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Critical
care

2nd Edition


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Critical
Care

2nd Edition

Notes
Clinical Pocket Guide

Janice Jones, PhD, RN, CNS
Brenda Fix, MS, RN NP
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4223_Tab01_001-044 29/08/14 10:46 AM Page 1

1
Physical Assessment
Reusable Assessment Form
Pt. Identifier:
Diagnosis:

Room:

Age:

Diet:

DNR/DNI:

Surgeries/Past Hx:
Activity:
Allergies:
Neurological/MS:
ICP:
Cardiac:
VS/A-line:
ECG:
Hemodynamics: PAD
IABP:
Respiratory:
Ventilator:
ABGs/SpO2:
GI:
GU:
Wounds/Incisions:
Drainage tubes:
Treatments:
Special needs:
Other:

BASICS

PAS

PCWP

CVP


4223_Tab01_001-044 29/08/14 10:46 AM Page 2

BASICS

Normal Arterial and Venous Blood Gases
Blood Gas
Components

Arterial
7.35–7.45
80–100 mm Hg
35–45 mm Hg
22–26 mEq/L or mmol/L
–2 to +2 mEq/L or mmol/L
95%–100%

pH
PO2
PCO2
HCO3Base excess (BE)
O2 saturation

Venous
7.31–7.41
35–40 mm Hg
41–51 mm Hg
22–26 mEq/L or mmol/L
–2 to +2 mEq/L or mmol/L
68%–77%

Values denoted are at sea level.

Quick Blood Gas Interpretation
PCO2

↑ HCO3-



↓ and (+)
base excess
↑ and (–)
base excess




↓ if
compensating
↑ if
compensating


↑ if compensating
↓ if compensating








Acid-Base Disorder
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
Mixed respiratory and
metabolic acidosis
Mixed respiratory and
metabolic alkalosis

pH

Full or total compensation: pH will be within normal limits.

2





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3
Blood Gas Results
Arterial

Venous
pH
PO2
PCO2
HCO3Base excess (BE)
O2 saturation

Compensation:
■ Respiratory problem → the kidneys compensate by conserving or excreting
HCO3■ Metabolic problem → the lungs compensate by retaining or blowing off CO2

Also look for mixed respiratory and metabolic problems. PaCO2 or HCO3- in a
direction opposite its predicted direction or not close to predictive value. May
result from cardiac arrest, vomiting with renal failure and COPD as comorbidities, and salicylate toxicity.

Common Causes of Acid-Base Imbalances
Respiratory acidosis

Respiratory alkalosis
Metabolic acidosis

Metabolic alkalosis

BASICS

COPD, asthma, head injury, pulmonary edema,
aspiration, pneumonia, ARDS, pneumothorax,
cardiac arrest, respiratory depression, CNS
depression, or head injury
Hyperventilation, anxiety, fear, pain, fever, sepsis,
brain tumor, mechanical overventilation
Diabetes mellitus, acute and chronic renal failure,
severe diarrhea, alcoholism, starvation, salicylate
overdose, pancreatic fistulas
Loss of gastric acid (vomiting, gastric suction),
long-term diuretic therapy (thiazides, furosemide),
excessive NaHCO3 administration, hypercalcemia


4223_Tab01_001-044 29/08/14 10:46 AM Page 4

BASICS

Pulse Oximetry
SpO2 monitoring may be intermittent or continuous. Indirectly monitors oxygen
saturation.

SpO2 Level
>95%
91%–94%
85%–90%
<85%
<70%

Indication
Normal
May be acceptable, provide O2 as necessary, encourage
C&DB, or suction prn
Provide O2 as necessary, encourage C&DB, or suction prn;
may be normal for COPD patient
Prepare for possible intubation
Unreliable; obtain ABG

Values denoted are at sea level.

False readings may occur because of anemia, carbon monoxide poisoning,
hypothermia, hypovolemia, hypotension, peripheral vasoconstriction, and poor
peripheral perfusion caused by disease or medications.

Continuous Monitoring
■ Alarms are set for low SpO2, tachycardia, or bradycardia.
■ Waveform should be sharp with a clearly identified dicrotic notch.
■ The probe may be placed on the finger (preferred), toes, or ear lobe or
pinna.
■ Patient must have SBP >80 mm Hg.

