Group 3, Cluster A, Sub-Cluster 1 Mackie, Sunshine Adeline Natividad, Eloissa Keith Medical Intensive Care Unit A specialized section

on of a hospital containing the equipment, medical and nursing staff, and monitoring devices necessary to provide intensive care. It cater to patients with the most severe and life-threatening illnesses and injuries; that require constant, close monitoring and support from specialist equipment and medication in order to maintain normal bodily functions. They are staffed by highly trained doctors and critical care nurses who specialise in caring for seriously ill patients. The MICU is a Patient-Centered ICU and as such, families are always welcome at their loved one's bedside. The MICU eliminated visiting hours so the ICU is open to families 24/7. The MICU also began a practice called family presencing. This enables family members to stay in the patients room at all times, even during a serious emergency such as a cardiac arrest. In emergencies a MICU nurse stays with the family to provide information and reassurance. Patients, to the extent they are able, and their families participate in all discussions and decisions about their care. Because of the variety of conditions and illnesses in the MICU, length of stay varies from hours to months.

Routine activities in MICU: a. b. c. d. e. f. g. h. i. j. I. Oxygen Inhalation Endotracheal intubation Mechanical ventilation ECG Nebulization Suctioning Titration Cardiac monitoring Infusion pump What to do in cases of cardiac arrest Routine activities

1. OXYGEN THERAPY Oxygen therapy is the administration of oxygen as a therapeutic modality. It is prescribed by the physician, who specifies the concentration, method of delivery, and liter flow per minute. Oxygen Delivery Systems: 1. Nasal Cannula Also called nasal prongs. Is the most common inexpensive device used to administer oxygen. It is easy to apply and does not interfere with the clients ability to eat or talk. It delivers a relatively low concentration of oxygen which is 24% to 45% at flow rates of 2 to 6 liters per minute.

2. Face Mask It cover the clients nose and mouth may be used for oxygen inhalation. Exhalation ports on the sides of the mask allow exhaled carbon dioxide to escape.

Simple Face Mask - Delivers oxygen concentrations from 40% to 60% at liter flows of 5 to 8 liters per minute, respectively. Partial Rebreather Mask Delivers oxygen concentration of 60% to 90% at liter flows of 6 to 10 liters per minute, respectively. Non Rebreather Mask Delivers the highest oxygen concentration possible 95% to 100% by means other than intubation or mechanical ventilation, at liter flows of 10 to 15 liters per minute. Venturi Mask Delivers oxygen concentrations varying from 24% to 40% or 50% at liter flows of 4 to 10 liters per minute.

3. Face Tent It can replace oxygen masks when masks are poorly tolerated by clients. It provide varying concentrations of oxygen such as 30% to 50% concentration of oxygen at 4 to 8 liters per minute. Steps:

Check doctors order

get baseline O2 sat

Prepare materials needed

Inform client or significant other

Attached the type of device as ordered

Fill the humidifying chamber if itd below the line

Check humidifying chamber

Assess condition of the patient

Document procedure Set the level of Oxygen as ordered

2. Endotracheal Intubation Endotracheal intubation is a procedure by which a tube is inserted through the mouth down into the trachea (the large airway from the mouth to the lungs). It is an invasive procedure. Nurses only assist in the procedure. The doctor often inserts the tube with the help of a laryngoscope, an instrument that permits the doctor to see the upper portion of the trachea, just below the vocal cords. During the procedure the laryngoscope is used to hold the tongue aside while inserting the tube into the trachea. It is important that the head be positioned in the appropriate manner to allow for proper visualization. Pressure is often applied to the thyroid cartilage (Adam's apple) to help with visualization and prevent possible aspiration of stomach contents. The endotracheal tube serves as an open passage through the upper airway. The purpose of endotracheal intubation is to permit air to pass freely to and from the lungs in order to ventilate the lungs. Endotracheal tubes can be connected to ventilator machines to provide artificial respiration. This can help when a patient is unconscious and by maintaining a patent airway. It is often used when patients are critically ill and cannot maintain adequate respiratory function to meet their needs. The endotracheal tube facilitates the use of a mechanical ventilator in these critical situations. The materials needed in intubation are: Endotracheal tube, Blades and laryngoscope handle (macintosh blade-curve blade, straight blade- miller blade, used for

obese and pediatric client), ambo bag with face mask, 10 cc syringe, adhesive tape, suction catheter and machine, NGT tubing and bumb syringe, KY Jelly, pulse oximeter, stylet/guide wire. Steps:
Get the consent of the patient (conscious) or the significant members Prepare the materials needed

Check doctors order

Get baseline 02 sat

Hyperoxygenate patient

Get suction machine on standby

Place patient on sniffing position

Assist doctor in the procedure while monitoring the vital signs

Document the procedure done

3. MECHANICAL VENTILATOR A mechanical ventilator is a machine that makes it easier for patients to breathe until they are able to breathe completely on their own. Sometimes the machine is called just a ventilator, respirator or breathing machine. Usually, a patient is connected to the ventilator through a tube (called an endotracheal tube) that is placed in the windpipe. Sometimes, patients can use a machine that assists breathing through a mask or mouthpiece but this may not work with severe respiratory problems. Despite their lifesaving benefits, mechanical ventilators carry many risks. Therefore, the goal is to help patients recover as quickly as possible to get them off the ventilator at the earliest possible time.

