Critical Care Nursing Archives - Page 2 of 3

Preventing Secondary Brain Injury

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Primary brain injury can only be prevented through education and health promotion, and surviving the initial head injury is only a small part of the battle for the patient with a brain injury. Preventing secondary brain injury is even more important since it may have a greater influence on the final outcome than the primary brain injury itself. Throughout this blogpost we will go through ways of preventing secondary brain injury as much as possible.

Causes of Secondary Brain Injury

Causes of secondary brain injury include:

hypoxia
hypotension
hypercapnia
acidaemia
anaemia
intracranial mass
hyperglycaemia OR hypoglycaemia
hyperthermia OR hypothermia

Preventing secondary brain injury is possible by preventing ALL mentioned causes through early treatment
Most causes mentioned are related to raised ICP – Intracranial Pressure

The Monro-Kellie Hypothesis

The Monro-Kellie hypothesis states that the total volumes of brain (approximately 80%), CSF (approximately 10%) and intracerebral blood (approximately 10%) are constant. The cavity in which these three are housed a.k.a. the cranial cavity, is not able to expand, and so, an increase in one should cause a decrease in one or both of the remaining two. This ensures that the total volume of the three components remains fixed, and that no rise in ICP is caused.

ICP (Intracranial Pressure) is the pressure exerted by the intracranial contents against the skull. The brain normally is able to tolerate a significant increase in intracranial volume WITHOUT increasing much the ICP. If, however, this normal compensation mechanism becomes exhausted and the compliance limit is exceeded, an increase in ICP becomes imminent.

NOTE: an increase in ICP causes changes within the patient’s Vital Signs.

In normal circumstances, ICP is less than 10mmHg (in adults). If ICP increases to >20mmHg treatment is required!

preventing secondary brain injury — Retrieved from https://resources.wfsahq.org/atotw/cerebral-physiology-part-2-intracranial-pressure-anaesthesia-tutorial-of-the-week-71/ on 2nd January 2023

Signs of Increased ICP

unexplained changes in vital signs
cushing’s triad – isolated systolic hypertension, bradycardia, and altered breathing patterns
headache
nausea & vomiting
sensory deficits
impaired motor function
pupillary changes – if ICP >18mmHg
altered level of consciousness
decreased level of consciousness
seizures

Cushing’s Triad

Monitoring Intracranial Pressure

Monitoring ICP can be done through the use of:

ventriculostomy – intraventricular catheter
subarachnoid bolt or screw
subdural OR epidural catheter or sensor
fibreoptic transducer-tipped intraparenchymal catheter
non-invasive methods such as an automated IR pupillometry

Possible Causes of Increased ICP

Pathological Causes	Non-Pathological Causes
traumatic brain injury	coughing / sneezing
temperature	lifting / bending / body positioning
intra-thoracic pressure	stress / emotional responses
intra-abdominal pressure	pain
acidosis / hypoxia	blood pressure changes
lesions occupying space eg. bleeding, hydrocephalus, tumour, oedema, abscess, infection	valsalva manoeuvre

Factors affecting ICP

MAP : Mean Arterial Pressure – both hypertension and hypotension may raise ICP
Brain Trauma – expanding lesions increase ICP and may cause herniation a.k.a. brain matter displacement
CMR Changes – Changes in Cerebral Metabolic Rate may happen due to hyperthermia and increase in blood flow to meet demands, which leads to an increase in ICP
Conditions Causing Acidosis – results in cerebral vascular dilation such as hypoxia, ischaemia, and hypercapnia
Increased Intra-Thoracic / Intra-Abdominal Pressure – may happen during coughing or suctioning and due to high PEEP
Conditions Affecting Venous Return – pressure on jugular veins or patient positioning

Cerebral Perfusion Pressure

Cerebral Perfusion Pressure CPP is the difference between the MAP (Mean Arterial Pressure) and the ICP.

CPP = MAP – ICP

Ideally, CPP should be between 50-70mmHg, as this ensures an adequate blood supply to the brain. On the other hand, ICP should be approximately 10mmHg.

A decrease in CPP or rise in ICP may cause ischaemia, neuronal hypoxia, and even death.

NOTE: if MAP = ICP, cerebral blood flow may cease.

Preventing Rise in Intracranial Pressure

1. Control of Vital Signs

HYPOTENSION reduces oxygen and nutrient perfusion; CPP = MAP – ICP; aim for MAP of >80mmHg to ensure CPP of >60mmHg with ICP of 20mmHg; to increase blood pressure administer fluids and vasopressors.
HYPERTENSION may result following interventions or due to decreased cerebral perfusion; sedatives may help avoid blood pressure from increasing during procedures; primary anti-hypertensives such as beta blockers can be administered, but only if ICP is monitored, OR SBP is >180mmHg, OR MAP is >110mmHg; AVOID vasodilators as these increase ICP.

2. Ventilation

HYPERCAPNIA causes vasodilation – a 30% increase in cerebral blood flow leads to a 10mmHg increase in PaCO2, which raises ICP.
HYPOCAPNIA causes vasoconstriction, which in return reduces cerebral blood volume and ICP, leading to ischaemia.
HYPOXIA causes cerebral vasodilation, leading to an increased intracranial blood volume and increased ICP (high levels of PaO2 have not shown evidence of any affect on CBF).
GOOD OXYGENATION should be maintained (ideal SPO2 of >95% and PaO2 of >80mmHg), if needed, through intubation and mechanical ventilation. IMPORTANT – avoid high tidal volume (as this may cause acute lung injury) and use a low level of PEEP (5-8mmHg) to maintain good oxygenation.
pH BALANCE should be maintained between 7.35 and 7.45
AIM FOR LOW NORMAL PaCO2 (approx. 35mmHg) – although hyperventilation may be required temporarily to reduce cerebral vasodilation and enhance venous return; AVOID LOW PaCO2 as excessive vasoconstriction leads to ischaemia, restricting oxygen supply to the injured area, leading to an increase in damage.

Relationship between CBF and PaC02 (1st image) & Relationship between CBF and PaO 2 showing almost no effect on CBF in the
normoxaemic range (2nd image); CBF increases if PaO 2 is less than 50mmHg. – Retrieved from https://www.frca.co.uk/Documents/170907%20Cerebral%20physiology%20I.pdf on 3rd January 2023

3. Patient Positioning

ELEVATE HEAD OF BED to about 30% – patient’s neck should be3 kept midline; gravity promotes CSF and venous drainage, resulting in a lowered ICP; NOTE: evidence as to whether or not bed elevation may lower CPP has been inconclusive in a recent systematic review (Alarcon et al., 2017).
VENOUS RETURN OBSTRUCTION causes an increased ICP due to factors such as head rotation to one side, extreme flexion of arms and hips, neck angulation and pressure on jugular veins (eg. from tight ETT tie or lateral positioning), trendelburg positioning, and prone positioning.

4. Procedures & Environmental Factors

SUCTIONING
RAPID POSITION CHANGES
PAIN & COUGHING
VENEPUNCTURE
REMOVING ADHESIVE TAPE
USE OF BEDPANS/ENEMA

AVOID ACTIVITY CLUSTERING and instead promote resting periods between procedures mentioned above. If needed, a short acting sedative may be administered as a bolus prior to the procedure.
AVOID UNNECESSARY INSTRUMENTAL TOUCH & PAINFUL PROCEDURES
REDUCE LIGHTING in the patient’s room
REDUCE UNNECESSARY ENVIRONMENTAL NOISE such as unneeded alarms – set appropriately and in relation to the patient’s norms
SUCTIONING increases intra-thoracic pressure, impedes venous return and increases ICP; hypoxia may lead to cerebral ischaemia. Reduce impact on the patient by providing hyperoxygenation before and/or after the procedure, hyperventilating, suctioning using a closed suction system, limiting the frequency and the duration of suctioning, administering a sedation bolus, or Lignocaine IV or via Tracheal Tube.

NOTE: Some studies have shown that the presence, touch, and voice of patient relatives may help decrease ICP. Other unrelated studies have also shown that oral hygiene, bed bathing, catheter care and chest percussion do not result in a significant rise in ICP.

Retrieved from http://www.learnpicu.com/neurology/ICP (left image) & http://pedsccm.org/FILE-CABINET/head_trauma/sld028.htm (right image) on 3rd January 2023

5. Sedation & Analgesia

SEDATIVES, MUSCLE RELAXANTS & ANALGESICS can help reduce the effects of unpleasant procedures; Sedatives administered are usually opioids or benzodiazepines; Muscle relaxants should be avoided if possible, and should they be administered, ensure that the patient is sedated first.
ADEQUATE VENTILATION may also be achieved through the effect of sedation and analgesia.
ATTENTION!! Sedation and Analgesia may affect the MAP, leading to an affect on the CPP (cerebral perfusion pressure), thus, ensure adequate fluid volume. Similarly, sedation and analgesia may also mask certain aspects related to the neuro assessment, thus, for a patient on such medication, rely more on pupillary reaction rather than the neuro assessment.

6. Fluid Management

In relation to OSMOTIC THERAPY, large molecules (eg. Mannitol) or Hyperosmolar solution (eg. hypertonic saline, which is considered to be superior and with less side effects) remain in circulation, increasing osmolarity. For osmosis to happen, an intact blood-brain-barrier is required, where fluid is drawn from diluted areas to more concentrated areas (from extracellular to intravascular space). This reduces cerebral oedema whilst improving blood flow.
When administering osmotic therapy, CAREFUL MONITORING is required – monitor electrolyte levels especially Potassium and Sodium; replace fluid as necessary to avoid hypovolaemia; serum osmolarity should not exceed 320mOsm/L…higher levels may induce pulmonary oedema or rebound cerebral oedema.
HYPERTHERMIA, unless infection is involved, may be induced by localised damage in the thermoregulatory centre within the hypothalamus. A 1°C rise in body temperature causes 6-10% increase in cerebral metabolic rate, increased oxygen demand, increased blood flow and volume due to vasodilation, and increased ICP. IMPORTANT: monitor the patient’s body temperature and help cooling by removing any extra blankets and administering antipyretics.
THERAPEUTIC HYPOTHERMIA may reduce ICP, however, evidence of improved survival is still inconclusive to date. Additionally, avoid rapid cooling as shivering raises ICP, thus, should be prevented.

7. Seizure Control

POST-TRAUMATIC SEIZURES happen in 5% of patients with head injuries.
Seizures increase CEREBRAL METABOLIC DEMANDS: increased blood flow causes an increase in ICP; if flow doesn’t meet the cerebral metabolic demands, the patient experiences ischaemia and neuronal destruction.
PHENYTOIN is considered to be an effective medication in the prevention of early seizures (always monitor serum levels when administering).

8. Nutrition & Elimination

PROTEIN is very much required by a hypermetabolic brain.
STRESS ULCER PROPHYLAXIS is commonly administered to patients with an increased risk of stress-related mucosal bleeding from the upper gastrointestinal tract. Apart from administering early enteral feeding, ideally through an orogastric tube, administer pharmacological prophylaxis such as H2-blockers, proton-pump inhibitors, or sucralfate.
Attempt to maintain NORMOGLYCAEMIA – hyperglycaemia is associated with increased ICP, while hypoglycaemia is associated with aggravated brain injury. It’s also important to mention that intensive insulin therapy does not improve outcome, and may actually worsen the patient’s condition and prognosis.
STOOL SOFTENERS may be required especially if the patient is constipated, since constipation increases intra-abdominal pressure and ICP.
GASTRIC DECOMPRESSION is intended for patientS with gastric distention receiving aggressive ventilatory resuscitative measures prior to intubation. A NG tube may be used to perform gastric decompression for the patient with known or suspected gastric distension. Check tube placement. Attach suction or a large syringe and evacuate the stomach.NOTE: for patients with facial trauma use an orogastric tube instead.

