NURSING THE ICU

PATIENTS
OUTLINE

• General understanding of nursing care to ICU patients and guiding

Principles to the ICU care
• Classification of ICU/CCU Patients
• Management of critically ill patient
• ICU Environment
• Conclusion
GENERAL UNDERSTANDING

• Critical care nursing is the field of nursing with a focus on the utmost
care of the critically or unstable patients.
• Critically ill patients: are those who are at risk for actual or potential life
threatening health problem
GUIDING PRINCIPLES

• Delivery of optimal and appropriate care

• Relief of distress
• Compassion in care
• Dignity
• Information
• Rehabilitation
• Care and support of relative and care givers
CLASSIFICATION OF ICU/CCU PATIENTS

• Level 0: - Normal acute ward care

• Level 1: - (general at risk ward patients)
a)Acute ward care to patients who at risk of
deterioration
b)Who are recovering after higher levels
of care and still have great nursing needs.
CONT:

•Level 2: - (High dependence)

- Detailed observation or interventions
e.g. Patients with failing single organ system, or
post – operative patients, or patients stepping
down from higher levels of care.
•Level 3: - (Intensive care)
- Patients need advanced respiratory support care,
or basic respiratory support together with
support of at least two organ systems.
MANAGEMENT OF CRITICALLY ILL PATIENT

The order of management/care in nursing ICU patients should focus on the

followings;
• Closed and continued monitoring
• Respiratory care
• Cardiovascular care
• Gastrointestinal/Nutritional care
• Infection control and skin care
CONT:

• Neuro muscular care

• Comfort and reassurance
• General hygiene and mouth care
• Fluid, electrolyte and glucose balance
• Bladder care
• Dressing and wound care
• Communication with patient and relatives.
CLOSE AND CONTINUES MONITORING

Monitor the Primary survey: A,B,C,D,E Models

-Airway: Patency position of artificial airway
(if present), adequacy of oxygenation
-Breathing: Quality and quantity of
respirations(rate, pattern, symmetry, effort,
use of accessory muscles). Breathing sounds,
presence of spontaneous breathing.
CONT:
• Circulation and Cerebral perfusion:
-Peripheral pulses and
capillary refill skin, color, temp, presence of
bleeding, sweating, urine output.
• Disability: altered conscious level using either GCS or AVPU
• Exposure: to examine unseen hemorrhage, wound leakage
(ii) Secondary survey: diagnostic investigation e:g ECG FAST. physical
reassessment -
head to toes & review of system(e.g. RS,CVS,GU,)
RESPIRATORY CARE

• Respiratory Assessment
- RR, Nasal flaring,
-airway obstruction- chest excursion (air entry)
- altered ventilation,
-atelectasis/lung collapse (chest expansion)
- impaired muscle function (use of accessory muscle)
-poor secretion clearance (ability to cough).
CONT:

• Suction/Pulmonary toilet – 4 hourly or on when needed

• Intubation – ETT for airway, Nasopharyngeal T
• oropharyngeal - to keep mouth open and as
stick bite to protect ETT)
• Oxygenation to those with oxygenation failure
• Ventilation with knowledge to operate ventilator machine.
• Chest percussion and assist coughing.
OTHER CONDITIONS

• VAP(Ventilation association pneumonia) Prevention

- Bed elevation 35 – 45 degree also limit aspiration risk
- Mouth wash with chlorohexidine
- Sedation interruption(holiday) and check for possible EXTUBATION.
HEAD OF BED ELEVATION
CARDIOVASCULAR ASSESSMENT

• BP, PR, Peripheral perfusion

• capillary refill, oedema(sites),
• cardiac rhythm, new cardiac murmur
• skin condition:-color, turgor , texture.
• Urine output,
• Prolonged immobilization may cause postural hypotension, tilt of bed may be
beneficial prior to mobilization
CONT:

• Regular assess fluid and electrolyte balance

• Deep venous thrombosis DVT prophylaxis to prevent DVT (due to trauma,
sepsis, surgery, immobility and predisposing to life threatening PE)
- Mechanical ( pneumatic pump, DVT compression Stockings)
- Chemical : LMWH, Unfractionated Heparine 5000 units sub Q bid , Clevane
40mg OD,
DVT COMPRESSION STOCKINGS
GASTROINTESTINAL/NUTRITIONAL
EVALUATION
• Abdomen(soft, hard, distension or tender),
• Bowel sounds(normal, hyperactive, hypoactive or absent),
• Is NPO or per NGT- insertion date,
• Assess nutrition requirement, type(oral/PN),
and amount (input and output)
• Vomitus- The supine position predispose to gastroesophageal reflux &
aspiration pneumonia
CONT: SITUATION