7 Purpose: 1. 2. 3. 4. 5. 6. 7. For COPD patient For comatose patient (depressed respiratory muscle) For tetanus patient (spasm of respiratory muscle) For patient with rib cage fracture/injury For patient with spinal cord injury For patient with blood dicussia eg. anemia For the administration of anesthesia

Parameters of Mechanical Ventilator 1. FIO2 (fraction of inspired oxygen) -% of oxygen in each breath inspires * as patient condition improve it is being decreased 2. Tidal volume -the amount of air inhaled and exhaled during vemtilation - wt. of pt. (kg) x 10 ml (constant) 3. Back up rate or Respiratory Rate

-number of breaths per minute 4. Modes -define how dependent is the patient on ventilator a. Assist control -the machine delivers all the breathing -all parameters are present b. Synchronized intermittent mandatory ventilation -patient initiate to breath in between ventilator delivered breath -all parameters are present c. Continuous positive airway pressure - patient can breathe but cannot maintain a normal arterial oxygen saturation in the blood Salient points:

Assessment

Check the connection if there is desaturation Check patients condition ( O2 sat, cold clammy skin, profuse sweating) Check O2 tank Check if there is secretion s in the murpheys eye

Action

Suction if needed Replace O2 tank Fix loose connection/ attach connection Set parameters as ordered

4. ECG The electrocardiogram (ECG or EKG) is a noninvasive test that is used to reflect underlying heart conditions by measuring the electrical activity of the heart. By positioning leads (electrical sensing devices) on the body in standardized locations, information about many heart conditions can be learned by looking for characteristic patterns on the EKG.

V1 - 4th intercostal space, right of sternum V2 - 4th intercostal space, left of sternum V3 - midway between V2 and V4 V4 - 5th intercostal space, in the midclavicular line V5 - same level as V4, at anterior axillary line (between V4 and V6) V6 - in 5th intercostal space, in the

Placement of the leads

midaxillary line

Steps:

Check Doctors order

Explain procedure to client

Provide Privacy

If the chest of client is hairy, clip or shave it

Turn on and set the machine

Apply jelly and place electrodes

Remove necklace watches and any electronic device near the area

Position Client

Check the connections and the strip of the machine

Wait for the result

Document the procedure

5. Titration

Verify/check doctors order

Check VS of client as baseline for the increment and decrement of the rate

Compute for the map if its the basis of adjusting the rate

Document procedure

Adjust rate based on the assessed VS or computed MAP as prescribed by the doctor

6. Nebulization -usually done before meals or 30 minutes after meals Steps:

Assess client condition (RR, pattern of breathing, O2 sat)

Check doctors order if there is prescribed nebulization

Prepare materials needed

Compute for the right dose of the drug to be nebulized

Document the procedure

After Nebulization do bronchial tapping if conscious if not do suctioning

Get a standby suction machine

7. Suctioning -done when there is secretion on the ET the or in the mouth

Salient points

It should be done before feeding or 30 minutes after feeding Elevate the head of the bed to prevent aspiration Dominant hand should be handling the tip of the catheter, non dominant hand controls the air vent During suctioning, wipe catheter from proximal to distal before reinserting the catheter tip Flush sterile water in the catheter every interval Single use per catheter use only For clogged ET, instil 5 cc of NSS and suction after 5 minutes but if there is presence of bubbles suction immediately For maximization of resources, suction 1st the Et tube before suctioning the mouth Suction for period of 10 seconds and an interval of atleast 20-30 seconds per suctioning document

8. CARDIAC MONITORING cardiac monitoring generally refers to continuous monitoring of the heart activity, generally by electrocardiography, with assessment of the patients condition relative to their cardiac rhythm. It is different from hemodynamic monitoring, which monitors the pressure and flow of blood within the circulatory system. The two may be performed simultaneously on critical heart patients. A small monitor worn by an ambulatory patient is known as a Holter monitor. Transmitting data from a monitor to a distant monitoring station is known as telemetry or biotelemetry. Steps: Assess the condition of the machine (connection and patches) Assess the placement of the patches Assess the vital signs in the cardiac monitor

Assessment

Action

Properly attach or change any loose connection Change defect patches Properly position the patches Report any abnormalities in the vital signs of the patient

Reassessment

Reassess if the machine is functioning well (Efficient data appear on the screen)

INFUSION PUMP Infusion pump is designed to help nurses administer intravenous (IV) medications safely to their patients. It has features that control dosage to minimize the occurrence of human error as well as protocols that keep the entire process sanitary. Using the infusion pump is a process that nurses must master.