In Summary…

List of Interventions to Minimise ICP

1. AIRWAY & VENTILATION

monitor pH, pCO2 and pO2
if GCS <9 ensure early intubation and mechanical ventilation
avoid tight ETT or Tracheostomy ties
avoid high PEEP
suction only when necessary
keep head elevated and aligned
provide mouth care to eliminate oral secretions
perform gastric decompression

2. ICP & CPP

prevent rise in ICP
prevent drop in CPP
remember: CPP = MAP – ICP
mannitol or furosemide may be administrated to reduce intracellular volume
hypertonic saline reduces cerebral oedema whilst improving blood flow

3. NEUROLOGICAL & HAEMODYNAMIC MONITORING

avoid drops in the patient’s blood pressure
monitor the patient neurological status through the Glasgow Coma Scale and Pupil Reactivity

4. NUTRITION & FLUIDS

ensure adequate nutrition and fluid intake as indicated
fluid restriction may be indicated so as to prevent an increase in ICP
monitor the patient’s electrolytes
an adequate MAP can be achieved through administration of normal saline +/- inotropes
monitor for diabetes insipidus (a rare condition which causes increased urination (polyuria) and increased thirst (polydipsia); Diabetes Insipidus is not related to type 1 or type 2 diabetes)

5. PREVENTION

prevent hyperthermia
prevent hyperglycaemia
prevent hypoglycaemia
prevent seizures
prevent pain
prevent anxiety
prevent venous thromboembolism VTE

6. NEUROLOGICAL INTERVENTIONS

an expanding haematoma may require ventriculostomy for CSF drainage and ICP monitoring
craniectomy may also be indicated if an increase in space is required

7. PATIENT SAFETY

ensure patient safety at all times

8. PSYCHOSOCIAL CARE

promote congnitive function
provide support to the patient’s relatives
provide health literacy and rehabilitation advice to the patient and relatives

References

Alarcon, J. D., Rubiano, A. M., Okonkwo, D. O., Alarcón, J., Martinez-Zapata, M. J., Urrútia, G., & Bonfill Cosp, X. (2017). Elevation of the head during intensive care management in people with severe traumatic brain injury. The Cochrane database of systematic reviews, 12(12), CD009986. https://doi.org/10.1002/14651858.CD009986.pub2

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Performing a Neurological Assessment – GCS & Pupillary Reaction

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Performing a Neurological Assessment

When performing a neurological assessment, one would be assessing the nervous system for the purpose of identifying abnormalities affecting the activities of daily living. The Glasgow Coma Scale (GCS) is an assessment tool which can objectively describe the extent of consciousness impairment incurred by acute medical and trauma patients. Similarly, pupillary reaction is assessed as an attempt to trigger a normal physiological response to the size of the pupil via the optic and oculomotor cranial nerve.

The Glasgow Coma Scale GCS Neurological Assessment

Through the use of the Glasgow Coma Scale GCS the nurse assesses the patient’s level of consciousness in a way that determines the degree of stimulation required to elicit a response.

the GCS is based on 3 modes of behaviour, namely Eye Opening, Verbal Response, and Motor Response
the GCS’s overall score should not be used alone in determining clinical findings, and must be combined with Pupillary Reaction and Vital Signs
the patient can score from 3 to 15, with 15 being the best score possible, and 3 being the least score possible; a patient with a score of <9 is considered to be severe, requiring an ETT
repeated observations indicate static, improving, or worsening of the patient’s neurological condition
action must be taken even if minor changes are noted

Retrieved from https://www.firstaidforfree.com/glasgow-coma-scale-gcs-first-aiders/ on 29th December 2022

neurological assessment — Retrieved from https://standardofcare.com/abnormal-posturing/ on 29th December 2022

Structured GCS Assessment

#1 – CHECK

identify factors which may interfere with assessment such as pre-existing factors (eg. language barrier, intellectual deficits), effects of current treatment (eg. sedation or tracheostomy), and effects of pre-incurred injuries (eg. cranial fracture or spinal cord damage)
if any of the above factors are determined, NT (Not Testable) should be recorded, and no total score should be listed

#2 – OBSERVE

observe patient for evidence of spontaneous behaviour
if no spontaneous behaviour is noted, observe behaviour in response to stimulation

#3 – STIMULATE

try to illicit a response by increasing the stimulus intensity gradually
for auditory stimulus, speak, and if needed, shout, using the patient’s preferred name
for physical stimulus to illicit eye opening, use a peripheral method by pressing on the distal part of the patient’s fingernail, increasing the intensity for up to 10 seconds
for physical stimulus to illicit localisation, use central methods such as the trapezius pinch or the supra-orbital notch pressure
AVOID sternal rub since this method can cause bruising to the patient!

#4 – RATE

if during your initial ‘check’ you determine that certain domains are not testable, document as NT and do not list total score
determine if top criteria is met based on observation – if yes, document appropriately; if no, attempt to illicit a response through stimulus as mentioned above
in relation to motor response, different responses between the left and right side (arms or legs) of the patient, document the best response
different responses between the peripheral stimulus and central stimulus, document the response stimulated centrally

NOTE:

EYE OPENING aim is to assess brain stem function
VERBAL RESPONSE aim is to assess interpretative speech and language area in the temporal lobe within the brain
MOTOR RESPONSE aim is to ascertain whether the cerebral cortex can interpret sensory messages and translate them to a motor response

Retrieved from https://www.physio-pedia.com/Glasgow_Coma_Scale on 29th December 2022

For more information about the Glasgow Coma Scale please visit https://www.glasgowcomascale.org/

Pupillary Reaction

In the Critical Care setting, the eyes are considered to be a ‘window to the brain’.

pupillary reaction to light may be brisk, sluggish, or fixed
sluggish, suddenly dilating, or unequal pupils may indicate compression of oculomotor cranial nerve (3rd), and/or compressed brain stem due to oedema or haematoma worsening; urgent intervention may improve outcome
pinpoint pupils may indicate narcotic/opioid use

NOTE: certain eye drops such as Atropine may dilate pupils.

Additional Signs & Symptoms

Autonomic Dysfunction a.k.a. Dysautonomia – happens when the autonomic nervous system, which controls functions responsible for wellbeing and maintaining balance, does not regulate properly; signs include hypertension and hyperpyrexia
Persistent Vegetative State – a state of ‘eyes-open unresponsiveness’ in patients in a coma for 30 days or more; it is considered to be a chronic disorder in which a patient with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings
Prolonged Unconsciousness a.k.a. Coma – a prolonged state of unconsciousness during which a person is unresponsive to their surrounding environment; while the patient is alive and looks like they are sleeping, they cannot be awakened by any stimulation, including pain

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Head Injury Nursing Care of the Patient in ICU

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Head Injury is a phrase referring to a vast array of injuries occurring to the scalp, skull, brain, or the underlying tissue and blood vessels within the head. Based on the extent of the head trauma, a head injury is commonly referred to as brain injury or traumatic brain injury. Head injury nursing care varies according to the cause, damage and complications.

The Parietal and Temporal bones are more likely to fracture in a head injury. And since the brain is quite soft in texture, a cranium injury can easily be the cause of a brain injury.

Retrieved from https://twitter.com/medillustrates/status/1347603734508015617?lang=fr on 26th December 2022

The Meninges

The meninges consist of three membranous connective tissue which enclose the brain, namely the pia mater, arachnoid mater and dura mater.

PAD – the 3 layers of the brain = Pia Mater, Arachnoid Mater, and Dura Mater.

Retrieved from http://treattheathlete.com/head/meninges/ on 26th December 2022

Cerebral Blood Flow

The brain has high metabolic demands. It depends on ongoing energy/glucose which can be supplied through continuous blood flow, especially since it does not store any glucose itself. Blood is supplied to the brain through 4 arteries which are fused together, forming the Circle of Willis.

the brain amounts to not more than 2% of the total body weight
the brain requires between 15 to 20% of resting cardiac output (50ml/100g of brain tissue per minute which amounts to 700ml/min in an individual weighing 70kgs)
the brain requires 15% of the body’s total oxygen demand
the brain doesn’t store glucose, and doesn’t have any glycogen stores
the brain doesn’t tolerate hypoperfusion

Retrieved from https://www.vedantu.com/question-answer/the-amount-of-blood-supplied-to-the-brain-per-class-10-biology-cbse-5f4cbf7956e9d4741097efd0 on 26th December 2022

Traumatic Brain Injury

A traumatic brain injury refers to a blunt or penetrating head injury which disrupts the brain from functioning in its normal way, causing impaired thinking and memory, personality changes, and sometimes sensory and motor changes.

A traumatic brain injury can be classified as either Primary or Secondary, as listed below…

Primary Brain Injury	Secondary Brain Injury
*– damage incurred at the time of injury*	*– complications following initial injury*
– cerebral laceration	– hypoxia / ischaemia
– concussion / contusion	– brain oedema
– skull fractures	– brain herniation
– intracranial bleeding	– intracranial hypertension
– diffuse axonal injury	– CSF leak and infection

A primary brain injury can only be prevented through education and health promotion, whilst a secondary brain injury can be prevented from a clinical point of view.

Primary Brain Injury

Focal Injuries:

affect specific brain locations as in cerebral contusion (scattered areas of bleeding on the brain’s surface, commonly located along the under-surface and poles of the frontal and temporal lobes), laceration, or intracranial haemorrhage (bleeding into the brain tissue – can be classified as Epidural Haematoma, Subdural Haematoma, Subarachnoid Haemorrhage, or Intracerebral Haemorrhage)

Diffuse Injuries (diffused/spread injuries):

concussion (caused by a bump, blow, or jolt to the head, or by a hit to the body which causes the head and brain to move rapidly back and forth)
moderate to severe Diffuse Axonal Injury (shearing of the brain’s long connecting nerve fibers a.k.a. axons, which happens when the brain is injured through shifting or rotating inside the skull; DAI commonly causes coma and injury to many different parts of the brain)

head injury nursing care — Retrieved from https://www.physio-pedia.com/Classification_of_Traumatic_Brain_Injury on 26th December 2022

Cerebral Contusion ~ Focal Injury

Cerebral Contusion refers to scattered areas of bleeding on the brain’s surface, commonly located along the under-surface and poles of the frontal and temporal lobes. This is typically caused by coup and/or contrecoup injuries, happening by:

blunt trauma to the brain tissue
bruising of the brain due to capillary bleeding into superficial brain tissue, typically in the frontal or temporal bone areas of the skull

Cerebral Contusion signs & symptoms may include:

confusion
neurological deficit (featuring changes related to personality or speech and vision)

Cranial Fracture ~ Focal Injury

Types of cranial fractures include:

Linear Fracture – a thin-line break in a cranial bone, without any splintering, depression, or distortion of bone; in a linear fracture, the dura mater remains intact
Depressed Fracture – a break in the cranial bone or a crushed part on the skull with depression of the cranial bone toward the brain
Open Fracture – an injury in which the fractured bone or haematoma are exposed to the external environment due to a traumatic violation of the soft tissue and skin; the wound may lie at a site distant to the fracture, not directly over the fracture itself
Impaled Object – an injury in which an object remains impaled into the cranium eg. a bullet or knife; it is crucial that no one attempts to remove an impaled object unless in a healthcare facility where emergencies can be attended to

Base of skull fracture a.k.a. basilar skull fracture ~ Focal Injury

Typical signs of a base of skull fracture include:

Raccoon Eyes – unilateral and/or bilateral periorbital ecchymosis
Battle’s Sign – unilateral retro-auricular / mastoid ecchymosis
Haematotympanum – blood behind the ear drum
Halo’s Sign – a fracture located at the base of the skull may lead to blood or CSF leakage, or both, from the nose (rhinorrhoea) and/or the ear (otorhoea); CSF is a straw-coloured fluid which typically produces the ‘halo sign’

Retrieved from https://www.semanticscholar.org/paper/Periorbital-Ecchymosis-%28Raccoon-Eye%29-and-Orbital-Nasiri-Zamani/0337e88c6d4e2ff8d234edc189bee96dc2bdaca3, https://25hournews.com/news/the-battle-sign-that-appears-behind-the-ears-3000 & https://onlinelibrary.wiley.com/doi/pdf/10.1197/j.aem.2003.09.004 on 26th December 2022

Basilar Skull Fracture Head Injury Nursing Care

DO NOT perform nasal suctioning
DO NOT attempt to insert a NGT
If a gastric tube is indicated, it is better to insert an orogastric tube instead. The risk is higher with NGT insertion than with an orogastric tube because the roof of the nasal cavity is practically shared with the base of the skull
DO NOT plug bleeding site – instead wipe drainage with a sterile swab
Instruct patient to perform NO STRAINING and NO VALSALVA (breathing method that may slow the heart during tachycardia)
QUERY SURGERY – if indicated, surgery may be attempted to seal CSF leak, repair damaged vessel/s or relieve ICP

Complications:

brain injury
cranial nerve palsy
blood vessel injury
CSF leak (may lead to infection: meningitis)

Intracranial Bleed ~ Focal Injury

Risk factors for intracranial bleeds include:

basilar skull fracture
older age
previous neurosurgery
use of anticoagulants
blood clotting disorders
history of loss of consciousness
retrograde amnesia (amnesia where one cannot recall memories formed before the event which caused the amnesia)
anterograde amnesia (memory loss which occurs when one cannot form new memories, permanently losing the ability to learn or retain new information)

