenal Glands* release ALDO; goes to *distal tubules in kidneys* 3. Message is to ***conserve Na+*** - passive Na+ resorption; active Na+/K+ pumps a. Water follows Na+; K+ is pumped into lumen and into urine (wasted) **ELECTROLYTE BALANCE** **Electrolytes:** Elements or compounds that dissociate into ***ions*** in water - Located in ALL body compartments in varying concentrations - ICF, ECF - Electrolytes in the body vary in normal concentration ranges - e.g., K+: 3.5-5.0mmol/L - ICU does not want "normal" - ICU wants "**tight normal**" - not normal high or normal low - E.g., 3.6 or 4.9 K+ is bad -\> want 4.2mmol/L - There are standing orders to modify for this purpose - Bodies are so sick and working to maintain homeostasis, they don't need added stress **Potassium (K+; 3.5-5.0mmol/L):** The main [intracellular] positive electrolyte - *"Salty Banana"*; salt is on the outside and potassium is inside the banana - Transport relies on membrane carriers like Na+/K+/ATPase pumps; pumps K+ into cells ***Function:*** - *[Muscle Contractility:]* Heart especially (myocardial), but also skeletal and smooth muscle - Transmission of *[nerve impulses]* (Action Potentials) - Intracellular osmolality - increases solute concentration inside the cell - Enzymatic reactions - Acid-Base Balance ***Dysfunction:*** NOTE: The worse the dysfunction, the *more likely* the symptoms - not guaranteed; treat the patient, not the number - *[Hypokalemia (\5.0mmol/L):]* Too much K+ = muscle excitement and increases likelihood of action potentials overfiring - ***ECG:*** As K+ gets higher, the QRS complex gets wider and wider (\~8), eventually **flatlines**, may also have peaked T's (lower end of high), lost P wave, heart block\... - ***S/S:*** Arrhythmias, Muscle Weakness (overfiring, abnormal firing), Diarrhea/Abdominal Cramping (overactivity), Anxiety/Irritable/Restless - ***Tx:*** STOP K+ Supplements, IV Insulin (drives K+ into cells, out of plasma temporarily), Kayexalate (cation-exchange resin permanently binds K+ into the GI to get rid of it) **Sodium (Na+; 135-145mmol/L):** The main [extracellular] positive electrolyte - Mainly used to control for things like fluid status and fluid restrictions - water follows the salt - When treating sodium, treat based on ***hydration status*** - are they euvolemic, hypo/hypervol? - E.g., euvolemic - small lyte bolus; hypo - large bolus + lytes; hyper - high conc. Lytes ***Functions:*** - [Body fluid movement and retention:] Water follows the salt - Extracellular osmolality - solute concentration outside of the cells - Active transport mechanisms (Na/K pumps) - Neuromuscular activity - needed in action potentials - Enzyme activities - Acid-base balances ***Dysfunction:*** - *[Hyponatremia (\ headache/lethargy/disoriented -\> confusion/hostile/N/V/lethargy -\> delirium, convulsions, coma (\145):]* - ***S/S:*** Thirsty, Weak/Lethargic/Agitated, Edema/Weight Gain (retains water, draws out) - ***Tx:*** Either add more fluid (dilute it) or restrict salt intake (if fluid balanced) **Calcium (Total Serum Ca++; 2.25-2.75mmol/L):** Must differentiate *total serum* and *ionized*; the latter being free calcium that is biologically active/free for use in things like clotting - serum calcium is ALL calcium (including those bound to proteins, inorganic ions/sulfate or phosphate) - Controlled by various factors like ***PTH, Calcitonin, Vitamin D***; the [most abundant] lyte (1200g) - Most calcium is stored in the ***bones***; when low -\> draw from the bones ***Function:*** - [Hardness of bones/teeth] - [Skeletal Muscle Contraction] + Heart Muscle contraction - Blood coagulation - Cellular permeability ***Dysfunction:*** - *[Hypocalcemia (\ Oral supplementation, Assess Vitamin D, IV CaCl, IV Calcium Gluconate (1-2g/50mL D5W over 10-20m) - *[Hypercalcemia (\>2.75):]* - ***S/S:*** Lethargy, muscle weakness, stupor; nausea/constipation; thirst/polyuria; arrhythmias (especially prolonged, strong contractions) - ***Tx:*** Promote *renal excretion*; **diuretics**, high-volume IV N/S; **calcitonin** (promotes excretion, prevents bone breakdown) **Magnesium (Mg++; 0.65-1.05mmol/L):** Important but also similar to other lytes; used for enzyme, protein, lipid, carbohydrate functions - production and use of energy - 2nd most abundant intracellular -lyte after potassium ***Function:*** - *[Neuromuscular transmission]* - *[Heart Muscle contraction]* - Activates enzymes for cellular metabolism, I guess - Cellular active transport (idk) - Transmits hereditary information (reproductive?) ***Dysfunction:*** - *[Hypomagnesemia (\ IV Direct 1-2g/10mL D5W over 15m; Mild/Mod -\> over 1-2h - *[Hypermagnesemia (\>1.05):]* *Very rare. Kidney failure, over-supplementation, tumour lysis* - ***S/S:*** Too much = pass out (remember 371?); Arrhythmias (bradycardia, heart block); lethargy/coma; hypotension; hypoventilation - ***Tx:*** Prevention (don't give to renal failure), Loop Diuretics, Dialysis in renal failure - Mg control is in the KIDNEYS **Bicarbonate (HCO3-; [22-28mmol/L]; 21-28 onQ; 22-26 textbook):** Super important [anion] in the [extracellular fluid] - used as one of the main blood buffers that maintain ***acid-base balance*** - ***Regulation:*** At the level of the kidneys; responds to blood pH levels (H+). At the glomerulus, essentially all Bicarb is filtered out of the blood. - *[Too