Lactic Acidosis
Lactic acid is a byproduct of anaerobic metabolism. Increased levels indicate
inadequate perfusion of vital organs with resultant tissue hypoxia. May result
from inadequate perfusion and oxygenation of vital organs; post cardiac or respiratory arrest; cardiogenic, ischemic, or septic shock; drug overdoses; seizures;
cancers; or diabetes mellitus (refer to Multisystem tab).
Normal lactate level <2 mmol/L; >5 mmol/L indicates lactic acidosis.

4


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5
Respiratory Terms and Calculations
■ Functional residual capacity (FRC) is the volume of air in the lungs after
normal expiration.
Normal = 2,400 mL.
■ Hypoxemia is the severe reduction of O2 in arterial blood.
■ Hypoxia is the severe reduction of O2 at the cellular level.
■ Minute ventilation (MV) = respiratory rate (RR) × tidal volume (VT).
To improve MV and ↓ PaCO2 with mechanical ventilation: ↑ VT, and/or ↑ RR;
↑ inspiratory pressure, prolong inspiratory time, ↑ pressure support level,
↓ airway resistance, suctioning, use of bronchodilators.
■ P/F (PaO2/FIO2) ratio. The smaller the value, the worse the patient’s gas
· ·
exchange. Frequently calculated to suggest ARDS and V/Q mismatch.
Normal = 300–500; impeding or actual respiratory failure = 200–300 (may
· ·
need to intubate); ARDS or V/Q mismatch = <200, indicates hypoxemia and
need to intubate.
Formula: PaO2 (from ABG in mm Hg) ÷ FIO2 (converted to decimal) = P/F
ratio number.
Example: PaO2 = 87 mm Hg and patient is on room air (21% = 0.21) =
77 ÷ 0.21 = 366.
■ SaO2 is the saturation of oxygen in hemoglobin in arterial blood =
95%–100% normal. Obtained from arterial blood sample.
■ SvO2 is the percentage of O2 bound to hemoglobin in venous blood =
60%–80%. Assesses tissue perfusion or oxygenation of tissues. May be
monitored intermittently or continuously using an oximetric pulmonary
artery catheter. ScvO2 is a central venous sample from internal jugular or
subclavian catheters = >70%.
↑ SvO2 ( >80%) indicates an↑ in O2 delivery or ↓ O2 extraction by tissues.
↓ SvO2 (<60%) indicates a ↓ in O2 delivery or ↑ extraction by tissues
→ cardiac output not adequate to meet tissue O2 needs; Hgb may be
low; O2 consumption > oxygen delivery.

End-Tidal Carbon Dioxide Monitoring (ETCO2)
ETCO2 or capnography/capnometry is the measurement, display, and monitoring of the concentration or partial pressure of CO2 (ETCO2) in the respiratory
gases at the end of expiration. ETCO2 values are usually 2–5 mm Hg lower than
the PaCO2 value. The capnogram displays the maximum inspiratory and expiratory CO2 concentrations during a respiratory cycle that indirectly reflect the production of CO2 by the tissues and the transport and clearance of CO2 to and in
the lungs. Sudden changes in CO2 elimination should be monitored in selected
cardiorespiratory patients and postoperatively after major cardiothoracic surgery.

BASICS


4223_Tab01_001-044 29/08/14 10:46 AM Page 6

BASICS
ETCO2 monitoring can also be used to verify ETT position, assess readiness for
extubation, and monitor the effectiveness of CPR and predict patient survival.
ETCO2 <10 mm Hg after 20 min CPR indicates poor outcome. It is sometimes
referred to as the “ventilation vital sign.”