Epidural Haematoma ~ Focal Injury

FACTS:

bleeding is located between the skull and the dura mater
commonly results from a temporal bone fracture
commonly involves arterial bleeding, usually from the middle meningeal artery
typically features a ‘lucid interval’, which is a temporary improvement in the patient’s condition after a traumatic brain injury, following which fast deterioration occurs
if left undrained may displace brain into foramen magnum
requires immediate surgery

CT SCAN FEATURES:

edges are sharply defined
convex or lens-shaped appearance
the dura strips from the cranium’s under-surface, causing the haematoma to assume its shape
the ventricular system’s midline shifts to the side opposite the haematoma

Retrieved from https://radiopaedia.org/cases/epidural-haematoma-4 on 27th December 2022

Subdural Haematoma ~ Focal Injury

FACTS:

venous bleed occurs between the dura mater and the arachnoid mater, within the meninges
bleed may be acute, sub-acute, or chronic
neurological deterioration progresses slowly
risk factors include trauma, hypertension, anticoagulant use, and alcohol abuse
- excessive blood is usually drained by an extravascular catheter

CT SCAN FEATURES:

an acute subdural haematoma presents in a crescent shape, covering the entire brain surface
prognosis for an acute subdural haematoma is worse than that of an epidural haematoma, with underlying brain damage typically being more severe
rapid surgical evacuation is required especially in the case of >5mm midline shift and raised intracranial pressure

Acute-on-Chronic Subdural Haematoma – Retrieved from https://radiopaedia.org/cases/acute-on-chronic-subdural-haematoma-1 on 27th December 2022

Subarachnoid Haemorrhage ~ Focal Injury

FACTS:

blood pooling is located in the subarachnoid space, between the arachnoid membrane and the pia mater
bleeding happens spontaneously through ruptured aneurism, trauma, or hypertension
a common sign of a subarachnoid haemorrhage is a ‘thunderclap headache’ – a headache that strikes suddenly like a clap of thunder as the name implies

CT SCAN FEATURES:

in a CT scan, a subarachnoid haemorrhage appears as a high-attenuating, amorphous substance that fills the normally dark, CSF-filled subarachnoid spaces around the brain

ATTENTION!!

avoid an increase in intracranial pressure
explore possibility of surgery for haematoma drainage
explore possibility of surgery for aneurism clipping

Retrieved from https://en.wikipedia.org/wiki/Subarachnoid_hemorrhage on 27th December 2022

Intracerebral Haemorrhage A.k.a. intraparenchymal cerebral haemorrhage ~ Focal Injury

FACTS:

blood pooling caused by rupture of a blood vessel within the brain tissue – the cerebrum
may be a spontaneous rupture as in a CVA
may be caused by a traumatic event as in a penetrating injury, depressed skull fracture, contusion, or laceration
signs and symptoms are similar to that of a stroke
prognosis depends on the size and location of the intracerebral haemorrhage, however, this type of haemorrhage carries a high mortality rate

CT SCAN FEATURES:

a CT scan of an Intracerebral Haemorrhage features a hyper-dense collection of blood, commonly surrounded by hypo-dense oedema
complications such as extension of the haemorrhage into other intracranial compartments may also be present

Concussion ~ Diffuse Injury

FACTS:

the brain remains structurally intact when a concussion is incurred
transient loss of consciousness may take from a couple of seconds to hours
concussion prognosis is commonly a complete recovery without treatment

SIGNS & SYMPTOMS:

mild headache
dizziness
lethargy
irritability
poor concentration
confusion / disorientation
post-traumatic amnesia

Severe Diffuse Axonal Injury

FACTS:

shearing and tearing of axons in the cerebral hemispheres and brainstem usually result from rapid deceleration
damage is on a microscopic scale, thus is usually invisible in tests
symptoms include coma, persistent vegetative state, and abnormal posture
severe diffuse axonal injury carries a high mortality rate

Secondary Brain Injury

As previously mentioned, a primary brain injury can only be prevented through education and health promotion, whilst a secondary brain injury can be prevented from a clinical point of view.

For this reason, another blogpost focusing on secondary brain injury prevention will be published in the upcoming days. Subscribe below to receive notification of newly published blogposts in your inbox 😉

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Pulmonary Oedema Nursing Care of the Critically Ill Patient

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Pulmonary Oedema refers to an accumulation of fluid in the interstitial spaces of the lungs that diffuses into the alveoli. This accumulation causes severe hypoxia. Thus, in pulmonary oedema nursing care, the patient’s oxygenation needs are prioritised.

Pulmonary Circulation VS Systemic Circulation

Pulmonary Oedema Pathophysiology

excess vascular water fills the interstitium
interstitial lymphatics situated within the pulmonary system are unable to drain excess water
alveolar spaces flood and become unable to perform gas exchange due to ventilation/perfusion (V/Q) mismatch

RIGHT SIDE Heart Failure = Peripheral Oedema

LEFT SIDE Heart Failure = Pulmonary Oedema

Retrieved from https://www.otsuka.co.jp/en/health-and-illness/heart-failure/symptoms/ on 19th December 2022

Cardiogenic Pulmonary Oedema VS Non-Cardiogenic Pulmonary Oedema

Pulmonary oedema can be Cardiogenic Pulmonary Oedema a.k.a. Hydrostatic (pressure-related), Non-Cardiogenic Pulmonary Oedema (increased permeability), or a combination of both.

Cardiogenic Pulmonary Oedema a.k.a. Hydrostatic Oedema happens due to increased left ventricular filling pressure.

Non-Cardiogenic Pulmonary Oedema happens in the absence of elevated left ventricular pressure.

Pulmonary Oedema Signs & Symptoms + Radiographic Features

Pulmonary Oedema signs and symptoms onset is usually sudden, requiring immediate medical attention, usually due to intense dyspnoea resulting from the sudden V/Q Mismatch (happens when part of the lung receives oxygen without blood flow or blood flow without oxygen – respiratory reserve can help continue/preserve perfusion in V/Q mismatch, but only for a limited time), which leads to the patient becoming anxious and scared. Noisy respirations are also present due to secretions within the larynx and trachea. The patient’s skin becomes moist, cold and clammy – signs of shock.

Cyanosis develops rapidly in the late stage of respiratory failure. The patient develops a cough with copious frothy blood-stained sputum. Crepitations are heard throughout the chest on auscultation. A chest x-ray typically features a bat-like picture of the lungs. Note that a chest x-ray featuring pneumonia is very similar to one featuring pulmonary oedema, thus, in critical care it is important to distinguish between the two.

Full list of signs & symptoms of pulmonary oedema includes:

restlessness
anxiety
breathlessness
sense of suffocation
cyanotic nail beds
greyish skin tone
cold and moist hands
weak and rapid pulse
jugular vein distension
coughing
increasing foamy sputum
confusion and stuporous (as pulmonary oedema progresses)
rapid noisy moist-sounding breathing
significant decrease in oxygen saturation level
assessment includes crackles on auscultation

Retrieved from https://twitter.com/onsquares/status/1346344297214447616 on 18th December 2022

Cardiogenic Pulmonary Oedema Causes

Congestive Heart Failure (CHF) – the heart muscle doesn’t pump enough blood as it should, causing blood to back up, leading to fluid build-up in the lungs
Mitral Stenosis – narrowing of the valve between the two left heart chambers which reduces or blocks the blood flow into the heart’s left ventricle, leading to left-sided heart failure
Cor Pulmonale – a condition that causes the right side of the heart to fail
Myocardial Infarction a.k.a. heart attack – when blood flow to the heart muscle is blocked

Non-Cardiogenic Pulmonary Oedema Causes

Acute Respiratory Distress Syndrome – ARDS occurs when fluid builds up in the alveoli, keeping the lungs from filling with enough air; less oxygen reaches the bloodstream, depriving the organs of much needed oxygen to function adequately
Smoke Inhalation Burns

Pulmonary Oedema Nursing Care

record and monitor vital signs
administer high oxygen concentration to relieve cyanosis
position patient in an upright position or with legs and feet down or ideally dangling over the side of bed to promote better circulation – correct positioning increases the vital capacity of the patient’s lungs
reassure patient to reduce anxiety – do not leave patient alone
morphine can be administered to help further with the reduction of anxiety, as well as dilating peripheral circulation leading to a reduction in left ventricular pressure during diastole; IMPORTANT – morphine can depress the respiratory system, so never leave patient unattended
administer diuretics – monitor for medication effects including patient’s fluid and electrolyte levels; diuretics, especially if loop diuretics are administered, waste potassium and sodium; potassium administration may be required
bronchodilators can be used to relieve bronchospasm and facilitate bronchial toilet a.k.a. toilet bronchoscopy – a potentially therapeutic intervention to aspirate retained secretions within the endotracheal tube and airways and revert atelectasis; aspiration of airway secretions is the most common indication to perform a therapeutic bronchoscopy in the intensive care unit (ICU)
patients with pulmonary oedema are at times electively ventilated so that through PEEP,t further water leakage into the alveoli may be prevented
identify and treat primary cause eg. need for mitral valve prosthesis, opening blocked arteries etc.

NOTE: intubation and mechanical ventilation may be required if the patient’s condition worsens; haemodynamic monitoring (BP and PAWP) and ABGs act as guidance in artificial ventilation management.

NOTE: PAWP refers to Pulmonary Artery Wedge Pressure which is the pressure within the pulmonary arterial system that occurs when catheter tip ‘wedges’ in the tapering branch of one of the pulmonary arteries.

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Ventilated Patient Nursing Care in the ICU

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Ventilated patient nursing care requires a lot of observation, preparation and monitoring. This is not just specific to monitor readings…the patient needs to be evaluated as a whole in conjunction to the readings being provided.

Safety Checks

When working in a critical care setting, at the beginning of each shift:

check that the manual ventilation bag is connected to oxygen supply
check that the suctioning equipment is in good working order
check for availability of equipment and drugs required for re-intubation and resuscitation
check that the ventilator settings are the same as documented and mentioned in handover

Whenever you move or turn your patient:

check that the endotracheal tube or the tracheostomy tube are secure
check that any other catheters/lines are in place and still secure

Constant safety checks:

monitor the patient’s haemodynamic stability
monitor the patient’s respiratory stability
ensure that alarms are set sensibly
DO NOT IGNORE ALARMS!

Airway Management of the Ventilated Patient

Ventilated patient nursing care includes:

care of the endotracheal tube or tracheostomy
humidification
suctioning
cuff pressure management
patient communication
patient swallowing ability
weaning from mechanical ventilation

Ventilated Patient Monitoring

Ventilated patient monitoring is crucial, especially since deterioration can happen fast. Monitoring requirements include monitoring the patient’s:

haemodynamic stability
pulse oxymetry
capnography
level of consciousness
pain and agitation

Sedation and Analgesia

A ventilated patient can benefit from sedation and/or analgesia since these:

provide the patient with comfort and tube tolerance
reduce oxygen consumption by promoting patient-ventilator synchronisation whilst reducing dyspnoea and anxiety
reduce the risk of complications such as self-extubation and laryngeal damage
reduce the need of muscle relaxants

NOTE: Muscle relaxants may still be necessary in patients with head injuries and/or with excessive airway pressure; when administering muscle relaxants ensure that the patient is fully sedated.

sedation disadvantages

vasodilation – patient may need IV fluids and inotropes eg. norepinephrine, epinephrine, and vasopressin
sedative accumulation – sedatives with long half-life are not ideal for patients with hepatic or renal failure
over-sedation – prolongs ventilation period and lengthens the patient’s stay in the critical care setting

NOTE: sedation breaks may lead to shorter duration of mechanical ventilation and shorter stay in the critical care setting.

NOTE: sedation scores such as the Ramsay Sedation Scale, the Richmond Agitation-Sedation Scale (RASS), and the Nursing Instrument for the Communication of Sedation (NICS) can help prevent over-sedation.

Retrieved from https://ebrary.net/40984/health/sedation_assessment_with_subjective_methods on 12th December 2022

Analgosedation

Retrieved from https://healthmanagement.org/c/icu/issuearticle/sedation-and-analgesia on 12th December 2022

Patient Comfort Guidance

E-CASH – early comfort with the use of analgesia, minimum sedation and maximum care.