much; i.e., basic blood:]* Secretes bicarb from the kidneys (partial reabsorption) - *[Too little; i.e., acidic blood:]* Absorbs bicarb (full reabsorption) and creates new bicarb *Review how acids and bases are kept in balance in the body and interpret an arterial blood gas report* **ACID-BASE BALANCE:** **pH:** "Potential Hydrogen" or "Power of Hydrogen"; measure of the concentration of \[H+\] ions in blood - pH refers to the presence of H+ ions; derived from inverse log or something like that - Measured from 0-14; 7 being neutral - ***Acidic***: A high amount of H+ ions and therefore a LOW pH (0 to \7 to 14) - Bases ACCEPT H+ ions (from water) when dissolved in solution **pH and Homeostasis:** The body's pH has to remain within a range of 7.35-7.45 to sustain life - The body has a number of systems in place to keep pH from changing too greatly - ***Chemical Buffers:*** [Instantaneous] chemical reactions that reduce pH changes when acid or base is added (e.g., Bicarb/Carbonic acid system) - ***Respiratory Control:*** Second-line, [Minutes-to-hours] system that works to breathe out CO2 to reduce carbonic acid in the blood - ***Renal Control:*** Last line, [days-long] but with maximal effects as it filters out H+ ions and excess HCO3- **Chemical Buffers:** Fastest acting ([instantaneous]) primarily regulators of pH - These systems chemically alter strong acids to weak acids, binds acids to neutralize them, binds bases as well - E.g., ***Carbonic Acid-Bicarbonate System:*** H2O + CO2 \ H2CO3 \ HCO3- + H+ - dThis is the primary buffering system for ECF - There are also phosphate buffers (urinary), protein buffers (primary ICF), and HgB buffers (secondary ECF) - we will not discuss them **Respiratory Control:** This helps to regulate the carbonic acid-bicarbonate system when there is excess H+ floating around in the bloodstream - H2O + CO2 \ H2CO3 \ HCO3- + H+ - Chemoreceptors in the brain medulla sense extra H+ floating around as a result of extra CO2 - This triggers an **[increase in respiratory rate]** to blow off the excess Co2 - In the lungs, the reaction reverses to form H2O and CO2, the excess CO2 is exhaled - Acidic blood -\> Increases RR -\> decreases H+, H2CO3 in the blood - Basic blood -\> decreases RR -\> maintains H+, H2CO3 levels in the blood - Hyperventilation can lead to alkalosis AS A GENERAL RULE: Respiratory control deals with ACIDS **Renal Control:** Kidneys are doing the MOST as chemical engineers to control homeostasis - The kidneys can control BOTH H+ and HCO3- levels to fine-tune the blood pH - However, it is much slower than the other two. - ***Bicarb:*** Excrete, resorb, conserve, or create new HCO3- - All plasma bicarb is filtered out in the glomerulus; but almost all is reabsorbed - In alkalosis, not all of it is reabsorbed to get rid off the excess - ***H***+: The kidneys can eliminate excess H+ ions AS A GENERAL RULE: Renal control is the only area that deals with BASES **ARTERIAL LINES:** These are put in to determine *arterial blood gases* to get a sense of\... - Are we OXYGENATING THE BLOOD PROPERLY? - Are we REMOVING ENOUGH CO2? - What is the BLOOD pH? - Every unit has a blood gas analyzer machine, there are RTs there as well - If their blood gases are bad, low sats, SoB, LoC decreasing - need to **ventilate soon** - Could be a result of the disease process, they're tired, etc. - A **ventilator** breathes for them and can get their ABGs back to normal - RT deals with the ventilator settings - don't touch! ***Insertion:*** - Art lines are only put in by RTs or physicians; nurses can draw blood from them if existing - ***Allen Test:*** Tests for collateral circulation, because obviously the art line blocks off one of your major hand arteries and you want circulation to still go to your hand - Can also use venous blood gases, but it's not gold standard **ARTERIAL BLOOD GASES:** We measure pH, PaCO2, PaO2, and HCO3- **Partial Pressure of Oxygen (PaO2) [80-100mmHg]:** Pressure of oxygen dissolved in blood - PaO2 tells us how they're oxygenating: normoxemia, hypoxemia, hyperoxemia **pH [7.35-7.45]:** A measure of hydrogen ions in the blood - pH gives us an idea of if they are ***acidotic*** or ***alkalotic*** **Partial Pressure of Carbon Dioxide (PaCO2) [35-45mmHg]:** Pressure of CO2 dissolved in blood - PaCO2 gives us an idea of ***respiratory function*** - are we able to blow off CO2? **Bicarbonate (HCO3-) [22-28mmol/L:]** Amount of bicarbonate (pH buffer) dissolved in blood - HCO3- gives us an idea of ***kidney function*** - can we filter out excess bicarb? [ABG Interpretation:] Do what works for you. 1. **Look at oxygenation status:** Is PaO2 in normal ranges? (80-100mmHg) a. *[High PaO2]* - they're oxygenating well; get RT to wean their O2 down b. *[Low PaO2]* - they're not oxygenating well; RT assess to increase or ventilate 2. **Look at the pH:** Is the pH outside of normal range (7.35-7.45), and on which side of normal? c. *[Acidosis:]* pH \7.45 f. *[Alkalotic Normal:]* pH between 7.40-7.45 g. *[Exactly 7.40:]* Kristen will get back to you. 3. **What's causing the pH shift?:** Even if pH is in the normal range. h. Look at **PaCO2:** Recall; PaCO2 deals with ACIDS and LUNG function; high PaCO2 means high acid ([low pH]); low PaCO2 means low acid ([high pH]); i. *[Normalcy:]* PaCO2 between 35-45mmHg ii. *[Respiratory Acidosis:]* **Low