Causes of ↑ ETCO2
Fever
Hypertension
Increased cardiac output
Respiratory compromise
Hypoventilation
Airway obstruction
Bronchial intubation
Hypovolemia
Sepsis
Seizures

Causes of ↓ ETCO2
Hypothermia
Hypotension and shock
Cardiac perfusion changes
Decreased cardiac output, heart failure
Cardiac arrest and apnea
Hyperventilation
Airway obstruction
Accidental extubation
Pulmonary embolus
Hypervolemia

Normal range of ETCO2 is 35–45 mm Hg. CO2 and ETCO2 should correlate within 2–5 mm Hg.
↑ RR (hyperventilation) → ↓ CO2 → ETCO2 < 35 = respiratory alkalosis
↓ RR (hypoventilation) → ↑ CO2 → ETCO2 > 45 = respiratory acidosis
Five characteristics of the capnogram should be evaluated: frequency, rhythm,
height, baseline, and shape. Also note changes if patient is disconnected from ventilator and attempts of spontaneous breaths if patient is receiving paralytic agents.

Normal Capnogram
Expiration

Inspiration

mm Hg

III
II
I
Time

Phases I, II, and III represent expiration; the bolded lines represent inspiration.
Long periods of a flat wave form indicate apnea, dislodged endotracheal tube,
esophageal intubation, or patient disconnection from ventilator.

6


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7
Artificial Airways and Mechanical Ventilation
Artificial Airways
Endotracheal Tube
■ Adult oral tube sizes: males, 8.0–8.5 internal diameter (I.D.) (mm); females,
7.0–8.0. I.D. (mm).
■ Placement is 2–3 cm above the carina. Verify by auscultating for breath
sounds bilaterally, uniform up-and-down chest movement, CXR, and checking ETCO2 immediately after intubation.
■ Cuff pressure: 20–25 mm Hg.

Rapid Sequence Induction (RSI): Minimizes time to intubation and secures a
patent airway.
■ Procedure outline:
■ Preoxygenate patient with 100% O2.
■ Induction drug administered: etomidate, propofol, ketamine, thiopental
or scopolamine.
■ Neuromuscular blocking agent administered: succinylcholine.
■ Apply cricoid pressure.
■ ETT inserted.
■ Nursing concerns:
■ Know patient’s K+ level.
■ Have routine intubation supplies available.
■ Check for workable suction source and provide regular suction catheter
and Yankauer catheter.
■ Provide emotional support to patient and notify patient’s family of rapid
induction of ETT.

Cuff pressure can be monitored via a calibrated aneroid manometer device.
Connect manometer to cuff. Deflate cuff. Reinflate cuff in 0.5-mL increments
until desired cuff pressure is achieved. Check cuff pressure every 8–12 hr or per
agency protocol.

Tracheostomy Tube
■ Tracheostomy tubes may be cuffed or uncuffed and have either a reusable
or disposable inner cannula. Both fenestrated and Passy-Muir valves allow
the patient to speak.
■ Size will vary.
■ Cuff pressure: 20–25 mm Hg.
■ Early replacement of ETT with tracheotomy has not been shown to improve
patient outcomes.
■ Other artificial airways include oropharyngeal airway and nasopharyngeal
airway.

BASICS


4223_Tab01_001-044 29/08/14 10:46 AM Page 8

BASICS
Oxygen delivery systems include the nasal cannula, face mask, Venturi mask,
partial rebreather mask, nonrebreather mask, tracheostomy collar, and T-piece.
■ Nonrebreather mask allows for 80%–90% FIO2 to treat lowing O2 levels as
exhibited by decreasing SpO2 or impending respiratory failure prior to
intubation.
■ The T-piece may be connected to either an ETT or a tracheostomy tube.
Frequently used in ventilator weaning.

Mechanical Ventilation
Classification of Ventilators
Positive Pressure Ventilation
■ Volume-Cycled Ventilator: Delivers a preset constant volume of air and preset O2.
■ Pressure-Cycled Ventilator: Produces a flow of gas that inflates the lung
until the preset airway pressure is reached.
■ Time-Cycled Ventilator: Programmed to deliver a volume of gas over a specific time period through adjustments in inspiratory-to-expiratory ratio.
Primarily used in neonates.

Negative Pressure Ventilation
Uses the old iron lung principle by exerting negative pressure on the chest wall
to cause inspiration. No intubation required. Custom-fitted “cuirass” or “turtle”
shell unit fits over the chest wall. May be used at night for patients who require
assistance during sleep.