ABCDEF BUNDLE:

A = ASSESS, prevent, and manage pain
B = BOTH Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)
C = CHOICE of analgesia and sedation
D = DELIRIUM – assess, prevent and manage
E = EARLY mobility and exercise
F = FAMILY engagement and empowerment

Ventilated Patient Personal Care

Mouth Care

clean patient’s teeth using a small soft toothbrush and toothpaste twice daily
use antiseptic liquid or gel between brushing for oral cleansing and moisturising; this helps prevent plaque formation whilst reducing oral colonisation of Gram-negative bacteria and resulting respiratory infections
provide frequent oropharyngeal suctioning for the hypersalivating patient due to endotracheal tube use; this reduces the risk of central line contamination and risk of micro-aspiration

Eye Care

provide artificial eye lubricant (methyl cellulose) – a patient on sedation loses the blink reflex, making the eyes exposed to corneal drying, infection, abrasion and dust
apply eye pads and/or tape if required
assess regularly for infection and conjunctival oedema

Nutritional Care

While the patient is Nil-By-Mouth, a nasogastric tube is usually used so that abdominal distension is prevented, since it hinders ventilation.

ensure that the patient is started on enteral nutrition early since this promotes gut integrity whilst reducing GI complications; it also helps provide the patient with caloric and protein required for mechanical ventilation, prevents muscle atrophy, as well as helps during the weaning process
prop the patient up in a semi-raised position to prevent aspiration; aspirate the patient’s stomach regularly to assess absorption
assess for need of a PEG or TPN
stress ulcer prophylaxis may be prescribed

Elimination & Related Care

document patient intake and output on proper charting sheets to ensure patient fluid and electrolyte balance; document any abnormal stools
constipation may result from use of drugs, diet changes and immobility, which may cause abdominal distension; to avoid problems with diaphragmatic and ventilatory capacity consider using glycerin suppositories and enemas
diarrhoea may result from antibiotic resistance and enteral feed intolerance; take stool specimens for culture and sensitivity testing and Cl. difficile, apply barrier cream to prevent moisture lesion formation, and ensure fluid and electrolyte balance are maintained

Psychosocial Care

assist patient to use alternate means of communication since this is a common trigger for patient frustration
provide constant orientation and reassurance
provide health literacy to the patient’s family in simple terms free from medical jargon
involve relatives in patient care – encourage touch and patient reassurance, communication and orientation, and lip care

Patient positioning

ensure that no lines, wires and catheters are left under the patient
provide regular position changes for pressure relief and movement of secretions; this also helps provide a conscious patient with a different perspective of surroundings
splints, passive and active ROM (range of motion) exercises
ensure patient is seen by physiotherapist and that chest physio in the form of percussion, vibration, and postural drainage is provided (unless contraindicated as with neurological patients)
whenever possible help the patient into prone position since this optimises alveolar recruitment by expanding the dorsal aspect of the lungs, and improves oxygenation and survival in ARDS (acute respiratory distress syndrome) patients

NOTE: with prone positioning, caution needs to be exerted: ensure an adequate amount of personnel are available to reposition patient, ensure that the patient’s airway is protected at all times, ensure that the ETT, IV lines and tubes are all secure, ensure adequate pressure area care, and provision of mouth and eye care as well as suctioning as required.

The HOTSPUD Ventilator Care Bundle

Head of bed elevated 30-45 degrees
Oral care performed frequently
Turn patient from side to back to side every 2 hours
Sedation vacation – adjust sedation so as to wake patient up once every 24 hours
Peptic Ulcer prophylaxis to be administered to high risk patients
Deep vein thrombosis prophylaxis in the form of drugs or leg compression

Other Ventilation Strategies

ECMO – Extra-Corporeal membrane oxygenation

blood oxygenation outside of the body
allows lung rest without exposure to high pressure oxygen levels

Permissive Hypercapnia

tolerate higher carbon dioxide levels to provide protection to the lung from barotrauma

High Frequency Ventilation HFV

very high frequency ventilation of 60-2000breaths/min
very low tidal volume of 1-5ml/kg

Preventing Ventilator-Associated Pneumonia (VAP)

avoid intubation unless absolutely necessary
extubate as soon as possible
perform meticulous hand washing and gloving
ensure correct endotracheal tube cuff pressure is maintained
use HME (heat and moisture exchanger filters)
remove any condensation formation from ventilator circuits
avoid unplanned extubation
perform endotracheal and supraglottic suctioning

High Flow Nasal Cannula

High Flow Nasal Cannula is a light cannula with soft pliable prongs, warmed and humidified, with a Flow of up to 60L/min and FiO2 up to 100%. The HFNC:

improves oxygenation
reduces breathing work
provides a continuous flow of fresh gas at high flow rates, replacing the patient’s pharyngeal dead space
washes out the patient’s re-breathes of carbon dioxide and replaces it with oxygen

Retrieved from https://www.researchgate.net/figure/Basic-components-of-a-high-flow-nasal-cannula-HFNC-system_fig1_333448617 on 12th December 2022

Respiratory Support Progression

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Mechanical Ventilation of Critically Ill Patients

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Ventilation is the movement of air into and out of the lungs. Ventilation carries oxygen to provide tissue perfusion and removes carbon dioxide which accumulates from aerobic metabolism. Sometimes, especially within the critical care setting self-ventilating becomes difficult or impossible for the patient. This is where mechanical ventilation is introduced – to provide artificial control or support during each breathing cycle through the use of a machine, namely a ventilator.

A ventilator typically has the following colour-coded pipes:

white pipe – oxygen at 100%
- white and black pipe – compressed air at 21%
yellow pipe – suction

These pipes have the following features:

uncrushable – cannot be crushed if stepped over etc
pin indexed – one pipe cannot be inserted by mistake into a different socket by mistake
tug test – may tug oxygen hose after the probe is plugged into wall or cylinder socket to ensure it is firmly attached
internal battery
electricity supply

Mechanical Ventilation Indications

Before mechanical ventilation takes place, clinical judgement has to ascertain that such an intervention would be providing improved quality of life whilst lowering the mortality risk of the patient. Thus, mechanical ventilation should be opted for…

when the patient’s own ventilation mechanism is unable to sustain life
when the critically ill patient needs ventilation control
when there is the risk of impending collapse of physiological functions, in which case mechanical ventilation is opted for as a prophylactic measure

(Byrd et al., 2006)

Mechanical Ventilation helps the critically ill patient by:

improving alveolar ventilation and oxygenation
decreasing the required breathing effort and oxygen consumption
reversing hypoxaemia (low level of partial pressure oxygen in the blood)
reversing acute respiratory acidosis (too much carbon dioxide leading to an acidic base)
enabling sedation and muscle relaxation eg. prior to surgery

Specific indications for mechanical ventilation include:

apnoea
impending respiratory arrest
heart failure
pulmonary oedema
pneumonia
sepsis
chest trauma
surgery complications
ARDS (Acute Respiratory Distress Syndrome – a life-threatening condition with which the lungs are unable to provide the body’s vital organs with enough oxygen)
COAD acute exacerbation (Chronic Obstructive Airway Disease – a long term lung disease a.k.a. chronic bronchitis or emphysema, or the latest term COPD)
neuromuscular disorder
acute brain injury – mechanical ventilation almost always required since it controls the level of air that is exchange; the more carbon dioxide, the more vasodilation and the more blood pooling in the brain
coma

Mechanical Ventilation aims to prolong life, not prolong death…

Negative Pressure Ventilation

Air moves from one area to the other due to the difference in pressure a.k.a. pressure gradient. Spontaneous breathing happens through the generation of negative pressure. Negative pressure ventilation increases the normal physiological breathing pattern by producing a negative pressure outside the chest wall, which then causes the air to be automatically inhaled when the patient opens the airway.

Retrieved from https://understanding-vertebrates.weebly.com/respiratory-system.html on 9th December 2022

The Iron Lung vs Today’s Negative Pressure Ventilation Equipment

The Iron Lung, which was used extensively for patients up to the mid 1950’s, was a large airtight metal cylinder which enclosed patients fully, exposing only their head and neck. It worked through an electric pump which generated negative pressure, causing the patient’s chest to rise.

The Iron Lung – Retrieved from https://www.rochester.edu/newscenter/brief-history-of-ventilators-424312/ on 9th December 2022

Modern Negative Pressure Ventilation equipment comprises of airtight jackets or flexible canopies a.k.a. cuirass, which cover the chest area only. They are available in oscillatory mode so as to assist with secretion clearing.

Patients who benefit from such equipment include patients receiving home care who suffer from respiratory muscle group weakness, skeletal problems which restrict thoracic function, and patients with central hypoventilation syndrome.

mechanical ventilation — Modern Negative Pressure Ventilation Equipment – Retrieved from https://link.springer.com/article/10.1007/s42600-021-00149-0 on 9th December 2022

Negative Pressure Ventilation Limitations

Within the critical care setting, it is difficult to achieve accurate pressure, volume and gas flow due to abnormal lung compliance and impaired airway control. Additionally, the seal required around the patient’s chest wall may lead to pressure sores. With regards to nursing care, invasive procedures and chest examinations become difficult to perform. And while a Negative Pressure Ventilator provides ventilation, it does not provide oxygenation.

(Ashurst, 1997)

Positive Pressure Ventilation

Through positive pressure ventilation, the normal pressure gradient is reversed as oxygenated air is forced into the patient’s lung by the ventilator, and as airway pressure drops, recoil of the chest causes passive exhalation by pushing out the tidal volume.

Routes for Positive Pressure Ventilation Delivery

INVASIVE ROUTES:

oral or nasal endotracheal tube
tracheostomy

NON-INVASIVE ROUTE:

This is achieved through the use of a NIV – non-invasive ventilator. Whilst this type of ventilation does not require sedation and it reduces the risk of nosocomial pneumonia, a NIV requires that the patient is conscious, breathing spontaneously and is compliant. It also requires the use of a tight-fitting face mask, nasal cannula or helmet.

NON-INVASIVE VENTILATION with CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP):

PEEP – positive pressure is maintained throughout inspiration and expiration
reduces breathing effort requirement
improves oxygenation
improves compliance

NON-INVASIVE VENTILATION with BI-LEVEL POSITIVE AIRWAY PRESSURE (BiPAP):

2 positive pressure settings include IPAP – inspiratory positive airway pressure, and EPAP – expiratory positive airway pressure
increases tidal volume
reduces PaCO2
improves oxygenation
reduces breathing effort requirement

Mechanical Ventilation Ventilator Variables

CONTROL: ventilator controls the pressure and the volume

TRIGGER: what starts off inspiration, where the flow, pressure or volume are generated by the patient, whist the time is triggered by the ventilator itself if the inspiration is not initiated by the patient (in other words, either the patient triggers inspiration, or the ventilator)

CYCLING: time, flow and volume trigger expiration

Volume Controlled Ventilation

In Volume Controlled Ventilation, a preset gas volume is forced into the lungs, whilst pressure is dependable on lung compliance.

Volume Controlled Ventilation ensures delivery of a constant tidal and minute volume, and is set based on the patient’s ideal body weight, height and sex.

However…

When a patient’s lung compliance decreases, an increased amount of pressure is required. Volume Controlled Ventilation will deliver the preset tidal volume with no regards to a patient’s airway condition change, which may lead to VILI (Ventilator-Induced Lung Injury)

Pressure Controlled Ventilation

In Pressure Controlled Ventilation, the lungs are inflated up to a preset pressure. The tidal volume is variable, depending on both lung compliance and resistance in breath delivery.

Pressure Controlled Ventilation helps prevent excessive airway pressure whilst reducing the risk of VILI (Ventilator-Induced Lung Injury).

However…

It does not guarantee minute volume, and this may lead to the patient experiencing hypoventilation leading to hypoxia.

To prevent this from happening, Volume Guaranteed Pressure Control Ventilation ensures that with each mandatory breath, a set tidal volume (VT) is applied with minimum pressure. Additionally, pressure adapts gradually to resistance and/or compliance changes so the set tidal volume is administered.

Mechanical Ventilation Ventilator Settings

FiO2 – FRACTION OF INSPIRED OXYGEN

FiO2 is the fraction of oxygen in each delivered breath. FiO2 should be set somewhere between 21% (0.21) and 100% (1.0). FiO2 is used to maintain oxygenation along with PEEP.

Oxygen toxicity risk increases when the patient’s dependency and duration on FiO2 are high. Additionally, oxygen metabolites may lead to tracheobronchitis (inflammation of the trachea and bronchi), absorptive atelectasis (loss of lung volume caused by the resorption of air within the alveoli), hypercarbia (increase in carbon dioxide in the bloodstream), lung fibrosis (lung tissue damage and scarring), and diffuse alveolar pulmonary membrane damage (changes which occur to the structure of the lungs).