pH** and **high PaCO2 (\>45mmHg)** iii. *[Respiratory Alkalosis:]* **High pH** and **low PaCO2 (\28 (high base) to try to offset the acid ***Respiratory Alkalosis:*** pH \>7.45 (alkalotic), PaCO2\45 (high acid), less breathing to hold in CO2 and increase blood acidity ***Mixed Acidosis:*** pH \7.45 (alkalotic), HCO3-\>28 (high base), PaCO2\ 85 -\> normal pH -\> 7.48 -\> Alkalotic; what is causing the high amount of base? PaCO2 -\> 28 -\> Low acid -\> Alkalotic, matches pH -\> **Respiratory Alkalosis** HCO3 -\> 22 -\> Normal amount of base -\> **Uncompensated** PaO2 -\>90 -\> normal - lmao this has been wrong for 6 weeks now I ain't even notice pH -\> 7.37 -\> normal, but on the *[acidotic]* side PaCO2 -\> 60 -\> high amount of acid -\> *matches [acidosis] ph -\> **Respiratory Acidosis*** HCO3 -\> 30 -\> high amount of base -\> must be compensating - pH Normal + Base offsetting respiratory acidosis -\> **Fully Compensated** PaO2 -\> pH -\> 7.27 -\> Acidic; what is causing the acidity? PaCO2 -\> 65 -\> High amount of acid, matches pH -\> **Respiratory Acidosis** HCO3 -\> 30 -\> High amount of base -\> pH is out of normal range -\> **Partially Compensated** PaO2 -\> pH -\> 7.26 -\> Acidic; what is causing the acidity? PaCO2 -\> 32 -\> Low amount of acid -\> Basic -\> Must be compensating HCO3 -\> 18 -\> Low amount of base -\> Acidic, matches pH -\> **Metabolic Acidosis** - pH abnormal + PaCO2 compensating for met acid -\> **Partially Compensated** PaO2 -\> 97 -\> Normoxemia pH -\> 7.31 -\> Acidic, what's causing it? PaCO2 -\> 22 -\> Low amount of acid -\> basic, must be compensating HCO3 -\> 9 -\> Low amount of base -\> acidic, matches pH -\> **Metabolic Acidosis** - pH still abnormal, PaCO2 is compensating -\> **Partially Compensated** PaO2 -\> 136 -\> Hyperoxemia -\> Call RT pH -\> 7.46 -\> Alkalosis, what's causing it? PaCO2 -\> 42 -\> Normal range of Acid -\> **Uncompensated** HCO3 -\> 29 -\> High base, matches pH -\> **Metabolic Alkalosis** PaO2 -\> 82, normal pH -\> 7.29 -\> Acidic PaCO2 -\> 73 -\> HIgh amount of acid, matches pH -\> **Respiratory Acidosis** HCO3 -\> 24 -\> Normal range -\> **Uncompensated** PaO2 -\> 113 -\> Hyperoxemia pH -\> 7.52 -\> Alkalotic PaCO2 -\> 53 -\> High acid -\> **Partial Compensation** since pH is still abnormal HCO3 -\> 40 -\> HIgh base, matches pH -\> **Metabolic Alkalosis** PaO2 -\> 44 -\> Hypoxemia pH -\> 7.16 -\> Acidosis PaCO2 -\> 65 -\> High acid -\> Acidosis HCO3 -\> 15 -\> Low base -\> Acidosis - Because they both contribute to acidosis, this is an **Uncompensated Mixed Acidosis** pH -\> 7.33 - Acidosis PaCO2 -\> 37 -\> Normal -\> **Uncompensated** HCO3 -\> 19 -\> Low Base -\> Acidic, matches pH -\> **Metabolic Acidosis** pH -\> 7.36 - Normal, but on Acidic side PaCO2 -\> 70 -\> High Acid, matches pH -\> **Respiratory Acidosis** HCO3 -\> 32 -\> High Base -\> **Fully Compensated** as pH is normal Do the Tic Tac Toe method if it works for you\... Algorithmically going through it works for me ***[WEEK 1: SIM LAB ICU ASSESSMENT/ART LINE]*** **General Assessment:** - Introduce self to patient and family; explain procedure regardless of LOC - Ensure proper PPE; HH - Awake/Alert? Pt Focus on you? Is the family stressed? - Neuro - LOC - Pupils - VS - Motor Strength - For both responsive and nonresponsive patients - TO get the best possible response - remove/reduce sedation prior to assessment - Palpate for peripheral pulses, inspection of skin - Pulmonary - Inspection and Auscultation, Rate/Rhythm, Shape of Chest; Apices to Bases - Abdo - Inspection, Auscultation, Palpation - Asymmetry, distension, abnormal colouring, scars; Tenderness; Feeding tube patency/length, tolerance, adequacy - Any Abdo wounds/drains - Assess pt's airway, ventilation setting - Foley -=\> Colour, amount of urine, urethra for irritation/discharge/damage, perineum for redness, skin breakdown - General Non-Responsive - LOC - May need to elicit pain response - Pupils manually **Arterial Line:** - ARtery catheter; monitor BP, titrate meds, used for ABG samples frequently - Radial, Femoral, or Brachial Arteries - Radial is most common; easy to control but small - Brachial is large and easy, but requires immobilization - Femoral is large, but risks for bleeding - Pedis not done - Radial - Allen Test - Release Ulnar, Positive Test - Collateral circulation - Red Waveforms - Systolic (Contraction), Dicrotic Notch is closure of aortic valve, Diastolic phase is diastolic pressure decrease - Damping - Over - Compliant tubing, loose connection, clot, kinked - Under - Long stiff tubing, stopcock, defective transducer - Zeroing/Calibrating System - Ignores atmospheric pressure - Level of phlebostatic axis; open stopcock to air/off to patient, press 0, replace cap, off to atmosphere - Zeroed qshift, q4h, after repositioning, after blood taken - Check BP accuracy - NIBP reading and art line should be similar - \>20mmHg is inaccurate - Neurovascular - Pain in extremity - Pulses in collateral, cap refil - Pallor nice pink, not white or blue - Paresthesia - no numbness or tingling - Paralysis - Can move extremity - Insertion - RN can help doctor or RT - Sterile gloves - Art line kit, etc.; change q72h - Drawing Blood - Waste 10mL - Shielded blunt cannula - Off to saline bag, draw tubes without then with additives, anticoag, and ABG - Zero and flush afterwards - Removing ART - No longer needing pressure monitoring, frqeuent blood sampling not needed - Neurovascular compromise, site bleeding - Infection/Sepsis - Art line system failure - kink or thrombus - When removing - Verify order, check coag studies, keep sterile tip, apply direct pressure for 15 minutes then pressure dressing; bleeding/hematoma/bruising - Assess 5P's ***[WEEK 1: EPIDURAL / REGIONAL ANALGESIA / ANESTHESIA LECTURE]*** *Review how to complete a comprehensive pain assessment* **ANALGESIA/ANESTHESIA:** ***Advanced competency***; need to be a registered staff with more requirements - Learning session with a theory component - Reviewing policy and procedures; i.e., from KHSC - Successfully complete a test, score \>80% - Perform and document the skill with a patient **THE PAIN EXPERIENCE:** - ***Acute*** - ***Chronic Non-Malignant*** - ***Chronic Malignant (Cancer)*** ***PAIN SUBTYPES*** - ***Somatic:*** Joints, bones, connective tissue, muscle, skin - ***Visceral:*** Deep internal organ - ***Neuropathic:*** Pain arising from your nerves; peripheral or central nervous **Acute Pain Mechanism: Nociception** 1. **Transduction:** Pain always starts with a *stimuli*; e.g., touching a hot stove -\> cell damage releases substances that activate receptors to start the action potential 2. **Transmission:** The action potential is transmitted to the spinal cord, then to brain a. The ***epidural acts here*** to stop the action potential from reaching the brain; lessens or stops or blocks the pain experience altogether (ideally) 3. **Pain Perception:** You feel the pain 4. **Modulation:** The brain reduces the pain **PAIN ASSESSMENT:** OPQRSTUV - You need to dig deep, ask all questions, look at trends - [Policy] per part of anesthesia to document q4h for pain - need to trend it, understand why it might have changed suddenly - If there's a problem, we have to know WHY there's a problem so the doctor can troubleshoot - *[Slide:]* Location (Region), Intensity (Severity), Onset, Duration, Variation/Rhythms, Quality, Exacerbation (P/P), Alleviation (P/P), Effects of Pain (Understanding) - ***Onset, Palliative/Provocative, Quality, Region/Radiates, Severity, Timing, Understanding, Values*** **O**nset: - When did your pain start? **P**alliative/**P**rovocative: - What makes your pain better or worse? **Q**uality: - How would you describe your pain? (Dull, Sharp, Throbbing, Burning, Aching, Electric) **R**egion/**R**adiating: - Where is the pain and does it travel anywhere? **S**everity: - How bad is your pain? (None,Mild,Moderate,Severe), How would you rate it from 0-10? - (Using other inventories, pain assessment tools) **T**iming: - Is there a time of day when the pain is worse? Morning? Night? Activities? Lying still? **U**nderstanding: - What do you think is causing the pain? **V**alues: - Any cultural, religious, personal/family beliefs about how you want to manage your pain? - Any medications? ("Afraid of addiction", "Afraid of cancer") *Understand the rationale for the use of epidural analgesia/anesthesia* **WHAT IS EPIDURAL ANALGESIA/ANESTHESIA:** The administration of medications into the epidural space where the spinal cord is (around the dura mater meninges) - Needle goes between the spinous processes, beyond the vertebra - Medication goes to the nerve roots and blocks the transmission directly - Epidural space is usually a protective cushion for the spinal cord - WIthin there is fat, connective tissue, lymph vessels, and ***spinal nerves*** - Med injected -\> Blocks nerves -\> Pain doesn't go past spinal cord to brain - NO perception of pain **Indications for an Epidural:** - *[Post-Op Surgical Analgesia:]* E.g., lung lobe removal surgery - that's gonna hurt! - IV meds or pills or injections are an option, but EVIDENCE proves that in acute post-op period there are better outcomes in the [acute] post-op period - *[Chronic Pain Mgmt:]* This is an option - *[Obstetrical (L&D) Pain Relief:]* Women in childbirth - *[Post-Traumatic Pain:]* E.g., multiple rib fractures, hurts too much to breathe - Can calm the body to allow it to start healing ***Benefits:*** - *[Early Ambulation:]* If it doesn't get to a motor block, patients can get up and moving if they aren't laying in bed and in pain; just goes onto the IV pole - *[Reduce Side Effects:]* Sometimes a lot less sedation vs. IV or PO route; less sedation, not just sleeping all day after surgery - can get them do DB&C, walking, eating - ***Bowel*** resumption: No PO -\> less likely they're constipated + mobility stimulates gut **Contraindications for an Epidural:** - *[Hemorrhage, Shock, Hypovolemia:]* Bleeding, related to SNS block -\> reduces BP, not stable - If you give them an epidural, it can put them at a lot of V/S risks - *[Infection:]* Don't - *[Coagulopathy/Anticoagulation:]* Risk of bleeding is big, sticking something into epi space - *[Allergy/Adverse Reaction:]* Self explanatory - *[Patient Refuses:]* They don't want one - *[Inadequate **Monitoring** Capability:]* You need to be able to have nurses trained, enough supplies, presence of pharmacy to respike bags when empty, switch out **Risks Associated:** Must explain prior to insertion - informed consent - *[Procedure Related:]* When entering space there are risks.. - Infection - at the site, if sterility is not held - *[Epidural Abscess/Hematoma:]* At the spinal level, it