Modes of Ventilation
■ Continuous Mandatory Ventilation (CMV): Machine controls rate of breathing. Delivery of preset volume (TV) and rate regardless of patient’s breathing pattern. Sedation or neuromuscular blocking agent usually required.
Very restricted use (e.g., SCI).
■ Assist Controlled Ventilation (AC or ACV): Patient controls rate of breathing. Inspiratory effort triggers delivery of preset volume.
■ Synchronized Intermittent Mandatory Ventilation (SIMV): A form of pressure support ventilation. Administers mandatory ventilator breath at a preset level of positive airway pressure. Monitors negative inspiratory effort
and augments patient’s spontaneous tidal volume or inspiratory effort.
Synchronized with patient’s breathing pattern.
■ Positive End-Expiratory Pressure (PEEP): Increases oxygenation by increasing functional residual capacity (FRC). Keeps alveoli inflated after expiration. Can use lower O2 concentrations with PEEP; decreases risk of
O2 toxicity. Ordered as 5–10 cm H2O.
■ Pressure Support Ventilation (PS or PSV): Patient’s inspiratory effort is
assisted by the ventilator to a certain level of pressure. Patient initiates all

8


4223_Tab01_001-044 29/08/14 10:46 AM Page 9

9







breaths and controls flow rate and tidal volume. Decreases work of breathing and promotes weaning.
Pressure-Controlled ventilation (PCV): Controls plateau pressures
in patients with ARDS and persistent oxygenation problems despite high
levels of PEEP and FIO2.
Pressure-Regulated Volume Control (PRVC): Preset rate, FIO2, and pressure
limit. Improves patient-ventilator synchrony and reduces barotrauma. May
require sedation.
Volume-Assured Pressure Support (VAPS) or Volume Guaranteed Pressure
Options (VGPO): Combination of pressure with guaranteed volume control.
High-Frequency Ventilation (HFV): Delivers very high breaths/min with low
tidal volumes. These include high-frequency oscillatory ventilation (HFOV
or HFO), high-frequency jet ventilation (HFJV), and high-frequency positive
pressure ventilation (HFPPV).
Inverse Ratio Ventilation (IRV): All breaths are pressure limited and time
cycled. Inspiratory time usually set shorter than expiratory time. I:E ratio is
usually 1:1.3–1.5

Noninvasive Mechanical Ventilation (NIV)
■ Continuous Positive Airway Pressure (CPAP): A form of noninvasive
mechanical ventilation (NIMC). Maintains positive pressure throughout the
respiratory cycle of a spontaneously breathing patient. Increases the
amount of air remaining in the lungs at the end of expiration. Fewer complications than PEEP. Ordered as 5–10 cm H2O.
■ Bilevel Positive Airway Pressure (BiPAP): Same as CPAP but settings can be
adjusted for both inspiration and expiration.

SIMV, CPAP, BiPAP, and PSV can all be used in the weaning process.

General Nursing Care for Mechanically Ventilated
Patients
■ General routine head-to-toe assessment to monitor for complications related
to mechanical ventilation.
■ Check ventilator settings for accuracy, especially rate, tidal volume, FIO2,
PEEP level, and pressure gauge; monitor ABGs after ventilator setting
changes.
■ Assess for oxygen toxicity. Cellular damage causing capillary leak →
pulmonary edema and ARDS. May develop if patient on 100% FIO2 for
>12 hr or >50% FIO2 for >24 hr. Monitor for dyspnea, ↑ lung compliance,
↓ A-a gradient, paresthesia in the extremities, and retrosternal pain. Keep
O2 at lowest possible concentration. Consider PEEP to ↑ FIO2. If patient is
anemic, transfuse RBCs.
■ Administer analgesics, sedation drugs, and neuromuscular blocking agents
as needed.

BASICS


4223_Tab01_001-044 29/08/14 10:46 AM Page 10

BASICS
■ Provide communication methods for patients, and communicate freely with
families.
■ Prevent infection including catheter-associated urinary tract infection
(CAUTI), central catheter-associated bloodstream infection (CLABSI), and
ventilator-associated pneumonia (VAP) (refer to VAP guidelines in
Respiratory tab).
■ Assess readiness to wean.