PEEP – POSITIVE END-EXPIRATORY PRESSURE

Positive pressure is maintained throughout inspiration and expiration, thus, pressure is not allowed to drop to zero at the end of expiration. This prevents the alveoli from collapsing, improves oxygenation without increasing the FiO2, helps prevent oxygen toxicity, whilst increasing the availability of alveolar surface area for gaseous exchange.

However, PEEP should be used with caution in patients with either a head injury and/or poor cardiac output. This is because PEEP increases the intra-thoracic pressure and hence reduces venous return, therefore cardiac output is reduced, and intracranial pressure is increased.

Similarly, patients with COPD and/or asthmatic patients who are not able to completely exhale tidal volume should also receive PEEP with caution.

Mechanical Ventilation Modes

CMV – COntinuous Mandatory Ventilation

CMV delivers a preset number of breaths with a preset tidal volume or pressure. In CMV the patient’s inspiratory efforts make no difference since all settings are preset. Settings involved include TV, Inspiration Pressure, FiO2, PEEP and RR.

All breaths controlled by ventilator, no triggered breaths – Retrieved from https://ddxof.com/tag/ards/ on 11th December 2022

a/c – Assist / control Ventilation

In A/C ventilation, the patient can trigger the ventilator to deliver the breath. This type of setting has the ability to sense the natural negative pressure generated by the patient, delivering a breath with a set volume or pressure. However, if the patient does not trigger any breaths, a set number of breaths is still delivered.

Every patient-triggered breath is fully supported, a backup rate is set; in the absence of patient-triggered breaths, AC acts like CMV – Retrieved from https://ddxof.com/tag/ards/ on 11th December 2022

simv – Synchronised Intermittent Mandatory Ventilation

In SIMV, a preset number of ventilator breaths per minute are delivered. Spontaneous breaths may be initiated by the patient at any point between ventilator breaths.

To augment the tidal volume of spontaneous breaths, pressure support is often used. Settings involved include a set rate, tidal volume, FiO2, with optional pressure support and PEEP.

NOTE: monitor total breathing rate, minute volume, and airway pressure.

Preset minimum mandatory breaths are synchronised to the patient’s efforts, with the patient able to breathe spontaneously between supported breaths – Retrieved from https://ddxof.com/tag/ards/ on 11th December 2022

PS/ spn-cpap: Pressure support ventilation

SPN refers to spontaneous mode of ventilation in which respirations are started and ended by the patient. SPN requires no preset rate and TV since both are determined by the patient, thus, need to be monitored well.

SPN may be combined with pressure support, where spontaneous breaths are aided by an extra push from the ventilator. Thus, if apnoea is detected, the ventilator starts providing backup mandatory ventilation.

With Pressure Support, all breaths are triggered by the patient, each of which is supported by preset pressure – Retrieved from https://ddxof.com/tag/ards/ on 11th December 2022

CPAP promotes spontaneous breathing at an elevated baseline pressure – Retrieved from https://ddxof.com/tag/ards/ on 11th December 2022

BiPAP – Bi-Phasic Positive Airway Pressure

In BiPAP, the ventilator alternates between IPAP (Inspiratory Pressure) and PEEP. BiPAP provides mandatory breaths synchronised with the patient’s breathing attempts for both inspiration and expiration. With this setting in place, the patient can breathe spontaneously at any time, supported by pressure support. This helps reduce the need for patient sedation whilst improving oxygenation.

Complications of Mechanical Ventilation

Carbery, 2008. Retrieved from https://journals.sagepub.com/doi/10.1177/175045890801800303 on 11th December 2022

Weaning Patient from Mechanical Ventilation

A patient on mechanical ventilation can be weaned off of the ventilator if he/she:

is conscious and cooperative
has an FiO2 of <50%
has adequate minute ventilation
is able to cough
has minimal or clear secretions
has no evidence of septic shock
has an adequate fluid status
has no significant acid-base or electrolyte imbalance
has minimal vasopressor requirement
is showing evidence of resolution of the primary reason which required mechanical ventilation

If the patient meets the criteria mentioned above, ventilatory support is decreased (mandatory breaths, FiO2 and Pressure Support), and replaced with spontaneous ventilation. Spontaneous breathing trials can be performed with the use of T-piece humidifier and flow inflated ventilation bags.

Whilst attempting to wean patient off of mechanical ventilation, it is very important to monitor for signs of respiratory distress!

Signs of respiratory distress include:

tachypnoea
tachycardia
hypoventilation
bradycardia
hypertension
hypotension
hypoxaemia – SPO2 <90%
agitation
altered level of consciousness
labored breathing
use of accessory muscles of breathing

References

Ashurst, S. (1997). Nursing care of the mechanically ventilated patients in ITU: Part 1 and 2. British Journal of Nursing 6(8, 9): 447-454, 475-485.

Byrd, R.P., Eggleston, K.L., Hnatyuk, O.W. (2006). Mechanical Ventilation.

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Acid Base Balance in a Patient’s Arterial Blood Gases ABGs

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In a critical care setting, the main aim is always oxygen perfusion; perfusion = survival = healing. Acid Base Balance a.k.a. pH balance, is the level of acids and bases in the blood at which the human body functions at its best. A pH between 7.35 and 7.45 is considered to be an optimum pH level since it promotes good oxygen perfusion throughout the body.

A cell without oxygen can compensate with the help of anaerobic respiration. This however produces lactate a.k.a. lactic acid. Thus, anaerobic respiration can only provide compensation for a short period of time.

Physiological pH values in the human body: retrieved from https://www.researchgate.net/deref/https%3A%2F%2Fdoi.org%2F10.1080%2F17425255.2021.1951223 on 18th November 2022

In normal circumstances, the body aims to maintain a healthy balance between the acid and alkaline within. This process is mostly active thanks to the lungs and the kidneys, both of which play an important role in maintaining the body’s pH balance. This means however, that for individuals with compromised kidneys or lungs, compensating pH imbalance becomes even more difficult.

An acid is a substance which is chemically able to donate a hydrogen ion to another substance. Acids, which have a pH <7, are formed by free H⁺ ions and carry a positive electrical charge a.k.a. cations.

A base a.k.a. buffer is any substance which is chemically able to accept a hydrogen ion. Most bases are insoluble, however, ones that dissolve in water are also called alkali. Alkalis are formed by OH^– ions a.k.a. Hydroxyl ions. They have a pH of >7 and carry a negative electrical charge a.k.a. anions.

pH is the measure of H⁺ (hydrogen ion) concentration in water.

pH is controlled by the following active organs:

LUNGS: excrete carbon dioxide in the form of carbonic acid (H₂CO₃), and dissociates into H₂O + CO₂ for excretion.

KIDNEYS: control bicarbonate excretion; the kidneys can form ammonia which combines with acid products of protein metabolism for excretion.

PLASMA PROTEINS: able to bind both to free H⁺ and OH^– ions, preventing changes in the pH (fine-tuning pH levels that are still within their normal range i.e. between 7.35-7.45).

Bicarbonate and pH Balance

Normal Blood Gases Values

	Arterial	Venous
pH	7.35-7.45	7.33-7.43
PO₂ (Partial Pressure of Oxygen)	80-100mmHg / 11-15KPa	35-49mmHg / 4.5-6KPa
PCO₂ (Partial Pressure of Carbon Dioxide)	35-45mmHg / 4.5-6.1KPa	41-51mmHg / 5-6.5KPa
SO₂ (Oxygen Saturation)	95-100%	65-80%
HCO₃ (Bicarbonate)	22-26mmol/l	24-28mmol/l
Base Excess	-2 to 2	0 to 4

NOTE: In the UK, PaCO2 and PaO2 are normally measured in kPa (kilopascal) whereas in Malta they are usually measured in mmHg (millimetres of mercury). 1kPa = 7.5mmHg.

pH – acidity or alkalinity measurement based on the hydrogen ions present
PaO₂ – partial pressure of oxygen which is dissolved in arterial blood
SO₂ – arterial oxygen saturation
PCO₂ – the amount of carbon dioxide dissolved in arterial blood
HCO₃ – the amount of bicarbonate in the blood
Base Excess – the amount of excess or insufficient level of bicarbonate in the system

Interpreting Arterial Blood Gases — Retrieved from http://medcraveonline.com/JACCOA/JACCOA-05-00199.pdf on 26th May 2021

acid base balance abg's — Retrieved from https://www.slideshare.net/kerolus/basic-abg-notes on 26th May 2021

Retrieved from https://www.slideshare.net/kerolus/basic-abg-notes on 26th May 2021

Restoring Acid-Base Balance Through Compensation

The human body naturally attempts to keep the pH within normal range by restoring acid-base balance through the opposite unaffected system. For example, if the respiratory system is affected, the metabolic system attempts to compensate so as to restore normal pH.

Respiratory Compensation happens 2-4 HOURS following an established metabolic process.

Metabolic Compensation happens 2-4 DAYS following an established metabolic process.

ABGs Interpretation Algorithm

Retrieved from https://www.yournursingtutor.com/wp-content/uploads/2018/08/ABG-Decision-Tree-Freebie.pdf on 18th November 2022

Acid Base Balance Disorders

https://www.youtube.com/watch?v=X0VjnFKDNI0

respiratory alkalosis acid base balance — Body removing more CO2 than is being produced by the tissues – Retrieved from https://www.pinterest.com/pin/532761830894111979/ on 26th May 2021

metabolic acidosis acid base balance — Retrieved from https://www.pinterest.com/pin/427349452111640534/ on 26th May 2021

metabolic alkalosis acid base balance — Retrieved from https://healthjade.net/hyperchloremic-acidosis/ on 26th May 2021

ABGs Interpretation

Partially vs Fully Compensated & Uncompensated Arterial Blood Gases

Further information

Arterial Blood Gases Blogpost – http://student-nurse-life.com/arterial-blood-gases-interpreting-abg/

ABG Interpretation

Reference

Featured image retrieved from https://www.medistudents.com/osce-skills/arterial-blood-gases on 18th November 2022

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Tracheostomy Nursing Care in the Critical Care Setting

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Tracheostomy is a procedure in which an artificial opening a.k.a. stoma is created at the level of the second or third cartilaginous ring from where the tracheo-bronchial tree is accessed and a tracheostomy tube is inserted. Proper tracheostomy nursing care in the critical care setting ensures patient safety.

Retrieved from https://entokey.com/laryngeal-anatomy/ (left) and https://www.pinterest.com/pin/83387030589729256/ (right) on 1st November 2022

Tracheostomy indications

airway obstruction in relation to problems with tongue, pharynx, larynx, trachea and oesophagus
anaphylaxis
foreign body
facial trauma
facial or respiratory burns
prior to extensive head and neck surgery
vocal cord paralysis
sleep apnoea
instable cervical spine
inflammation
tumor
congenital anomalies (structural or functional anomalies which occur in-utero)

NOTE: Tracheostomy is preferred as a prolonged airway maintenance and ventilation method. It is also used in cases of failed and/or repeated intubation, following intubation complications, and where there is need for deep secretion removal.

Tracheostomy Advantages

less restricting for the patient
enables swallowing
enables better communication
less sedation requirement
allows better mouth hygiene
helps avoid upper airway complications related to ETT use
easier secretion removal
reduces anatomical dead space (shorter, wider and less curved tube = better breathing = quicker weaning from ventilator use)

Tracheostomy Preparation & Surgical Procedure

explain tracheostomy procedure to the patient and accompanying relatives
gain operation consent
ensure availability of needed drugs (sedatives/analgesics/muscle relaxants), blood in reserve, suction equipment, cautery machine (helps in cutting and stopping bleeding immediately and effectively), and procedure trolley
help patient in supine position with blanket roll between shoulder blades to ensure neck is adequately exposed.

an incision is made between the sternal notch and cricoid cartilage
a midline vertical incision is made to divide strap muscles
thyroid isthmus between ligatures is divided
cricoid is elevated along with the cricoid hook
an incision is made through the tracheal wall
a tracheostomy tube is inserted while the endotracheal tube is withdrawn
cuff is inflated
keyhole dressing is applied
tube is secured either with tape around the neck or with stay sutures
tube is connected to the ventilator tubing

tracheostomy nursing care — Retrieved from https://www.surgeryencyclopedia.com/St-Wr/Tracheotomy.html on 1st November 2022

Percutaneous Dilational Tracheostomy

As seen above, a surgical tracheostomy requires a surgical dissection to be made down to the trachea, the creation of a window in the trachea with the insertion of a tracheostomy tube for ventilation…

Compared to surgical technique, the percutaneous dilational tracheostomy (PDT) uses a modified Seldinger technique where the trachea is accessed with a needle and then a guidewire is inserted. The tracheostomy tube is introduced over the guidewire after dilation.
Rashid & Islam, 2017

Thus, a percutaneous dilational tracheostomy avoids surgical incision, is less traumatic, and carries a lower bleeding risk.

a large bore needle is inserted into the tracheal lumen between the 2nd and 3rd ring
a flexible guidewire is then inserted
serial dilations are made
tube is inserted

NOTE: Ideally, a percutaneous dilational tracheostomy are done under ultrasound or bronchoscopy guidance. The procedure is contraindicated in patients with goitre, obesity, and acute upper airway obstruction.