• Immobility is associated with gastric stasis and constipation – so gastric

stimulants and laxatives are also essential
• Mode of nutrition can be:
• (a)Parenteral nutrition- Indication e.g. Prolonged ileus, uncontrolled
vomiting, chronic diarrhea/malabsorption, GIT obstruction, short bowel
syndrome, NPO post op care
CONT . NUTRITIONAL CARE

• (b)Enteral feeding(EF) – method of delivery nutrients for GIT absorption

via:
-Nasogastric/nasoduodenal tube (4hly)- are
suitable for short term use eg. post op or
in critical care ventilation.
-Gastrotomy/jejunostomy tube – common to
pt’s whom long term feeding is anticipated eg.
those with upper GIT obstruction or surgery
GENITAL URINARY EVALUATION & CARE

• Urine output monitoring and notify/record for abnormal findings

• Foleys insertion date must be indicated as may cause infection if
prolonged days e.g. UTI
• Catheter should be changed every 7 days to a complete bed rest patient
NEUROMASCULAR EVALUATION & CARE

• Joint/muscle contracture and foot drops may occur

• Muscle atrophy/weakness may also occur(immobilization)
• Early ambulation or passive/active assisted mobilization are helpfully
(consult Physiotherapy)
• Splints to the joint may be required
COMFORT AND REASSURANCE

• Anxiety, discomfort and pain must be recognized and relieved with

reassurance, encourage patient & relative to express concerns.
• Primary source of anxiety for patient include the perceived or anticipated
threat to physical health, actual loss of control or body function and
environment that is foreign
• Clinical indicator for anxiety include agitation, increased BP, HR ,
restlessness
PAIN AND DISCOMFORT MANAGE,ENT
• Analgesic drug: Opiods eg fentanyl 100mg 6hly or PRN, Morphine 2mls
PRN(1mls + 9mls of water for inj)
• Sedation: to make pt calm and cooperate with mechanical ventilation and
other tube in situ.
eg. Midazolam 5mg 8 hourly, Propofol in a cont.
infusion to those with stable BP.
• PUD Prophylaxis- because of stress while on ventilation.
- Proton pump inhibitor
SKIN AND WOUND CARE

• Bed sore prevention by:

-change position 2hly, Air mattress use,
-bed making with change of wet sheets and
avoid wrinkles
-Check for presacral and heel pressure sores
-Patients to wear soft boots to protect heels
-Put soft padding under sacrum
• Aggressively treat early pressure sores & wound dressing.
CONTINUOUS & CLOSE MONITORING OF THE
PATIENT
• Continue monitoring of Patient and notify physician for abnormal changes.
-Hourly vital signs(BP, HR, PR, Temp, SPO2),
-Urine output,
- RBG ,
-ECG etc
GENERAL HYGIENE

• bed bath,
• mouth and eye care,
• DO NOT suction out the mouth and then use the same catheter to suction
the endotracheal tube
COMMUNICATION WITH RELATIVES

• Appropriate communication with family members about treatment,

procedures, patient recovery and patient response towards treatment
• For a well functional units each activities about pt should be informed to
the relatives to their knowledge level and informed conset must be
obtained.
ICU ENVIRONMENT

• The physical aspects of environment are contributing factors to patient recovery in

ICU.
- Regulate of atmospheric temperature, humidity, and air movement in the unit
- Adequate lighting
- Prevent excess noise in the unit
- Eliminate unpleasant odors
- Safe handling and disposal of biomedical wastes
- Control of visitor and keep privacy
- Proper placement of machine ,equipment and cleanliness (-5s and Kaizen)
CONCLUSION

• Incorporate the nurses in ICU Rounds

• Ask their opinion. Check on routine Nursing functions in a collegial way
—if you don’t care, they won’t care
• Its often the little things that lead to life threatening complications
• Provide total care prevent complication, provide psychological support to
patient & family members
REFERENCES

• M Takrouri. Intensive Care Unit. The Internet Journal of Health. 2019; 3(2).
• Guidelines for intensive care unit admission, discharge, and triage: Task Force of the American College of
Critical Care Medicine, Society of Critical Care Medicine. Crit Care Med. 2018;27(3):633-638.
• Marshall, J., Bosco, L., Adhikari, N., Connolly, B., Diaz, J., Dorman, T., Fowler, R., Meyfroidt, G.,
Nakagawa, S., Pelosi, P., Vincent, J., Vollman, K. and Zimmerman, J., 2017.
• What is an intensive care unit? A report of the task force of the World Federation of Societies of Intensive
and Critical Care Medicine. Journal of Critical Care, 37, pp.270-276.
• Sprigings, D., Chambers, J. and Sprigings, D., 2018. Acute Medicine. Hoboken, NJ: Wiley Blackwell.