Weaning
Sample Criteria for Weaning: Readiness
■ Alert and cooperative
■ FIO2 <40%–50% and PEEP <5–8 cm H2O
■ Hemodynamically stable with HR <120 bpm and no significant arrhythmias,
SBP >100 mm Hg
■ pH >7.34
■ PaO2 >80 mm Hg
■ PaCO2 <45 mm Hg
■ PaO2/FIO2 ratio >200
■ ETCO2 <40 mm Hg
■ Vital capacity 15 mL/kg and minute ventilation <10
■ Hemoglobin >7–9 g/dL and serum electrolytes within normal limits
■ Spontaneous respirations >6 bpm or <35 bpm
■ Negative inspiratory pressure –30 cm H2O
■ Relatively afebrile with limited respiratory secretions and good cough reflex
■ Good pain management
■ Inotropes reduced or unchanged within previous 24 hr
■ Sedation discontinued
■ Spontaneous breathing trials (SBT)

Weaning Protocol
Hospital Weaning Protocol

Patient’s Readiness for Weaning

Continued

10


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11
Weaning Protocol—cont’d
Hospital Weaning Protocol

Patient’s Readiness for Weaning

Weaning Methods
■ T-tube weaning: Place patient on T-tube circuit on same FIO2 as on ventilatory
assistance. Monitor ABGs after 30 min. Provide a brief rest period on the
ventilator as needed and continue to monitor ABGs until satisfactory.
Extubate when patient is rested, has good spontaneous respiratory effort,
and ABGs within acceptable parameters.
■ SIMV weaning: Decrease SIMV rate every 1–4 hr or 2 breaths/min. Monitor
spontaneous breaths, SpO2 with a goal of >90%, ETCO2, hemodynamics, and
ECG for dysrhythmias. Obtain ABGs within 30 min of ventilator change.
Allows for gradual change from positive pressure ventilation to spontaneous pressure ventilation. Titrate FIO2.
■ PSV: Use low levels of PSV (5–10 cm H2O). Decrease in 3–6 cm of H2O increments. Useful in retraining respiratory muscles from long-term ventilation.
■ CPAP/BiPAP: Provides expiratory support, maintains positive intrathoracic
pressure. BiPAP adds inspiratory support to CPAP. Prevents respiratory muscle
fatigue.

Nursing Assessment During Weaning












Vital signs and hemodynamic stability (PAS, PAD, PCWP, CO, CI)
Dysrhythmias or ECG changes
Oxygenation/efficiency of gas exchange: SaO2 >90% on <40% FIO2
CO2 production and elimination
pH level
Bedside pulmonary function tests
Work of breathing including use of accessory muscles
Adequate clearing of airway though effective coughing
Level of fatigue
Patient discomfort
Adequate nutrition

BASICS


4223_Tab01_001-044 29/08/14 10:46 AM Page 12

BASICS
Ventilator Alarms
Ventilator alarms should never be ignored or turned off. They may be muted or
silenced temporarily until problem is resolved.

Checklist of Common Causes of Ventilator Alarms
Patient causes:









Biting down on endotracheal tube
Patient needing suctioning
Coughing
Gagging on endotracheal tube
Patient “bucking” or not synchronous with the ventilator
Patient attempting to talk
Patient experiencing period of apnea >20 sec
Development of pneumothorax from increasing intrathoracic pressures

Mechanical causes:









Kinking of ventilator tubing
Endotracheal tube cuff may need more air
Leak in endotracheal tube cuff
Excess water in ventilator tubing
Leak or disconnect in the system
Air leak from chest tube if present
Malfunctioning of oxygen system
Loss of power to ventilator

Pathophysiological causes:





Increased lung noncompliance, such as in ARDS
Increased airway resistance, such as in bronchospasm
Pulmonary edema
Pneumothorax or hemothorax

Nursing Interventions






Check ventilator disconnects and tubing.
Assess breath sounds; suction as needed.
Remove excess water from ventilator tubing.
Check endotracheal cuff pressure.
Insert bite block or oral airway.