Tracheostomy Complications

During placement of tracheostomy, arising complications may include:

haemorrhage (due to the area being very vascular)
pneumothorax (accidental pleura laceration)
oesophageal trauma
laryngeal nerve injury (may cause hoarseness, difficulty in swallowing or breathing, or loss of voice)
vagal nerve stimulation (may lead to bradycardia, hypotention, or cardiac arrest)
incorrect placement

Post-op complications following a tracheostomy may include:

haemorrhage
aspiration
wound infection
infection in the trachea
infection in the lungs
tube obstruction caused by blood or secretions
tube displacement
subcutaneous emphysema (usually this is solved without any interventions)

Late complications related to tracheostomy use may include:

tracheal stenosis (abnormal narrowing of the trachea which restricts the patient’s ability to breathe)
tracheo-oesophageal fistula (abnormal connection between the trachea and oesophagus which causes swallowed liquids or food to be aspirated into the lungs)
tracheoinnominate artery erosion by cuff or tip of tube (may require resuscitative and operative measures)
stoma does not close following removal of tube
overgranulation and scarring

Types of Tracheostomy Tubes

Retrieved from https://www.exportersindia.com/product-detail/white-fenestrated-tracheostomy-tube-6433292.htm (left) and https://www.magonlinelibrary.com/doi/abs/10.12968/bjon.2019.28.16.1060 (right) on 1st November 2022

Cuffed Tube with Disposable Inner Cannula – Used to obtain a closed circuit for ventilation.

Cuff should be inflated when using with ventilators
Cuff should be inflated just enough to allow minimal airleak
Cuff should be deflated if patient uses a speaking valve
Cuff pressure should be checked twice a day
Inner cannula is disposable

Retrieved from https://www.hopkinsmedicine.org/tracheostomy/about/types.html on 12th November 2022

Cuffed Tube with Reusable Inner Cannula – Used to obtain a closed circuit for ventilation.

Cuff should be inflated when using with ventilators
Cuff should be inflated just enough to allow minimal airleak
Cuff should be deflated if patient uses a speaking valve
Cuff pressure should be checked twice a day
Inner cannula is not disposable; you can reuse it after cleaning it thoroughly

Cuffless Tube with Disposable Inner Cannula – Used for patients with tracheal problems and for patients who are ready for decannulation.

Save the decannulation plug if the patient is close to getting decannulated
Patient may be able to eat and may be able to talk without a speaking valve
Inner cannula is disposable

Cuffed Tube with Reusable Inner Cannula – Used for patients with tracheal problems and for patients who are ready for decannulation.

Save the decannulation plug if the patient is close to getting decannulated
Patient may be able to eat and may be able to speak without a speaking valve
Inner cannula is not disposable; you can reuse it after cleaning it thoroughly

Fenestrated Cuffed Tracheostomy Tube – Used for patients who are on the ventilator but are not able to tolerate a speaking valve to speak.

There is a high risk for granuloma formation at the site of the fenestration (hole)
There is a higher risk for aspirating secretions
It may be difficult to ventilate the patient adequately

Fenestrated Cuffless Tracheostomy Tube – Used for patients who have difficulty using a speaking valve.

There is a high risk for granuloma formation at the site of the fenestration (hole)

Metal Tracheostomy Tube – Not used as frequently anymore. Many of the patients who received a tracheostomy years ago still choose to continue using the metal tracheostomy tubes.

Patients cannot get a MRI
One needs to notify the security personnel at the airport prior to metal detection screening

CUFFED VS NON-CUFFED VS FENESTRATED

SINGLE VS DOUBLE TUBE

Double lumen tubes contain an inner cannula which can be removed for cleaning.

TRACHEOSTOMY VS LARYNGECTOMY

SHILEY TUBE

Upper Airway Bypass Effects

In normal upper airway functions there is humidification, warming and filtration of inspired air, ability to taste, smell and swallow, speech production by the passing of exhaled air through the larynx, and involvement in the cough reflex.

When bypassing the upper airway, lack of humidification leads to impaired mucociliary function, thicker secretions which can easily cause tube obstruction, as well as atelectasis (partial or full lung collapse) and infection. Similarly, air below body temperature may cause bronchoconstriction, reduced air flow, decreased PO2 (partial pressure of oxygen) and decreased SaO2 (oxygen saturation of arterial blood).

Humidification

Requirements for optimal gas exchange, which are in normal circumstances achieved through the upper airway, include:

a temperature of 37 degrees celsius
100% humidity
filtered air

Adequate humidification may reduce the need for suctioning, thus, in situations where the upper airway is bypassed by an ETT or tracheostomy, an external method providing warmth, humidity and filtration is needed.

Through an external humidification system, inspired gas is passed over heated water with a set temperature of about 60 degrees celsius. As the air passes along the tubing, it cools down to around 37 degrees celsius when reaching the patient.

Although this system provides a setting similar to what is required for optimal gas exchange, it poses a couple of problems: it requires equipment care, it restricts patient mobility, and it may also become an infection source for the patient.

The HME Filter – Heat Moisture Exchanger

HME filters a.k.a. heat moisture exchanger filters are devices used in patients who are mechanically ventilated to help prevent mucus plugging and endotracheal tube occlusion due to lack of humidification.

HMEs are made of hydrophylic material which retains heat and moisture in exhaled air, which are then recycled in subsequent inspirations, following filtration of inspired air.

HMEs improve patient mobility and lower risk of infection. However, they can still become easily blocked by secretions, and so, require frequent filter changes (usually changed within a couple of days based on manufacturer’s recommendations) or even cessation of use in case of profuse secretions.

Suctioning in Airway Management

Secretions are cleared by coughing under normal conditions. Cough involves pressure build-up in the lungs which depends on closure of the glottis. The use of a tube prevents the patient from increasing enough abdominal pressure to produce a cough that clears secretions in the airway. Additionally, the tube may also cause irritation which leads to increased sputum production.

Suctioning is a procedure that needs to be performed as often as required based on the patient’s individual needs, so as to clear secretions and maintain a patent tube.

suctioning should not be performed routinely but as needed
suctioning should be performed using a sterile technique
suctioning can be scary and unpleasant for the patient, thus, it needs to be performed with confidence and speed

Suctioning Indications

coughing
respiratory distress
increased peak airway pressure
decreased SaO2 (oxygen saturation of arterial blood) and PO2 (partial pressure of oxygen)
audible and/or visible secretions
suspected aspiration
signs of discomfort

Open Suctioning Procedure

explain procedure to the patient
provide the patient with hyperoxygenation at 100% oxygen
whilst keeping the catheter in its wrapper, attach it to suction tubing and switch it on
wear mask and sterile suction glove
insert catheter up to 1cm more than the tube length
apply suction on the way out; oropharyngeal cavity may also need suctioning
hyperoxygenate again
monitor patient

NOTES:

do not exceed 15 seconds in performing suctioning so as to prevent hypoxia
maintain aseptic technique whilst performing procedure
catheter width should not exceed half the tube’s diameter
catheters with multiple eyes produce less damage
negative pressure should not exceed 120mmHg
instillation of saline is not recommended any more, however, saline nebulisation may help in loosening secretions

Suctioning Complications

HYPOXAEMIA – arterial blood oxygen level lower than normal: happens due to the patient being disconnected from the oxygen source whilst suctioning is being performed; reduce risk by performing suctioning for not longer than 15 seconds and ideally using a closed suction system instead of the open suction one.

ATELECTASIS – complete or partial collapse of the entire lung or lobe of the lung: happens when excessive pressure is being used while suctioning; reduce risk by ensuring that pressure does not exceed 120mmHg.

BRONCHOSPASM – tightening of the muscles lining the bronchi a.k.a. airway tightening: happens due to catheter use stimulating the airway.

DYSRHYTHMIAS – abnormal or irregular heartbeat (especially bradycardia following suctioning): happens due to hypoxaemia and vagal stimulation.

HAEMODYNAMIC CHANGES – increased blood pressure and intracranial pressure; reduce risk by avoiding suctioning in patients with head injury.

TRACHEAL MUCOSA TRAUMA – reduce risk by avoiding deep suctioning, large catheters and excessive pressure.

INFECTION – reduce risk by using strict aseptic technique and using a closed suction system. NOTE: send specimens for C+S if infection is suspected.

Closed Tracheal Suctioning Procedure

Using a closed tracheal suctioning procedure allows suctioning of the airways without the need for disconnecting the patient from the ventilator. This is done by attaching the suction catheter in plastic sleeve directly to the ventilator tubing.

Advantages:

maintains oxygenation and PEEP (Positive End Expiratory Pressure) during suction
reduces the risk of complications related to hypoxaemia
provides HCPs with protection from secretions

Disadvantages:

possible auto-contamination (reduce risk by cleaning catheter after each use and change every 24 hours)
inadequate removal of secretions
extra weight on ventilator tubings may cause an unintentional extubation
expensive

Cuff Management

The use of a cuff provides a seal in mechanical ventilation of a patient. This seal provides protection from gross aspiration. However, it does not offer complete protection from aspiration, and it may also disguise aspiration signs. Additionally, cuff exerts pressure on the oesophagus, anchoring the larynx, thus reducing laryngeal elevation. Considering all the above…

The patient with an inflated cuff should be kept nil-by-mouth! Provide needed nutrition through a nasogastric tube, a nasojejunal tube, gastrostomy, or jejunostomy. Important: assist the patient as needed to maintain oral hygiene!

Cuff used should be a high volume low pressure cuff. Cuff pressure should be checked at the start of every shift, after turning the patient, after physiotherapy, after dressing change and if a leak can be heard. Pressure should be kept between 15-25mmHg.

A low cuff pressure causes a drop in tidal volume due to leak of exhaled air around the tube, as well as possible aspiration of gastric content.

A high cuff pressure may create a fistula between the trachea and the oesophagus a.k.a. tracheoesophageal fistula, especially if a stiff nasogastric tube is being used on the patient. It may also cause obstruction of capillary blood flow within the tracheal wall, leading to pressure sore necrosis and tracheal stenosis following formation and healing of scar tissue.

Tracheostomy Communication Through Speaking Valves

In normal circumstances, speech is created by the passing of exhaled air through the vocal cords. Since tracheostomy tubes are inserted below the vocal cords, sound cannot be formed. This may cause the patient to become anxious and feeling isolated.

The nurse should provide reassurance to the patient by explaining that loss of sound being experienced is only temporary, and voice returns once the tracheostomy tube is removed. The nurse should also encourage the patient to use different ways of communication whilst with a tracheostomy tube is inserted, such as using electronic devices, paper and pen, or speaking valves.

Speaking Valve Use

When using a speaking valve, ensure that the patient has a good gag reflex and that he is using either a non-cuffed or a fenestrated tube; if patient is using a cuffed tube, ensure that the cuff is totally deflated before attempting use of speaking valve
Upon inspiration, the valve opens, allowing air to be inhaled through the tracheostomy
Upon exhalation, the valve closes; air passes around the tube and through the vocal cords, enabling exhalation from the upper airway and voice production

NOTE: DO NOT USE A SPEAKING VALVE if the patient has poor lung compliance, in the case of excessive secretions, and if laryngeal or pharyngeal problems are present.