can form an infection -\> abscess grows -\> complications due to spinal cord pressure -\> a hematoma grows and grows in the very narrow spinal cord area - may suffer permanent paralysis, nerve damage (very small %, but informed) - *[Catheter Migration:]* - ***Into Vessel:*** Into blood vessels -\> systemic problems - ***Local anesthetic systemic toxicity (LAST)**:* Local anesthetic builds up in the body too quickly; very life threatening - Lip numbness (circumoral numbness), tingling, metallic taste in mouth - Dizziness, ringing in ears - early signs - *[Treatment:]* GIve lipids in an IV; helps to absorb the local anesthetic and reverse the symptoms - ***Into Intrathecal Space:*** Into the spinal column -\> directly affects the CSF - ***[Postdural Puncture Headache:]*** Needle/catheter goes beyond catheter and goes into the dura and results in a CSF leak into the space; produces a STRONG frontotemporal headache with neck pain; usually goes away in a couple days - the body will recover - Not pleasant; very small %; stays in the dark, no light/sound - Body eventually reabsorbs the CSF **Safety Considerations:** 1. ***MUST** have **IV Access*** *while infusing:* Don't necessarily need fluids running, but they need a S/L or PICC that WORKS (flushes, D&I) a. I.e., if they have LAST - need that IV 2. *Do **NOT change dressing** or **shower** while infusing:* Catheter is covered by a tegaderm, taped with a border - don't change it, you can reinforce the sides b. HUGE infection risk 3. ***Inspect/Assess Site** qShift/PRN* c. *Roll patient,* look at their back, especially if they say something is wrong 4. *Do **NOT** give other opioids/sedatives that are unapproved by pain management team* d. Needs that med review; we don't want to oversedate or get them into trouble e. Even *gravol* - needs to be ordered by pain service; Acute Pain Management Service 5. *May need a **urinary foley catheter** (retention):* Blockade of nerve fibres - may cause inability to go to the washroom f. Don't pull out foley until epidural is out *Understand related anatomy, physiology, and pharmacology* **What medications are in an epidural?** - How it gets there: Once the catheter is in, there's a number of ways - ***Injection*** (e.g., Bolus injection, syringe to inject one time dose - ***Continuous Infusion*** - What you usually see; pain pump delivers a mixture of meds - Will see CADD pump - usually locked up; primed by doctors, medication goes to the pump which is programmed (will see it in the lab) - Long tube has a filter; at the end is a long bendy catheter that goes into the epidural space in the patient's back, taped to it - Pump continuously infuses meds ordered into space - Also has PCEA option - **Patient-Controlled Epidural Analgesia**; patient can give themselves a top-up during breakthrough pain - There are limits and it locks out after some time - Machine also captures how many times it's pressed vs. delivers med - Either pain is really bad or teach them what it does ***Opioids:*** Diffuses past the meninges - dura and arachnoid mater, into the intrathecal space (spinal column) to act on the opioid receptors in the spinal cord; prevents pain transmission - Decreases the ***sensation*** of pain - *Lipid-Soluble:* Largest factor in how long it lasts, onset; the more lipid-soluble, the quicker it passes through the meninges and is absorbed - Lower solubility - slower absorption; may last longer, persist longer; floats around CSF and may have a bigger area - Hydromorphone - Fentanyl ***Local Anesthesia:*** Usually the first two; alters the [conduction] of nerve impulses - blocks Na+ channels to prevent the action potential from happening - no pain message [transmission] - *Lidocaine* - *Bupivacaine* - Ropivacaine Meds are put in combination in the bag by pharmacy; usually you will see BOTH - Synergistic pain control effect - they work together to have better pain control **Nerve Blocking:** All nerves that leave spinal cord are different sizes - sensitivity is related to the effect - Smaller nerve fibers carry pain more easily - easier to block - E.g., sensory and pain - Larger nerve fibers (e.g., motor fibres) are bigger - not affected as quickly - Takes longer or more medication to work *[Sequence of Nerve Blocking:]* 1. ***Pain & Sympathetic:*** THe first nerves to be blocked - the goal; the smallest fibres a. Symp: [BP will drop!] (no SNS stimulation = vasodilation) Common to have low BP i. How much it will drop is the issue 2. ***Temperature DIscrimination:*** Patient receiving epidural, depending on the level - if I touch with ice, they can't feel cold b. Nerve fibre that knows hot/cold is blocked c. Can sometimes feel pressure but won't feel cold/hot 3. ***Proprioception:*** Cells sense of self-movement; where limb is w.r.t. the rest of the body d. E.g., won't realize the leg is off the bed or be able to lift is up as well 4. ***Tactile (Touch) Stimulation:*** Depends on the effect of the medication 5. ***Motor Function:*** We DON'T want to reach this far - can't move Depends on the purpose of the epidural\... *Perform all activities included in the assessment of a patient with an epidural analgesia* **Assessment:** 1. ***Pain:*** Does it actually [work]? If not, do something about it. Is it working, right spot, etc. a. Contact doctors 2. ***V/S:*** [Q4H] if not more regularly; BP, HR, RR, Temp for Infx signs; [per policy] 3. ***Infusion Parameters:*** Make sure that the medication you think is supposed to be going in is ACTUALLY going in - are the parameters right 4. ***Sensory Blockade:*** Ice check 5. ***Motor Blockade:*** Testing how far into the blocking cascade are they? b. E.g., just pain, sensory/feel ice, can they move leg, walk around\... 