If cause of the alarm cannot be found immediately or cause cannot be readily
resolved, remove patient from ventilator and manually ventilate patient using a
resuscitation (Ambu) bag.
Call respiratory therapy stat.
Continue to assess patient’s respiratory status until mechanical ventilation is
resumed.

12


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13
Implementing the ABCDE Bundle at the Bedside From
the American Association of Critical Care Nurses
The ABCDE bundle is a group of evidence-based practices that help prevent
unintended consequences in critically ill patients. Detailed guidelines can be
found at: http://www.aacn.org/wd/practice/content/actionpak/withlinks-abcdetoolkit.content?menu=%20practice
The ABCDE bundle consists of:
ABC—Awakening and Breathing Trial Coordination: Awakening trials daily
(sedation vacations), with spontaneous Breathing trials to promote earlier
extubation as Coordinated with respiratory therapist.
D—Delirium Assessment and Management: Early identification and management of patients with delirium.
E—Early Exercise and Progressive Mobility: Enable patients to become progressively more active and, possibly, walk while intubated.
Analgesia/Sedation Protocol for Mechanically Ventilated Patients can be
found at: http://www.mc.vanderbilt.edu/icudelirium/docs/Sedation_protocol.pdf
■ Sedatives
■ Anxiolytics
■ Analgesics

Sedation weaning also includes:
■ Use of short-term sedatives
■ Daily sedation interruptions using the “Wake Up and Breathe” protocol.
Refer to: http://www.mc.vanderbilt.edu/icudelirium/docs/WakeUpAnd
Breathe.pdf
■ Treatment of pain
■ Use of sedation scales (refer to Basics tab on Sedation)
■ Regular assessment of delirium using the CAM-ICU (refer to Basics tab on
Delirium)

BASICS


4223_Tab01_001-044 29/08/14 10:46 AM Page 14

BASICS

Ventilator Complications
Complication
Barotrauma or volutrauma:
acute lung injury, may result in
pneumothorax or tension pneumothorax, pneumomediastinum,
pneumoperitoneum, subcutaneous crepitus
Intubation of right mainstem
bronchus

Endotracheal tube out of position
or unplanned extubation

Tracheal damage from excessive
cuff pressure (>30 cm H2O)

Damage to oral or nasal mucosa

Aspiration
Tracheoesophageal fistulas

Ventilator-associated pneumonia
Respiratory infection
Increased risk of sinusitis

Signs & Symptoms/Interventions
High peak inspiratory and mean airway
pressures
Diminished breath sounds
Tracheal shift
Subcutaneous crepitus
Hypoxemia
Insert chest tube or needle thoracostomy.
Absent or diminished breath sounds in
left lung
Unilateral chest excursion
Reposition ETT.
Absent or diminished breath sounds
Note location of tube at the lip
(21–22 cm).
Reposition ETT or reintubate.
Restrain only when necessary.
Blood in sputum when suctioning
Frequent ventilator alarm
Monitor ETT cuff pressure every 4–8 hr.
Ensure minimal occluding volume.
Skin breakdown or necrosis to lips,
nares, or oral mucous membranes
Reposition tube side-side of mouth
every day.
Apply petroleum jelly to nares.
Provide oral care with toothbrush every
2 hr. Follow VAP protocol for oral care.
Feeding viewed when suctioning
Keep head of bed 30–45 degrees.
Administer proton pump inhibitors or
histamine H2-receptor antagonists.
Blue dye in feeding not recommended.
Refer to Respiratory section on VAP
Assess color and odor of sputum.
Monitor temperature, WBC count, ESR.
Continued

14


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15
Ventilator Complications—cont’d
Complication
Decreased venous return →
decreased cardiac output from
increased intrathoracic pressure
Stress ulcer and GI bleeding

Gastric distention
Paralytic ileus

Inadequate nutrition, loss of
protein

Increased intracranial pressure

Fluid retention from increased
humidification from ventilator,
increased pressure to
baroreceptors causing release
of ADH
Immobility
Skin breakdown