Tracheostomy Nursing Care – Wound Care & Tape Changes

The surgical wound needs to be kept clean and dry at all times. The wound dressing used needs to be changed daily or whenever it becomes soiled. The aseptic non-touch technique should be used whilst cleaning the wound with saline, including careful cleaning of the area underneath the flange. Note that between the patient’s neck and tape there needs to be a space for one to two fingers.

prepared equipment for an arising emergency

1 spare tube in the same size as the one being used
1 spare tube in a smaller size than the one being used
suction and suction catheters
oxygen
tracheostomy mask
securing tape
tracheal dilators
scissors
suture cutter
lubricating gel
syringe (to inflate cuff)
drugs and equipment for resuscitation
sterile keyhole dressing
non-sterile gloves

Tracheostomy Tube Change

A single lumen tracheostomy tube should be changed every 7-10 days so as to prevent obstruction. Other indications for a tracheostomy tube change include:

cuff failure
blockage within the tube
displacement of the tube
needing to change to a larger or smaller tube

Tracheostomy Weaning and Decannulation

A tracheostomy is no longer needed if:

the reason for a tracheostomy has been resolved
the patient is alert, stable, and self ventilating on air
the patient has no significant signs of airway obstruction
the patient is able to swallow and cough up secretions
the patient is able to maintain good oxygen saturation

In case of the above:

cuff is deflated
tube is occluded for 24 hours
if no respiratory distress is experienced by the patient, tube is removed
the stoma is covered with a small occlusive dressing

Important Tracheostomy Nursing Care Observations

monitor patient for bleeding or oozing
monitor patient for signs of infection and/or inflammation
monitor patient for evidence of tissue damage
monitor cuff pressure and ensure it is kept within normal limits
monitor amount, colour and consistency of secretions

Reference

Johns Hopkins Medicine (n/d). Tracheostomy Service. Retrieved from https://www.hopkinsmedicine.org/tracheostomy/about/types.html on 12th November 2022

Rashid, A. O., & Islam, S. (2017). Percutaneous tracheostomy: a comprehensive review. Journal of thoracic disease, 9(Suppl 10), S1128–S1138. https://doi.org/10.21037/jtd.2017.09.33

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Oropharyngeal Nasopharyngeal and Endotracheal Tubes

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Airway management in the critical care setting depends on 4 steps which, when followed adequately, ensure patient’s safety:

timely clinical identification of airway compromise in patient
use of the most appropriate airway maneuver for the patient
appropriately choosing and introducing airway adjuncts
becoming aware if and when the need for ventilation arises, and delivering it effectively

Oropharyngeal and Nasopharyngeal airways are tubes made of plastic or rubber used to help maintain airway patency by keeping the tongue out of the way from obstructing the upper airway. Whilst in use, patient breathing should be assessed and confirmed so that proper positioning is ensured.

endotracheal tubes — Retrieved from https://twitter.com/myway_rt/status/1472980655696973825?lang=ar-x-fm on 28th October 2022

Complications

gagging
vomiting (may lead to aspiration)
bleeding following trauma to the oral or nasal cavity
airway obstruction caused by the oropharyngeal airway pushing the tongue to the back
laryngospasm – vocal chord spasm which causes temporary difficulties with breathing and speaking

NOTE: The oropharyngeal airway should only be used in unconscious patients with an absent gag reflex.

NOTE: Do not use the nasopharyngeal airway on patients with a fractured skull base.

Oropharyngeal & Nasopharyngeal Airway Insertion

Oral & Nasal Endotracheal Tubes

Oral endotracheal tubes are commonly used in emergency situations. Whilst oral ETTs can be inserted easily, they also facilitate insertion of a larger tube that facilitates breathing and secretion suctioning.

Nasal endotracheal tubes provide less discomfort to the patient since they enable swallowing and oral hygiene, as well as facilitate communication. They can be easily secured and stabilised, minimising the risk of unintentional extubation. Additionally, a nasal ETT is preferred for paediatric use, post-extensive dental or neck surgery, and for patients with a fractured jaw.

Endotracheal tubes are available in many sizes. At the distal end of an endotracheal tube is a cuff which can be inflated by an external pilot balloon using between 15 to 25ml of water. This helps the ETT to stay in place, helps keep ventilated air in the ETT without escaping back up, and may also help prevent aspiration (although micro-aspiration can still pass through). At the proximal end a 15mm adaptor can be attached. This adaptor enables the ETT to be connected to ventilator tubings or to manual resuscitation bags.

NOTE: in paediatrics, the ETT used is usually without a cuff, which means it can be easily coughed out.

Intubation Equipment

ETTs (different sizes)
Stylet and Boogie (used in difficult intubations)
Checked Suction
Suction Catheters
Manual Resuscitation Bag (connected to oxygen)
Ventilation Masks
Laryngoscope Handle + Blades (pre-checked)
IV Access
Haemodynamic and Respiratory Monitoring Equipment

Use of McCoy Laryngoscope & bougie

The McCoy laryngoscope’s blade has an adjustable hinged tip for improved visualisation of the vocal cords during difficult intubations.

Intubation Drugs

analgesics
sedatives (short-acting) eg. Etomidate or Propofol
muscle relaxants (short-acting) eg. Suxamethonium (Scoline) or Atracurium (Tracrium)
resuscitation drugs eg. adrenaline or atropine

NOTE: when ventilating a patient, it is very important to administer sedation first. When sedation effects kick in, a muscle relaxant can then be administered. Baseline parameters are then taken and patient is continuously monitored.

Intubation Procedure

prepare equipment and ensure that all is checked and in working order
position patient in a way which ensures airway patency
suction the patient’s oral cavity and the pharynx
provide patient with 100% oxygen through manual ventilation for a few minutes
attempt intubation – limit attempt/s to 30 seconds
use the BURP technique to increase visibility (apply pressure on thyroid cartilage whilst moving backward, upward, and rightward)
insert tube and inflate cuff
ensure correct tube positioning through auscultation of bilateral breath sounds, visible chest rise, x-ray imaging, and ETCO2 monitor
document size and depth of ETT used

ATTENTION: if the ETT is misplaced into the stomach and not in the trachea, upon ventilating with 100% oxygen, the stomach would inflate instead of the lungs – chest.

Intubation Complications

vomiting and aspiration
laryngospasm
trauma to the mouth, nose, pharynx, trachea and/or oesophagus
gastric intubation
right main bronchus intubation
hypoxaemia and/or hypercapnia leading to hyper/hypotension and tachy/bradycardia

Prolonged Intubation Complications

patient discomfort
communication difficulty
patient anxiety
hypersalivation
tube displacement
tube obstruction
aspiration
nasal injury
mucosal lesions
cricoid abscess – causes airway compromise reversible with treatment
sinusitis – causes nasal discharge and undetermined fever
laryngeal stenosis – scarring within the larynx at or above the vocal cords which limits the larynx from opening as it normally does
tracheal stenosis – unusual narrowing of the trachea which restricts normal breathing
tracheo-oesophageal fistula – unusual connection between the trachea and oesophagus which causes swallowed liquids and foods to be aspirated into the lungs

NOTE: An ETT should not be used for more than 12 days. If further ventilation is required, a tracheostomy should be considered instead.

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Basic Principles of Intensive Care Nursing

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Basic Intensive Care Nursing

Intensive Care Nursing Principles include care of the following immediate care aspects: airway safety, breathing, circulation, disability a.k.a. level of consciousness, and exposure. Basic ABCDE assessments of the patient in intensive care increases the patient’s survival rate.

Airway Safety in Intensive Care Nursing

In intensive care nursing, one may observe two types of airways used on patients, both of which are considered to be invasive: an endotracheal tube or a tracheostomy.

An endotracheal tube is usually indicated for patients in respiratory failure who are unable to breathe adequately by themselves, or who are experiencing physiological disturbances, leaving their airway unprotected.

A tracheostomy is a planned procedure indicated for patients in need of a prolonged period of mechanical ventilation.

Both devices deliver ventilation to the patient through a closed system
Both devices deliver oxygen from the trachea directly into the lungs
Both devices have an inflatable cuff near the tube end which provides a seal to avoid air from escaping as well as protection from aspiration of gastric content into the lungs.

intensive care nursing — Endotracheal Tube

Endotracheal Tube

To ensure proper care of an intubated patient, the following measures need to be taken:

Tube Sizing

tube size is identifiable on the cuff balloon
tube is usually tied at the lips
a standard ETT is around 26mm long

Cuff Pressure

cuff pressure must be checked every 4 hours using a manual device
cuff pressure must stay between 20-30cm of water
an over-inflated cuff causes tracheal pressure damage; an under-inflated cuff causes air to escape and the ventilator to sound its alarm for inadequate ventilation
cuff leaks may happen due to inadequate air in the cuff, damage to the cuff, higher pressure from ventilator exceeding pressure in the cuff, wrong tube fit for the person’s anatomy, or positional leaks on patient movement

ETT Securing

ensure that the endotracheal tube is secure (unplanned extubation or tube misplacement can jeopardise the patient’s safety)
note length mark at teeth/lips and document clearly on the nursing report
ensure tube is tied appropriately with tapes or devices used within your clinical area
recheck tapes regularly to ensure they do not become loose – only two fingers may be inserted between the patient’s face and ties; if ties become loose, re-tie using a two-person technique to ensure prevention of extubation: one person holds the tube in place whilst the other ties the tapes
do not tie tapes around the connector at the tube’s end since this can easily become disconnected
call for assistance if the tube becomes dislodged or if you are concerned

Breathing

Ventilation is the in-out air movement within the lungs’ alveoli during which gas exchange occurs.

During normal breathing, ventilation occurs through negative pressure – energy causes the respiratory muscles to contract, which then lead the respiratory muscles to enlarge the thoracic cavity, creating a negative intra-thoracic pressure, which then results in airflow from atmospheric pressure to enter the lungs…

In simple terms, during normal breathing, air is sucked into the lungs.

Mechanical ventilation uses a positive pressure approach in which a pneumatic system delivers gas into the lungs during the inspiration phase. Following inspiration, the patient exhales to the level of PEEP which is set on the ventilator, thus, expiration happens passively.

In simple terms, during positive pressure ventilation (PPV), air is blown into the lungs.

NOTE: PEEP stands for Positive End Expiratory Pressure, which is the pressure set on the ventilator – pressure set above the atmospheric pressure – aimed to improve oxygenation through the recruit of collapsed alveoli.

Mechanical Ventilation Indications

Respiratory failure can be classed in 2 categories:

Type 1: Acute Respiratory Failure
Type 2: Hypercapnic Respiratory Failure

NOTE: Occasionally patients may have both.

Type 1: Acute Respiratory Failure

Acute respiratory failure occurs when arterial oxygen level is <8kPa, which is then reflected in a significant drop in the oxygen saturation level – hypoxaemia.

In hypoxaemia, the patient becomes visibly short of breath, with rapid shallow breathing usually accompanied by anxiety and confusion due to insufficient oxygen saturation within the tissues.

Acute respiratory failure typically happens due to conditions affecting gas exchange within the alveoli, such as in COVID-19 which can result in severe pneumonia, commonly bilateral pneumonia affecting both lungs, Acute Respiratory Distress Syndrome (ARDS) which causes the lungs to become waterclogged like sponges, and Pulmonary Embolism.

Type 2: Hypercapnic Respiratory Failure

In hypercapnic respiratory failure, respiratory demand is not met due to inability to breathe in enough air or breathe quickly enough, and so, the patient experiences hypoventilation.

Hypercapnic respiratory failure causes a rise in carbon dioxide along with a decrease in oxygen level; PaCO2 >6.6kPa (50mmHg) with pH of <7.25; pH fall happens due to the rise in carbon dioxide causing acidity in the blood.

Causes of hypercapnic respiratory failure include: upper airway obstruction, epiglottis obstructive sleep apnoea, asthma, bronchospasm, narcotic overdose, chest trauma, flail chest, pleural effusion, pneumothorax, haemothorax, CVA, cranial trauma, Guilllain-Barre Syndrome, and spinal cord injury.

Respiratory Assessment & Physical Examination – Look, Feel & Listen!

Look…

Look at the patient’s chest:

can you see any obvious deformities?
is chest expansion equal on both sides?
are accessory muscles being used?
is there paradoxical chest wall movement in comparison to the ventilator?

Along with the above observations, take note of the patient’s rate, rhythm, and quality of respirations.

Feel…

Palpate the patient’s chest:

can you feel both sides of the chest expand?
can you feel any vibrations within the chest? If yes, this may be an indication of respiratory secretions or fluid – check further by auscultating with a stethoscope

Listen…

auscultate for breath sounds by pressing the diaphragm side of the stethoscope firmly against the patient’s skin directly
normal breathing sound a.k.a. vesicular, is soft and low pitched, with inspiration lasting longer than the expiration sound
crackles are intermittent non-musical sounds which are caused by collapsed or fluid-filled alveoli, most commonly heard on inhalation; crackles may not clear up following coughing or suctioning
wheezing is a high-pitched musical sound caused by airway narrowing, commonly heard in COPD, Asthma, chest infection or heart failure
if no chest sounds can be auscultated and chest expansion is absent or limited, call for urgent assistance

Measuring the Effects of Mechanical Ventilation on Gas Exchange

Oxygen saturations and carbon dioxide levels are shown on the monitor and ventilator, as well as on an ABG result strip. Capnography is another way of monitoring carbon dioxide. A CO2 waveform can confirm that the tube is in the right position and that the patient is being ventilated. Flat or dampened waveforms require adjustments.