6. ***Catheter Site:*** ***[STILL]*** c. Site: Dressing D&I, no peeling, little bit of blood is normal, not active or discharge d. Tubing: Connections are all still attached; from the site to the pump e. Ice: Put ice in a glove, see how far they're frozen f. Leg Lift: Motor function **Vital Signs:** - ***Temperature:*** [\>38C] is a red flag - high fever; possibly infection - ***Pulse:*** [\20 or \ motor block 5. ***Widening Sensory Block:*** Starts to get too much; creeping up less sensory and going lower b. Only need surgical site covered 6. ***Change in V/S:*** See above 7. ***Catheter Disconnected:*** Huge infection risk - stop pump, get up to assess **Documentation:** What the form looks like, 4h check - *[Analgesia Flowsheet]* - record pump numbers; pain intensity, RR, level of sedation, sensory/dermatomes, motor block - *[Progress Notes:]* Something happens, catheter D/C - what did you do, who called, resolution - *[V/S Record:]* Done **Q4H** *Understand the differences between epidural and spinal analgesia/anesthesia* **Spinal/Intrathecal:** Goes BEYOND the epidural space into the intrathecal space (subarachnoid) which surrounds the spinal cord - Opioid, Local Anesthetic, or both, injected into that space - Usually more of a *one-shot dose*; e.g., a spinal for a surgery - E.g., Kristen's knee surgery - didn't want general, gave her a spinal instead - Lost complete sensation, movement, everything to lower limbs, did surgery - Eventually it wore off after the surgery - Quicker to put in the drug, take it out, one shot, into the spinal column around the motor neurons - blocks motor - **Faster onset** - much less medication dosing for the same effect - *[Note:]* - NEVER inject above the L2/L3 region -\> risk of hitting the spinal cord; that's where the tail begins (cauda equina) - Anything below that, push the tail aside, no injury to the spinal cord - Large blood vessels in the subarachnoid space, CSF that supply the brain and spinal cord to provide relief - Medication given is **1/10th** that of the epidural space - generally - Opioids in the IT space will spread around (due to circulation of the CSF); receptors are acted on directly *[Before Discharge\...]* - Need to meet criteria - Regression of sensory block for about 2-3 dermatomes - Sensory block lower than T10 (regaining feeling) - Must be at least a Bromage 2 for Motor Block - Moving feet - Therefore we know that the medication is wearing off - takes a while to recede ***Vs. Epidural Space:*** 2 membrane away from the spinal cord; diffuses across the dura and arachnoid to get the spinal cord - Longer lasting, continuous, can affect more levels of spinal cord vs. spinal/intrathecal - Doesn't usually hit motor neurons as it shouldn't affect those fibres as deeply - Though it is possible *[Insertion:]* 1. ***Local Anesthesia*** to numb the area 2. Giant **Sterile Field**, draping the patient's back 3. Nurse helps by position the patient, arch forward, edge of bed, hands on shoulders a. Help position patient once it kicks in 4. How do they know they're in the right spot b. Feel/hear popping as they give way to different layers c. Test dose.. E.g., epi -\> quick parameter change to V/S ***[WEEK 2:]*** ***[MEDICATION ADMINISTRATION: BELOW THE DRIP CHAMBER - AIRWAYS, INTUBATION, & IV MED PUSH]*** *Describe the administration of IV Direct/IV Push/IV Medication Bolus, understand the appropriate requirements and give examples of its use.* **What does "Below the Drip Chamber" mean?** - We're used to giving meds above the channel, above the drip chamber, above the pump - It's safer, we have a lot more control, a lot more safety checks - We know how to use the parenteral therapy drug manual, diluents, programming\... - **BtDC** is an advanced competency for medication administration - IV Direct/Push, IV Bolus **It's kind of dangerous:** Administering an IV bolus incorrectly/too quickly can have serious patient outcomes. If anything, you should be a little scared/nervous - Double check with your nurse, triple-check your micromedex compatibilities - Get used to the stress! - Things can go wrong [very quickly] if you fuck it up, there's not as much time to recover if an adverse event happens - You will see your patient go south right in front of you - HR drops, O2 drops, ECG waveform deteriorates - especially because of the continual hemodynamic monitoring in the ICU setting - Because it's concentrated, the likelihood of adverse reactions is also higher - You need to monitor appropriately if you\'re going to give this - "***Will I be able to do this?"