Assessment of the critically ill patient Mrs.

Dablo

June 29, 2012

The 3 key stages of recognition and treatment of a critically ill patient: Understanding that an emergency exists Identifying and prioritizing problems Action and evaluation

Critically ill: Relating to the stage of pts dse or condition at which an abrupt change for worse maybe expected Relating to an illness or condition involving danger of death Failure to assess and monitor pts who are critically ill is a basis for liability that nurses that must be particularly aware of

Assessment: The nurse acts as pt advocate, monitoring, anticipating potential problems, planning, implementing, and constantly evaluating care, and communicating with other health care team staff involved in the pt care.

Pt ax systems: BLS, ALS Acute life-threatening events, recognition and treatment (ALERT) The advanced trauma life support (ATLS) A: airway (with C-spine protection in trauma) B: breathing C: circulation D: deficits in neurological status/disability

Emergency ax: Primary survey- focuses on stabilizing life-threatening conditions The ED staff work collaboratively and follow the ABCD Airway- supine chest, head tilt, chin lift o Clear o Airway obstruction Victim may clutch the neck between thumb and fingers Weak, ineffective cough; high-pitched noises on inspiration Inc respi distress Inability to speak, breathe, or cough Collapse o Immediate mgt: scooping, Heimlich manuever, airway support, intubate Breathing- distress, rate, chest movement, auscultate o Inspiratory and (expiratory) stridor, labored breathing o Use of accessory muscles (suprasternal and intercostals retraction), flaring nostrils

Inc anxiety Immediate mgt: O2 therapy, monitor O2 saturation, CPAP, non-invasive ventilation, intubate and ventilation Circulation: o Pulse: rate, rhythm, volume (<500cc) o Atrial pulse waves: Normal- brisker upstroke than downstroke Bounding and collapsing Aortic incompetence hyperdynamic circulation patent ductus arteriosus; complete heart block Small volume- shock, aortic stenosis o Blood pressure- direct arterial pressure o Peripheral perfusion Peripheral pulses Temperature Colour Capillary refill o Immediate mgt: venous access, fluids, vasoactive drugs

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Secondary survey- diagnostic and lab testing Insertion or application of monitoring devices such as ECg electrodes, arterial lines, urinary catheters Splinting of suspected fractures Cleaning and dressing of wounds Medical dx

Critical Illness: CVD History: general data, CC, HPI, past medical hx, family hx, personal and social hx Sx of CVD o CAD & MI Chest pain, chest discomfort, diaphoresis, HPoN Congestive Heart failure o Exertional dyspnea, easy fatiguability o Orthopnea, paroxysmal nocturnal dyspnea o Dypnea at rest, edema Arrythmia- palpitation, syncope, dizziness Ineffective endocarditis/ Rheumatic fever (tonsillitis) o Fever, peripheral emboli Peripheral vascular dse o Intermittent claudication o Phlebitis

Physical examination: A. General appearance: tachypnea, cyanosis B. Blood pressure, pulse pressure, pressure difference between the arms and legs o Pulsus paradoxus- exaggeration of the N dec in BP during inspiration

o Pulsus alternans- alternate strong and weak pulses Examination of the lungs, abdomen

Dx/lab tests: Non-invasive: ECG, cardiac rhythms Invasive: ABG, hemodynamic monitoring, CVP, pulmonary capillary wedge pressure

Hemodynamic monitoring- is an essential component of caring for post-operative or critically ill cardiac surgical pts Thus describes the observation and recording of the forces generated within the vasculature that are associated with the movement of blood Invasive lines fed into a central vein through the right of the heart and into the pulmonary artery. Its placement allows for measuring pressures such as CVP, PCWP Uses Swan-Ganz catheters

Pulmonary Capillary Wedge Pressures (PCWP)- a balloon at the tip of the Swan-Ganz catheter is inflated enough to occlude blood flow to a branch of the pulmonary artery