NOTE: sick patients may be aimed for a higher CO2 than normal – permissive hypercapnia.

Ventilation Risks

increased pressure in the thoracic cavity can cause lung trauma
increased risk of ventilator acquired pneumonia – a secondary lung infection; a good precautionary measure is to keep the patient’s head elevated to 30 degrees

Sputum Management

Intubated and ventilated patients cannot cough to clear their own secretions. For this reason, humidification, which is attached to the ventilator and should be checked regularly, is vital. In addition, closed suctioning of the ETT enables secretions to be suctioned out without breaking the circuit to atmospheric pressure.

Related Terminology

FiO2 – the fraction of inspired oxygen eg. 0.3 = 30% oxygen
Peak Pressure – airway pressure + alveolar pressure
PEEP -Positive End Expiratory Pressure
Tidal Volume – volume of air expired in one breath
Minute Volume – total volume of air expired in one whole minute

Circulation

As a nurse working in the ICU setting you need to make sure you go through a lot of ‘checks’ prior to starting your shift:

get a good handover by the nurse who was taking care of your newly assigned patient so that you know the patient’s normal parameter values
set the alarm limits based on the values given by the handover nurse; set alarms just above the highest and just below the lowest parameters taken during the previous shift
check all equipment to make sure all is in good working order

Setting alarms related to the cardiovascular system

heart rate – usually set between 60-100bpm; observe the patient’s ECG trace for a whole minute to know its normal trend
mean arterial pressure (MAP) – usually set between 60-65mmHg, however, these values are normally based on the patient’s normal limits to allow space for patient movement, coughing, etc
arterial line trace – observe the A-line trend for a minute so you familiarise yourself with it and be able to notice any differences straight away

Checking Equipment related to the Cardiovascular system

arterial line – needs to be monitored at all times; related alarms need to be always switched on; check for air bubbles and if any are visible, make sure you remove them; arterial line site needs to be kept clean, dressed with an intact see-through dressing, and kept visible at all times for easy monitoring

NOTE: the Arterial Line is marked with a red line all the way down the side so as to alert healthcare professionals that it is not a regular line.

IMPORTANT: Never inject anything into an arterial line! Special caps are used for arterial lines with the aim of preventing this!

central venous pressure line (CVP) – certain infusions need to be administered via a CVP line since if injected into smaller veins, these can be destroyed
check that all lines attached to the patient are clearly labelled with the medication being administered, and dated; this helps identify which line is which, in case a medication needs to be abruptly stopped or disconnected

NOTE: the Central Venous Pressure line may be clear or it may have a blue line running all the way down the side for easier recognition.

pressure bag + saline bag – the arterial line AND the CVP line should both be connected to a bag of 500ml normal saline 0.9% which sits in a pressure bag; pressure bag needs to be set at a pressure of 300mmHg which is clearly indicated by a green section on the pressure bag gauge
before zeroing the set, ensure that the bags of saline have enough fluid within them, and that they are up to pressure

transducer – this needs to be zeroed, sitting approximately in line with the right atrium, so as to ensure that both the arterial line and the cvp line are monitored continuously and accurately; zeroing needs to be done at every change of shift as well as whenever the patient is disconnected
both the arterial line and the cvp line need to be switched off to the patient, and be open to air, at the correct height, and with the pressure bag blown up, following which ‘zero all’ should be set on the monitor; then, both should be switched back on to the patient, caps should be put back on , and both should be reading correctly

Checking the patient

check that the patient’s heart rate corresponds to the ECG and arterial line trace and to the radial pulse of the patient
check that the ECG tabs are correctly placed and have good contact with the patient
check every line insertion site for any signs of infection or migration
re-check any significant heart rate change with a manual pulse, blood pressure output and a 12 lead ECG
check the patient’s limbs and note capillary refill time of all four
check for skin pallor, warmth, sweating, dry skin, wounds, and bleeding
check the MAP is reading adequately and whether it needs any fluids or drugs to maintain it
check the patient’s temperature: >39 degrees celsius needs to be taken care of; on the other hand, a patient can easily become cold in an ICU setting…avoid hypothermia – keep your patient warm!
ASK FOR HELP IF IN DOUBT AT ANY TIME!

NOTE: In the ICU setting, 5-lead ECG monitoring is used!

Check Urine Output

a urinary catheter is inserted in every sedated and ventilated patients
an average person’s urine output should be about 0.5ml/kg/hr; an inadequate blood pressure may later lead to a decrease in urine output, thus, check urine output every hour
a patient with a low blood pressure and poor urine output may be commenced on inotropes
common inotropes include Noradrenaline, Adrenaline, and Metaraminol

Inotropes:

are calculated in mcg/kg/min and titrated according to patient parameters to maintain an adequate MAP
should be administered through a central line
use should be accompanied with patient monitoring through an arterial line
are short-acting, thus, should be set to infuse continuously without running out; if left empty, patient’s blood pressure may drop dangerously low, possibly leading to a cardiac arrest
IV fluid boluses may also be prescribed, though usually, this is done more in other ward settings

Electrolytes

electrolytes which have a direct effect on the heart’s conduction, contraction and rhythm need to be closely monitored in intensive care nursing
potassium level should be >4 – 5.5mmols/L
magnesium level should be >1.0mmols/L
phosphate level should be >0.7mmols/L

Disability

Sedating the patient – why?

Sedation level is always decided by the ICU consultant. Reasons for patient sedation include:

ventilation facilitation
anxiety relief
acute confusion management
treatment implementation
diagnostic procedures
reduction of tachycardia, hypertension, or raised intracranial pressure

Commonly used Sedative drugs

Propofol – anaesthetic agent (negative inotrope)
Morphine – opiate
Midazolam – benzodiazepine
Fentanyl – synthetic opiate
Remifentanyl – short half life
Atracurium – muscle relaxant

The Non-Sedated Patient

assess and document the non-sedated and awake patient using the GCS or the AVPU scale to find out the patient’s level of consciousness and current mental state
assess and document the patient’s pupillary size and reaction
identify changes within the patient’s neurological state; if a patient becomes newly confused or difficult to wake up, check for any respiratory issues or medical condition deterioration

The Sedated Patient

assess the sedated patient using the GCS; include pupillary size and reaction in your assessment and documentation
document at which level is your patient sedated using the Richmond Agitation Sedation Scale (RASS)
assess patient at the beginning of your shift; continue performing assessments throughout your shift especially since the necessity for patient sedation level may change

NOTE: always check thoroughly syringe drivers with sedation, including rate and time; ensure replacement syringes are ready to be replaced prior to stopping. Sedation which is abruptly stopped may lead to patients waking up frightened and disoriented, leading to unplanned extubating or high levels of distress and anxiety!

Retrieved from https://handbook.bcehs.ca/clinical-resources/clinical-scores/richmond-agitation-and-sedation-rass/ on 22nd October 2022

Glucose Level Check

Whilst a patient may not be diabetic, one may still be on insulin in Intensive Care Nursing. This is because in ICU, patients often require an insulin infusion so as to keep their blood glucose level between 4-10mmols.

Thus, it is important to check the patient’s blood glucose levels frequently as per local guidelines, especially since in sedated patients, noticing hypoglycaemia is quite difficult.

Pain Assessment

Pain assessment is vital in intensive care nursing, especially since it may be a good indication of a newly evolving critical condition such as a Myocardial Infarction or an infection.

If a sedated patient exhibits physical stress responses such as an increased heart rate, blood pressure or agitation, consider pain as a possible culprit. A good Critical Care Pain Observations Tool (CPOT) may be used to assess pain in sedated patients. This considers the following aspects:

facial expression
body movements
ventilator compliance
muscle tension

If pain is suspected, analgesia should be administered. Whilst all ventilated patients are already on sedation and analgesia, an increased rate or a bolus may be considered, followed by a reassessment to check for improvement.

Retrieved from https://www.researchgate.net/publication/337928045_PAIN_MANAGEMENT_IN_INTENSIVE_CARE_UNIT_A_BRIEF_REVIEW/figures?lo=1 on 22nd October 2022

Exposure

Nutrition

In intensive care nursing, the patient should ideally be fed early. If awake and extubated and can eat and drink, assist in doing so. Remember that invasive lines and air mattresses can restrict patient mobility, and some assistance can go a long way!

Following intubation or tracheostomy, a patient needs to undergo a swallow assessment to ensure oral intake is advisable. At times, a nasogastric tube or jejuno tube may be indicated.

Retrieved from https://medlineplus.gov/ency/imagepages/19965.htm on 23rd October 2022

Positioning needs to be checked well whenever a new shift is taking over, as well as before oral intake is administered:

note tube position and compare current length with the previously documented length
ensure tube is well secured so as to prevent migration; change adhesive holder if necessary
checking pH of patients in intensive care nursing may be misleading; aspirate gastric contents every 4 hours and replace or discard as per local policy
to help with absorption, motility agents may be prescribed
tube feeding prescriptions are based on body weight and caloric and electrolyte needs; electrolytes, magnesium and phosphate replacement is usually prescribed together
cartridge may need to be changed every 24 hours
new lines should always be labelled with date and time of change

If enteral feeding fails, total parenteral nutrition is usually considered. TPN is administered via a PICC line or Central Line through a specific lumen – a white port. Medications are not administered via the same line.

NOTE: TPN is lipid based and so it requires strict asepsis when lines and bags are changed. New lines need to be labelled clearly with the date and time of change.

Nausea & Vomiting

An abdominal assessment needs to be performed on the patient in intensive care nursing …

LOOK at the shape and for distension, masses, ascites, prominent veins, bruising, scars, drains, or stomas.

LISTEN for bowel sounds using your stethoscope over the right lower quadrant.

FEEL and assess for localised or radiating pain and masses.

Bowel Assessment

check the last documented bowel action – patients in the Intensive Care Setting are prone to becoming constipated due to reduced bowel motility
administer any prescribed aperients (drugs to help with constipation) which are usually started early on in this setting to promote regular bowel movements
promote dignity especially in the case of incontinence
take positioning into consideration – assisting the patient with a hoist to a more natural defecation position can help conscious patients
if patient experiences uncontrolled diarrhoea, rectal tubes may be indicated to protect the skin and to measure fluid loss
record frequency and consistency

Assessing for Venous thromboembolism (VTE)

Patients in the intensive care setting are often provided with intermittent compression boots eg. flowtron, to help stimulate blood flow to deep veins, so as to help prevent thrombosis. Such devices need to be removed at least once per shift so the underlying skin is thoroughly assessed.

Mouth Care in the ICU Setting

Mouth care in the intensive care setting provides the patient with comfort. Additionally, it helps prevent Ventilator Associated Pneumonia. Toothpaste and baby toothbrushes are used twice daily. Ideally, water is given every 4 hours, and vaseline is applied to the patient’s lips every time.

Eye Care in the ICU Setting

Sedated patients are not able to blink, which leads to an increased risk of corneal sores. Use recommended eye drops as per local policy for this reason. Check the patient for redness, pus, dryness, and Scleroderma. Use eye drops and lacrilube.

Patient Skin Care

check for skin breakdown, redness, blistering surgical sites, existing pressure sores, wounds, dressings, or rashes; if needed, change the type of mattress they are currently on
encourage position changes or move sedated patients regularly to avoid formation of pressure sores
check the skin beneath flotrons or devices to avoid thrombosis at least when starting your shift
check the NGT for any markings onto the nostrils
check ETT and holders, repositioning / pressure alleviating devices; check tapes’ last change and note any ulcerations, bleeding gum or loose teeth
change saturation probe position at least every 2 hours
check for any lines or drain catheters underneath the patient
minimise shear and friction damage whilst handling the patient
ensure no creases are on the bed sheets since these may cause pain and sores
change any IV lines and feeding tubes as per local policy

Reference

Critical Care Outreach Team (2020). Basic Principles of Intensive Care Nursing. Royal Berkshire NHS Foundation Trust. Retrieved from https://www.baccn.org/media/resources/Basic_principles_of_Intensive_Care_Nursing.pdf on 18th October 2022

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