*** - You might be able to push meds, with appropriate preceptor supervision **IV Direct:** An advanced competency; as simple as drawing medication into a syringe, cleansing the PICC line or saline lock, then shooting in the medication - Could also be given through the secondary Y-port close to the luer-lock site - ***IV Medication Bolus (Push)*** is also an option that can be used; very similar but it gives a large dose of medication immediately - It's [programmed into the pump] - E.g., for Heparin loading dose before continuous - Boluses are considered to be administered up to [10 minutes or faster] - *[What is it:]* A **concentrated**, much **smaller volume** of medication given - Helps because you\'re not overloading 100mL of extra fluid overload - The body is so sick, already tired, has trouble balancing homeostasis - Don\'t want to overdo it by giving boluses and boluses of fluid - E.g., instead of added extra volume, drug to squeeze the vessels a bit and add BP **Nursing Considerations for IV Direct:** *[PATIENT MONITORING REQUIREMENTS]*: You need to be constantly monitoring the patient. In some areas of the hospital, you will never need to give that by push - there just isn't the same sense of urgency - ***so why?*** - The patient needs it now. - Think about **WHY** you are giving the medication - [urgency.] - *[E.g.]*, PRN Gravol/Dimenhydrinate, the patient feels a little nauseous - You can draw up a secondary - the patient isn't gonna yak right now - *[Vs.]* someone coming out of recovery room, fresh incision, retching and vomiting, vomiting will increase pressure on the wound site - They need that drug [now]. - E.g., Patient crashing, intubating someone, needs to be paralyzed medically - If you're using IV push, it better be time sensitive. - You need certain **staffing requirements:** Because of the continuous monitoring - E.g., patient you have 5 patients, you can\'t give that same level of care to all of them - You need certain **Equipment requirements:** Medication, cardiac monitoring, hemodynamic\... If you're in a situation where you're giving IV push\... that's a high level of urgent care needed. You can\'t go home on IV gravol push, or IV morphine push - Patients need to be stable on PO to be good for recovery *[MEDICATION COMPATIBILITY/WHAT IS INFUSING:]* - ***Micromedex Compatibility:*** Everything going in that line has to be compatible. - Push is highly concentrated - much more likely to form precipitates/adverse - ***NEVER blood products*** by push - In ICU, there's generally a ***big orange medication main line*** - It's only running saline, any [singular] medication is compatible - Problem is if you have to give 4 meds at the same time - Sometimes you have to wait, triage which meds can wait, what can\'t wait *[SELECTION OF IV LINE - Central vs. Peripheral:]* - ***Central Line:*** Larger blood vessels, faster blood flow, better circulation - *[E.g., IJ line]*: Multiple lumens where you don\'t have to check different compatibilities because the flow is so fast it's unlikely the meds will interact for long enough - *[E.g., vs PIV:]* A tiny hand vein, no blood flow, stays a while until it goes systemic - E.g., Drug desensitization process - needs **continuous cardiac monitoring** because you're giving the body an allergic reaction, essentially, since there are no other therapy options - For context, Kristen was telling a story - Don\'t just go along with what you\'re told - Just call the RACE team, they have more experience *[ASSESSMENT OF THE SITE:]* - ***Make sure your IVs actually work:*** Flush your saline locks, you don\'t want to be in a code situation and not have a working line - Getting an IV in can take anywhere between 30 seconds to 5 minutes - Getting an IV in during code is NERVE WRACKING - Flushing sites, making sure they work, site is healthy; D&I, perfused\... *[MEDICATION RIGHTS ]* - ***Right Patient*** - ***Right Medication/Indication*** - ***Right Dose*** - ***Right Route*** - ***Right Timing*** - ***Right Client Education*** - ***Right Documentation*** - ***Right Assessment*** - ***Right to Refuse*** - ***Right Evaluation*** **[What Will Medications Look Like in the Drug Guide?]** - Not intermittent/IV secondary -\> Will be under **IV DIRECT** - It'll tell you exactly how it is safe to administer - over so many minutes - You BETTER BE COUNTING - E.g., 2mL every minute, on your watch **Advanced Monitoring Requirements:** They will be outlined in bold. - *[BP Monitoring:]* Drugs requiring use of non-invasive BP monitoring with VS q1h - OR continuous ART LINE BP monitoring -\> That means it must be in critical care - You don't have art line monitoring anywhere else. - *[Cardiac Monitoring]* - Needs to be connected to a (stationary) cardiac monitor; NOT mobile TELEMETRY because you can't monitor them as much - *Person pushing medication* also needs to be available to ***interpret it*** - They need ***advanced cardiac monitoring competency*** - *[Respiratory Support:]* Must be physically on-site - Oral airway, Ambubag/BVM, Airway Suctioning, Oxygen Equipment - *[Ventilator Support:]* Some patients need an ETT or Trach tube in situ + mechanical ventilator - Like, they must be actively hooked up to a ventilator to use this. It is dangerous. ALWAYS REFER TO KGH PARENTERAL DRUG THERAPY MANUAL - Proceed with caution E.g., Gravol/Dimenhydrinate: IV Direct: A physician or RHCP, if using the IM formulation, 50mg/Ml, dilute each 50mg with 10mL NS, push over 2 minutes Heparin: IV Direct: Initial bolus dose given by Physician/RHCP; undiluted over 1 minute - Heparin drip runs through the channel - use pump "bolus" option to get it into their system - CRRT - Dialysis? Down to the mL; Continuous renal replacement therapy - I don't remember why we mentioned this - IV minibag... depends on your comfort level... - There are preprinted orders for heparin Fentanyl: WARNING: RESPIRATORY SUPPORT READILY AVAILABLE - IV Direct: Admin undiluted or dilute in 10mL n/s; give over 1-2 minutes - Fentanyl is VERY widely used in the hospital *Describe pain control, sedation, and paralysis in the ICU, its assessment, and its management* ***SEDATION & PAIN CONTROL*** ***How do we Assess Pain?