THE INDIVIDUAL ACROSS THE LIFESPAN IN EMERGENCY NURSING Diagnostics and lab tests: Non-invasive: 1. ECG Invasive: 1. ABG Normal values Ph- 7.35-7.45 PaO2- 80-100mmHg paCO2- 35-45mmHg HCO3- 22-26mEq/L Base Excess -2 to +2mEq/L O2 sat- 95-100%

A. B. C. D.

Metabolic acidosis- low bicarb Metabolic alkalosis- base bicarbonate excess Respi acidosis- carbonic Acid excess Respi alkalosis- carbonic acid deficit

Hemodynamic monitoring- is an essential component of caring for post operative or critically ill cardiac surgical pts To survey and to optimize the determinants by direct appropriate therapeutic intervention for the purpose of providing the oxygen delay to the tissues

Blood pressure: 1. Arterial lines- provides a direct, intra-arterial measurement of BP; assist in the continuous measurement of SBP, DBP, and MAP Method: 20g arterial catheter inserted into the radial, brachial or femoral artery connected to high pressure tubing leading to a pressure transducer and amplifier. Swan-Ganz catheter- invasive lines fed into the central vein, through the right of the heart and into the pulmonary artery Its placement allows for measuring pressures such as: CVP, right ventricular pressure, pulmonary artery pressure, pulmonary capillary wedge pressure

Central venous pressure- used to assess right ventricular function and venous blood return to the right side of the heart

A measurement taken from the right atrium and represents the amount of blood return to the right atrium (preload) Normal: 5-10cm H2O or 0-8mmHg Common causes of elevated waveforms: ventricular failure, pulmonary hypertension or stenosis, tricuspid regurgitation, hypovolemia, cardiac tamponade and constrictive pericarditis

Right ventricular pressure- measured directly only during the insertion of the Swan-Ganz catheter Normal RV systolic: 20-30mmHg Normal RV diastolic: 0-5mmHg In the absence of dse RV systolic and PA systolic pressures should be equal Causes for RV pressure abnormalities: pulmonary HPN, ventricular septal defects, pulmonic stenosis, RV failure, cardiac tamponade, and constrictive pericarditis

Pulmonary artery pressure- measures the pressure in the pulmonary artey and allow for interpretation of left sided ventricular filling and function Normal PA pressures are systolic......

Pulmonary capillary wedge pressures- a balloon at the tip of the Swan Ganz catheter is inflated enough to occlude blood flow to a branch of the pulmonary artery The pressures beyond the balloon are measured and represent retrograde pressures from the left atrium and the left ventricle at the end of diastole- reflecting preload of the left side of the heart An accurate indicator of the pump function of the left ventricle Normal PCWP is 8-12mmHg Elevated PCWP pressures are usually indicative of pulmonary congestion They may be falsely elevated if the pt is on PEEP or CPAP or if the catheter tip is not in the correct place Monitor tracing has 3 positive waves, A, C and V o A wave- represents left atrial contraction o C-wave- mitral valve closure o V-wave- left atrial filling pressure Common causes of elevated PCWP waveforms: inc resistance to ventricular filling as with mitral stenosis of left ventricular failure, mitral valve regurgitation and ruptured papillary muscle, hypervolemia, tampnade, or constrictive pericarditis

Arterial pressure- allows continous display of systemic, diastolic and Mean arterial pressure as well as vasculature Access for obtaining arterial blood samples for gas analysis Important indicators of systemic perfusion, particularly to that of heart, brain, kidneys and other vital organs

Catheter placement- sites for intra-arterial catheterization: Radial (most common) Pulmonary artery pressure- provides an index of the pressure which is the pulmonary vasculature and are affecting the compliance of the left ventricle, pulmonary vessels pressure, cardiac output (blood flow to the lungs), and the state of the lung tissue Nursing Diagnosis: Alteration in CO: decreased

Alteration in tissue perfusion Sleep pattern disturbance related to invasive monitoring