Signs & Symptoms/Interventions
Hypotension
Decreased CVP, RAP, and preload
Monitor vital signs and hemodynamics.
Blood in nasogastric drainage
Hematemesis and/or melena
Hematest nasogastric drainage, emesis,
feces.
Administer proton pump inhibitors or
histamine H2-receptor antagonists.
Auscultate bowel sounds. Consider NG
placement.
Absence of diminished bowel sounds
Provide nasogastric drainage with intermittent suction.
Turn and position patient frequently.
Refer to section on nutrition.
Start enteral feedings if appropriate.
Start total parenteral nutrition if GI tract
nonfunctional or contraindicated.
Changes in level of consciousness
Inability to follow commands
Assess neurological status frequently.
Assess for edema.
Administer diuretics.
Drain ventilator tubing frequently.

Turn and position patient frequently.
Assess skin for breakdown.
Assist patient out of bed to chair unless
contraindicated.
Keep skin clean and dry, sheets
wrinkle-free.

Continued

BASICS


4223_Tab01_001-044 29/08/14 10:46 AM Page 16

BASICS

Ventilator Complications—cont’d
Complication
Communication difficulties

Urinary tract infection

Deep vein thrombosis

Psychosocial concerns: fear, loss,
powerlessness, pain, anxiety,
sleep disturbances, nightmares,
loneliness

Signs & Symptoms/Interventions
Keep communication simple.
Obtain slate or writing board.
Use letter/picture chart.
Communicate using sign language.
Urine becoming cloudy, concentrated,
odorous
Change/remove Foley catheter.
Ensure adequate hydration.
Administer anti-infectives.
Painful, swollen leg; pain may increase
on dorsiflexion
Assess for pulmonary embolism. Refer
to Respiratory tab.
Administer heparin or enoxaparin.
Anxiety
Difficulty sleeping
Poor pain control
Administer anxiolytics, sedatives, analgesics.
Cluster activities to promote periods of
sleep.
Allow patient to make choices when
appropriate.
Allow for frequent family visits.
Keep patient and family informed.

Neuromuscular Blocking Agents (NMBA)
Purposes





Facilitate ETT intubation.
Facilitate mechanical ventilation and improve gas exchange.
Reduce ICP.
Control excessive shivering.

Neuromuscular Blocking Agents Used
■ Succinylcholine (Quelicin)
■ Rocuronium (Zemuron)

16


4223_Tab01_001-044 29/08/14 10:46 AM Page 17

17
■ Pancuronium (Pavulon)
■ Vecuronium

Peripheral Nerve Stimulator
■ Monitors the level of blockade with NMBA use.
■ Electrical stimulation is applied to the ulnar nerve, the facial nerve, or the
posterior tibial nerve.
■ Train of four (TOF) testing and monitoring should be instituted. The number
of twitches elicited through electrodes along a nerve path is counted. Depth
of blockage increases, number of twitches on the TOF decreases. Prevents
overparalyzing the patient and causing prolonged muscular weakness.

Specific Nursing Management
■ Patient must be intubated or have tracheostomy in place. Keep airway
patent, and respond to ventilator alarms quickly.
■ Monitor and assess response to NMBAs.
■ Monitor VS and neurological status, especially pupillary response.
■ Monitor ABGs and oxygenation levels.
■ Provide eye lubrication and/or taping.
■ Provide DVT prophylaxis.
■ Initiate pressure sore prevention actions.

Hemodynamic Monitoring
Hemodynamic Parameters
Arteriovenous oxygen difference...................................3.5–5.5 vol% or 4–8 L/min
Aortic pressure:
■ Systolic.........................................................................................100–140 mm Hg
■ Diastolic ...........................................................................................60–80 mm Hg
■ Mean ................................................................................................70–90 mm Hg

Cardiac output (CO = HR × SV)..................................................................4–8 L/min
Cardiac index (CO/BSA) ..........................................................................2.5–4 L/min
Central venous pressure (CVP)...............................................................2–8 mm Hg
**Same as right atrial pressure (RAP)
Cerebral perfusion pressure (CPP).....................................................70–90 mm Hg
Coronary artery perfusion pressure (CAPP)......................................60–80 mm Hg
Ejection fraction (Ej Fx or EF).....................................................................60%–75%
Left atrial mean pressure ......................................................................4–12 mm Hg
Left ventricular systolic pressure ...................................................100–140 mm Hg
Left ventricular diastolic pressure..........................................................0–5 mm Hg
Left ventricular end-diastolic pressure (LVEDP)..................................5–10 mm Hg
Left ventricular end-diastolic volume (LVEDV) .............120–130 mL up to 250 mL