*** - *[OPQRSTUV?:]* Yes, but this only works if they can respond to you. - *[Unresponsive?:]* Pain response, HR changes, grimacing (esp. in ICU), do they seem uncomfy, intubated patients remember things said, pain, etc. - Ideally, patients are under a light level of sedation and adequate pain control - This is hard to determine when patients can\'t talk to us. - Ideally - they open their eyes and dose off within seconds; RASS Score (-2) - Can they blink, squeeze hand, wiggle toes, are they comfortable\... - \"Fighting the ventilator\" - are they breathing on their own vs. mechanical vent - It is like breathing through a drinking straw - anxiety inducing, lots of sounds, things we don\'t want them to be aware of - so we paralyze them ***Why do we use sedation/pain control?*** - *[Patient Comfort:]* Nobody likes being in pain; surgery, MVA, 10 JP drains, etc. - *[Facilitate Patient Ventilator Synchrony]*: Patient is getting worked up, trying to fight the ventilator - First instinct is to YANK THE TUBE OUT - Fighting air being blown into your lungs, \"just relax\" is the last thing you want to hear - TALK to and reorient your patient, let them know it\'s okay, they\'re safe, they\'re here - *[Optimize Oxygenation:]* So they don't fight the ventilator, we can oxygenate to meet their bodily demands - *[Delirium Influence:]* Negative memories, long-term psychological effects [PAIN] ***What causes pain/anxiety in the ICU?*** - *[Recent Surgery:]* Incisions, broken bones, etc. - this is to be expected, normal - *[Pre-existing disease]* - *[Nursing care:]* Repositioning, wound care, needles, drains - 10 JP drains, suctioning (deep suction makes them blue, elicits cough) - *[Immobilization:]* Laying in bed for 3 days, feels bad man - *[ETT:]* "It's like breathing through a straw" - *[Monitoring Devices:]* Lots of blinking flashing lights, dinging - It's very unfamiliar, can cause a lot of anxiety - *[Drains:]* Drains suck, man. ***Consequences of Unmanaged Pain:*** - *[Physiological Stress Response:]* Poor O2 sat, higher HR, slower recovery, BP rising, agitation, delirium - *[Relationship of nurse-client breakdown:]* They are helpless and you are not helping them - *[Family stress:]* It is very unsettling to see. Nurse needs to calm down the family too - *[Longer LoS]* - *[Sleep Deprivation:]* From constant pain leads to poor recovery ***Measuring Pain:*** **CPOT SCALE**: "*Critical Care Pain Observation Tool*"; Higher = more pain; 0-8 - *[FACIAL EXPRESSION:]* Relaxed -\> Grimace - *[BODY MOVEMENTS:]* Absence -\> Restlessness - *[COMPLIANCE WITH VENTILATOR/VOCALIZATION:]* - Tolerating -\> Fighting - Talking normally -\> Sobbing - *[MUSCLE TENSION:]* Relaxed -\> Tense Doctors will give you a target in the orders; \"Aim\" for a CPOT of this score - Lots of ranges and lots of independence - E.g., propofol between 2-50mcg/hour okay but where do I start - \"Take them off vasopressors\" okay but at what speed [SEDATION] **Overall Goal of Sedation:** Offers comfort while allowing pt. to briefly interact with the environment - Again, being in the ICU is stressful, there are a lot of things in you and your first instinct is to take those things out - unsedated patients get restless, pull at catheters, tubes - Patient needs to get heavier sedation - Lots of titratable ranges because we don\'t know what people will need to get sedated - Lighten when possible - sometimes it isn't possible - *\"Arousable, able to follow orders, lighten when possible\"* **Benefits of Sedation** - *[Induces Sleep:]* Sleep helps patients recover, get rest, etc. - Q: Do patients have a sleep cycle? They can\'t really tell... may at night there's not as much traffic, lights are down, sometimes they don\'t even know the time of day - *[Created Unawareness:]* Don\'t want patients to worry about being in the ICU - *[Facilitates Ventilation:]* - *[Prevent Self-Injury/Self-Harm:]* Once they have the ETT, don\'t want them to dislodge it - *[Efficient Care Delivery:]* Nursing care is easier when pt is fully sedated; not resistive - *[Increase family acceptance of ICU care:]* Pt isn't thrashing, moaning, distressed **Complications of Sedation** - *[Immobility]* - *[Pressure Ulcers:]* From immobility; need to reposition frequently; often takes 4 people just because of the sheer amount of lines - *[Gastric Ileus]*: Peristalsis just temporarily arrests; stops working for a while - Usually they have an OG tube; not NG - just put in at the same time as the ETT - *[Pneumonia:]* Their defense mechanisms and reflexes like cough are down - *[Delayed Weaning:]* They aren't breathing for themselves - longer to wean off ventilator ***Measuring Sedation:*** THIS APPARENTLY GOES DOWN TO -5: UNAROUSABLE **RASS - Richmond Agitation Sedation Scale**: Validated ICU Scale to measure sedation depth/quality - Usually targeted for a RASS of -2 - LIGHT SEDATION - \"Briefly awakens with eye contact to voice \