Steps:

1. Turn the main machine on by pressing the "Power" button and holding it in for a few seconds. You'll have a primary machine and one or more separate pumps to operate with this system. The screen on the main machine will ask if you are working with a new patient; make the appropriate answer using the keys on the right side of the screen. When the screen asks for the Patient ID, look on your patient's code on her armband and enter it. Confirm the ID when asked. 2. Move to the pump. Press "Menu" and choose the substance to run through the pump. When prompted, enter the rate of infusion and the VTBI (volume to be infused). Choose a volume smaller than your IV bag, so that when the volume runs out on the machine, you will hear an alert in more than enough time to replace the bag before the IV line goes dry. 3. Press the "Silence" button on the main machine to keep the system from beeping while you're hooking the line up. The alerts are important for safety when you have a patient on the IV, but there are no safety concerns without a patient present. 4. Flip up the lever on the right side of the pump you're going to use. Take the protective covering off the tubing and insert it into the open pump. Put the blue outlet plug at the bottom, inside the door, and the blue source plug in the slot at the top, and close the machine. Wait for the machine to check the line for air bubbles. When ready, the pump will glow green at the top. 5. Press "Start" to begin the flow of the IV drip, and insert the IV into the patient's hand (or other location as appropriate).
Check if the machine is functioning Check if the air vent of the infusion pump is open Check the patency of the Line Check for the presence of bubbles Open the air vent Remove the bubbles Manipulate machine if it alarms Flush blood clots on the IV line

assessment

Action

9. What to do when there is a Cardiac arrest?

Assess the clients VS (RR, HR, O2 sat, body temp., BP) Refer any abnormal finding to a doctor Lower down head of the bed in preparation for CPR

Detach mechanical ventilator to the ET tube and attach ambo bag connected to a oxygen tank (15L/min)

Prepare materials needed

Maintain patent airway of the client

Perfrom CPR with ambo bagging simultaneous with suctioning

Perform ECG tracing

Continue with ambo bagging and CPR

ASSESSMENT (SOC I) 1.Collects appropriate patient information to form a thorough and organized data base for patient care. - Reviews the patients chart, - Gets report from members of the health care team to clarify information and provide for continuity of care. - Organizes and records data as directed. - Prioritizes data collection based on patients condition. 2Performs thorough and accurate physical assessments. -Assess the condition of gadgets attached - Obtains and records vital signs, intake / output, GCS accurately. - Documents assessment findings accurately in appropriate records. - Identifies changes in patients health status and takes action when necessary.

II. 1. 2. 3. 4. 5. 6.

Nursing Process Assessment Diagnosis Outcome evaluation Planning Implementation Evaluation

DIAGNOSIS (SOC II) 3. Analyzes data to identify appropriate nursing diagnoses. - Selects and documents appropriate nursing diagnoses. - Identifies actual or potential problems that threaten or promote adaptation. OUTCOME IDENTIFICATION (SOC III) 4.Identifies appropriate patient outcomes. - Derives outcomes from written nursing diagnoses. - Establishes desired patient outcomes as realistic and obtainable goals. - Documents outcomes appropriately. - Participates with patient, family and health care team to establish patient-centered outcomes PLANNING (SOC IV) 5. Creates and documents a well-developed plan of care. - Develops a plan of care with input from the patient, family, other members of the health care team. - Includes appropriate patient and family learning and discharge needs. - Creates a plan that provides for continuity of care. - Incorporates patients cultural and spiritual beliefs in plan of care. - Incorporates patients physiologic, psychosocial, developmental needs, and patient strengths in plan of care. 6. Establishes priorities for nursing care. IMPLEMENTATION (SOC V) 7. Provides appropriate interventions based on the patients plan of care. - Implements plan of care according to the patients needs and established priorities. - Promotes the patients optimum level of functioning and adaptation to changes in health status. 8. Provides for physiologic health and safety of the patient - Follows universal precautions when providing care. - Provides for patients hygiene needs. Demonstrates safe performance of nursing skills. - Administers medications safely and correctly and documents appropriately. - Follows established hospital policies, procedures, protocols, and routines. - Demonstrates understanding of aseptic technique when providing patient care. - Administers parenteral fluids safely and documents appropriately.

9.

10. Utilizes therapeutic communication skills in interactions with the patient and patients family.

11. Demonstrates accurate and appropriate charting and written communication EVALUATION (SOC VI) 13. Determines the effects of nursing interventions on the patient. - Participates with the patient, family, and health care team to evaluate thepatients progress towards writ 14. Revises plan of care based on ongoing assessments.