BASICS


4223_Tab01_001-044 29/08/14 10:46 AM Page 18

BASICS
Left ventricular stroke work index (LSWI) ...................................30–50 g/beats/m2
Mean arterial pressure (MAP) ..........................................................70–100 mm Hg
Mean arterial pressure used to determine whether BP is sufficient to perfuse
the heart, brain, kidneys and other organs
Oxygen consumption (VO2)............................................................200–250 mL/min
Oxygen delivery (Do2)...................................................................900–1100 mL/min
Pulmonary artery pressure (PAP):
■ Systolic.............................................................................................20–30 mm Hg
■ Diastolic ...........................................................................................10–20 mm Hg
■ Mean ................................................................................................10–15 mm Hg

Pulmonary capillary wedge pressure (PCWP) ....................................4–12 mm Hg
Pulmonary vascular resistance (PVR) .....................................37–250 dyne/sec/cm
Pulse pressure (SBP-DBP) ........................................................................40 mm Hg
Right atrial mean pressure .....................................................................2–6 mm Hg
Right ventricular pressure:
■ Systolic.............................................................................................20–30 mm Hg
■ Diastolic ...............................................................................................0–8 mm Hg
■ End diastolic ........................................................................................2–6 mm Hg

Right ventricular stroke work index (RSWI) ....................................7–12 g/m2/beat
Pulmonary vascular resistance (PVR) .................................20–130 dynes/sec/cm-5
Pulmonary vascular resistance index (PVRI) ...............200–400 dynes/sec/cm5/m2
Pulmonary ventricular stroke index .................................................5–10 g/beat/m2
Right atrial pressure (RAP).....................................................................2–6 mm Hg
Stroke index (SI) .........................................................................30–650 mL/beat/m2
Stroke volume (SV = CO/HR) ...........................................................60–100 mL/beat
Systemic vascular resistance (SVR) ...............................900–1,600 dynes/sec/cm-5
Systemic vascular resistance index.......................1,360–2,200 dynes/sec/cm-5/m2
Systemic venous oxygen saturation (SvO2) .............................................60%–80%

Cardiac Output Components
Preload
Pao2
Right atrial pressure
Central venous pressure
Left ventricular enddiastolic pressure

Contractility
Sao2
Stroke volume
Cardiac output
Tissue perfusion

18

Afterload
Hemoglobin (Hgb)
Pulmonary vascular resistance
Systemic vascular resistance
Blood pressure


4223_Tab01_001-044 29/08/14 10:46 AM Page 19

19
Pulmonary Artery Catheter
The purpose of the pulmonary artery catheter, also known as the Swan-Ganz
catheter, is to assess and monitor left ventricular function and can determine
preload, assess contractility, and approximate afterload.
PCWP approximates left atrial pressure and left ventricular end-diastolic pressure.
Increases in PCWP, LAP, or LVEDP indicate heart failure, hypervolemia, shock,
mitral valve insufficiency, or stenosis. Decreases in PCWP, LAP, or LVEDP indicate hypovolemia.

PA Catheter Waveforms
The pulmonary artery catheter is threaded through the right atrium and right
ventricle and into the pulmonary artery. Insertion is done via fluoroscopy or
monitoring waveform changes.

40
30
mm Hg

Catheter advanced to
right atrium, balloon
is inflated. Pressure
is low, usually
2–5 mm Hg.

20

Balloon
catheter
Right
atrium

10
0
Time

40
30
Balloon
catheter

mm Hg

Catheter is floated to
right ventricle with
the balloon inflated.
Waveforms indicate
a systolic pressure
of 25–30 mm Hg and
a diastolic pressure
of 0–5 mm Hg.

20
10
0

Right
ventricle

Time

Continued

BASICS


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