General Overarching Concepts

NU2ICU V3 logoGENERAL OVERARCHING CONCEPTS   (the 15 minute version)

R.E.S.P.E.C.T.

You have the right to expect every staff member to model respectful behaviours in every interaction.  The right to speak, be listened to, considered and respected.

As a novice nurse or as a senior we all come to work to do our best and should feel safe in our workplace.

Should you feel unsafe, threatened or disrespected in the workplace discuss with a trusted senior,  Ward Leadership team or Human Resources as soon as possible.

 

FASTHUGS

To improve general ICU care in 2005, JL Vincent popularised the mnemonic FAST HUGS, it stood for;

Feeding/fluids

Analgesia

Sedation

Thromboprophylaxis

Head up position

Ulcer prophylaxis

Glycaemic control

Spontaneous breathing trial

To make the process more inclusive Vincent and Hatton updated the mnemonic in 2009 to

FAST HUGS BID it stood for;

Feeding/fluids

Analgesia

Sedation

Thromboprophylaxis

Head up position

Ulcer prophylaxis

Glycaemic control

Spontaneous breathing trial

Bowel care

Indwelling catheter removal

De-escalation of antibiotics / un-needed treatments / end of life

Why do the Consultants refer to FAST HUGS BID?

The mnemonic is a reference to evidence based essential aspects of ICU practice.

F – Feeding – all patients should be fed enterally or orally within 48 hrs of ICU admission.  Should this not be able to be commenced within 72 hours parental nutrition should be considered.  Better nutrition leads to better healing – end of story!

A & S – analgesia and sedation – all patients should have pain and sedation documented minimum 4 hrly (ICU is performed hourly) All patients should have a target Richmond Agitation and Sedation Score (RASS) documented on the chart.  No one should need to be in pain in a fully monitored environment and it can lead to respiratory complications and delirium.    By using a lower RASS it decreases length of ventilation, improves secretion clearance and reduces risk of VAP.

T – thromboembolic prophylaxis should be considered for every ICU patient by use of anticoagulants or compression devices.

In ICU, unless specifically ordered, we always remove TED stockings if in place under SCUDs.  It has long been recognised that venous thromboembolism is the single most preventable cause of hospital associated death among inpatients.

H – head up for all ICU patients and be maintained in a semi-recumbent position with head of bed at >30 degrees to help prevent Ventilator Associated Pneumonia (VAP).   All ICU standard beds have protractors fitted under the head split end to ensure a minimum of 300 is achieved.  VAP accounts for up to half of all infections in the ICU in the critically ill, it prolongs duration of ventilation, prolongs duration of ICU stay and increases risk of mortality

S – stress Ulcer prophylaxis to prevent gastrointestinal haemorrhage in ICU patients. Upwards of 75% of all patients in ICU demonstrate evidence of stress related mucosal damage which can lead to bleeding in 2-6% of cases.  Consequences of GI bleeding include prolonged hospitalisation, increased length of stay in the ICU and significant mortality.  ICU also uses early feeding as stress ulcer prophylaxis

G – glycaemic control for ICU patients aiming between 5.1 and 10.0.  High blood glucose level associated with poor patient mortality with MI, stroke, head injury, medical and surgical critical illness, post-CABG, etc.  High blood glucose also increases infectious complications

B – bowel function with daily evaluation and maintenance of appropriate levels of function observing for diarrhoea as can lead to electrolyte imbalances, dehydration, haemorrhoid irritation with resultant anemia and delirium.   Constipation can lead to discomfort, feeding intolerance, perforation, surgical intervention and delirium.

I – indwelling catheters of all kinds are assessed daily and removed as soon as able (arterial, venous, urinary, etc.)   Decreases safety and infection risk, patient discomfort and can promote a feeling of progress for the patient

D – de-escalation of antimicrobial and other pharmacotherapies, treatments and end of life concepts, decreases multi factorial resistance to antibiotics, tolerance of drugs, promotes weaning of drugs IE steroids etc.   Empowers discussion regarding ongoing therapies and if “breaks” are appropriate IE CVVHDF (dialysis)

The daily review of possible futility of ongoing care or aspects of care and discussion with key stakeholders (discussion on end of life decisions, limitation of treatment, etc).

Adequate urine output is integral to homeostasis and in ICU all patients are expected, with successful treatment and support, to achieve an output of greater than 30mls per hour every hour of the day.   Should the patients output drop below 30mls for more than one hour, inform the T/L unless this has previously been acknowledged as satisfactory.

REFERENCES

Essentials of Critical  Care Nursing: a holistic approach 1st Edition 2013 by Patricia Gonce Morton, Dorrie K. Fontaine

AACN essentials of critical care 1st Edition 2007  by Marianne Chulay, Suzanne Burns

ACCCN’s critical care nursing 2nd Edition 2012 by Doug Elliott, Leanne Aitken and Wendy Chaboyer

Oh’s Intensive Care Manual 7th Edition 2014 by Andrew Bersten, Neil Soni

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