OTHER GENERAL OVERARCHING CONCEPTS
Richmond Agitation and Sedation Score (RASS) or whichever system your ICU uses (Ramsay, Sedation Assessment Scale, Motor Activity etc) allows specific targeted ordering and scoring or similar enables your ICU to achieve the minimum (and by default also the maximum) required level of sedation for patients. Every patient should have a target RASS score documented on their ICU chart each day
Minimising sedation helps decrease length of invasive ventilation, improves secretion clearance by keeping patients comfortable yet able to cough to stimulus and reduce risk of Ventilator Associated Pneumonia (VAP) by increasing airway protection. If the patient does not reflect the target RASS score discuss with your T/L which infusions to alter to best achieve the goal.
For more on RASS click here
In ICU it is important to understand that “Oxygenation” and “Ventilation” are two entirely different mechanisms that both rely on the respiratory cycle.
- oxygenation relies on the inspiratory phase and refers to the amount of oxygen (O2) available and utilised.
- ventilation relies on the expiratory phase and refers to the amount of carbon dioxide (CO2) produced during the metabolic cycle of the cells, and exhaled from the body.
- oxygenation and ventilation are BOTH needed, in proper proportion, to sustain life.
Image – http://what-when-how.com/paramedic-care/ventilation-clinical-essentials-paramedic-care-part-1
Is the amount of oxygen taken in by the lungs and made available to the cells. Oxygenation relies on the inspiratory phase of the respiratory cycle
There are at lease two ways to check a patients oxygenation status;
Invasively an arterial blood gas (ABG) can be obtained which measures, among other things, the PaO2 (Partial Pressure of Oxygen dissolved in the blood plasma of arterial blood)
Non-Invasively pulse oxymetry can be obtained which measures the amount of oxygen that is bound to the haemoglobin
This reflects to the amount of carbon dioxide in arterial blood and expelled from the body through exhalation. Ventilation relies on the expiratory phase of the respiratory cycle and can be measured in two ways (more on this later!)
Invasively the same arterial blood gas (ABG) sample that measures the PaO2 also measures the PaCO2 (Partial Pressure of carbon dioxide dissolved in blood plasma of arterial blood)
Non-Invasively the PETCO2 (Partial pressure of carbon dioxide in exhaled gas) can be measured. This is measured breath by breath at the end of the expiratory phase on invasive ventilators. There are even percutaneous CO2 monitors should your hospital have them
Arterial Blood Gas
To support decisions regarding oxygenation and ventilation ICUs generally take an ABG 4 hourly minimum unless otherwise indicated/agreed by your Team Leader (T/L)
Show the printed result to your T/L for interpretation of need for escalation / change
Other key areas displayed on the ABG includes electrolytes, Hb, lactate and BGL
ICU likes (always observe for sudden changes in any level)
Na (sodium) between 137 – 145mmol/L
Cl (chloride) between 107 – 110mmol/L
K (potassium) between 4.0 – 4.5mmol/L
Ca (calcium) between 2.1 – 2.55mmol/L
Hb (haemoglobin) between 7.0 – 16.5g/L
Lactate less than 2.0mmol/L
BGL between 5.1 – 10.0mmol/L
The completion of the ICU chart
If you still live in a world of paper then on most ICU charts you may find;
- your daily nursing care plan including records of what needs changing and when
- Braden scoring to be done every shift
- total hours for fluids and ventilation (fluids balance and funding…)
- nutritional intake record
- legends for GCS, RASS etc
All of this information for your charting needs to be observed and filled out during your shift according to what you see with your patient, should you have any questions talk to your T/L
Most ICU patients are dependant for all aspects of hygiene, one of the most important roles for the ICU nurse is to supply and promote good regular mouth care
Teeth brushing – every patient even those without teeth have been shown to benefit from tooth brushing, it promotes decreased VAP, lessens thrush, provides routine dental care and simply makes the patient, especially if awake, feel “normal” and help free from halitosis and toxic flavours from medications and fasting.
Intubated (and, of course, non-intubated) patients should have their teeth / gums brushed BD – no excuses!
Bleeding teeth / gums should be gently massaged with mouth probes – no patient has ever required a transfusion as a result of mouth care (well not commonly anyway).
Image – https://sage-products.co.uk/product-oral-hygiene/
Pressure Area Care (PAC)
Most ICU patients are at least partially dependent on nursing staff for avoidance of pressure areas (decubitus ulcers) it is not just immobility that places the ICU patient at risk – hypotension, hypoxaemia and medications, such as noradrenaline, along with poor nutrition place greater risks on ICU patients than most other types
In ICU, charting should include a BRADEN scoring system based on 6 criteria
- sensory perception
- friction and shear
This score should be assessed and documented AND ACTED ON every shift
Nearly all ICU patients that have any of the preceding listed issues should be on an air inflated pressure relieving mattress, if not on admission then within 24 hrs. Add to that list all patients with integument issues, COPD, advanced age, emaciated, obese, pre-existing pressure areas and much more
3 hrly PAC is the usual minimum standard and please remember NO patient is too sick to move. ICU patients are also at risk of complications to integument from ETT security, nasogastic tubes, even simple nasal cannula can cause sores to the ears.. we must constantly check, ask the patient (if able) and be proactive with PAC
Patients, both in pain due to levels increasing or receiving analgesia due to lack of sensation, may refuse movement, both must still be moved 3 hrly unless otherwise assessed by your T/L. The choice to allow greater periods without disturbance should be documented in notes or in your charting due to increased risk it poses
If ever unsure refer to your units MINIMUM STANDARDS, every ICU should know what it expects of its staff and what its staff can expect of it. This is your guide to the expected care of HDU and ICU patients
Image – http://healthywa.wa.gov.au/Articles/A_E/During-your-hospital-stay
Save your back!
In a modern ICU mobility technology has seen a greater convenience for manual handling aids
Hovermats, hoverjacks, slide sheets, fixed and portable lifters etc – its all there
SO PLEASE USE THEM…
Should you feel moving a patient can be better assisted and made safer by use of a different manual handling aid SPEAK UP, you cannot be forced to place yourself at risk*
Your safety is YOUR responsibility
* Part of this is also maintaining an uncluttered bay and facilitating easy access to both the patient and safety equipment
The most ongoing issue on any average shift that causes greatest concern to the running of the ICU is time management. Being late for breaks or going home is usually a symptom of a deeper issue with time skills
Sending other staff for breaks first is great on the odd day where things have changed or gotten behind however if this becomes a regular event it can lead to staff exhaustion (you do need a break too) and not an hour after everyone else. Every ICU has the staffing, skills and teamwork ethics that means you should be comfortable to hand on what is required if something needs to be done urgently
If you can feel your work falling behind or getting on top of you, ask for help from your work neighbor or T/L
If you know that falling behind is a frequent occurrence ask for help from a Nurse Educator (NE) or your preceptor. Time management is a learned skill that is as important as anything else we do
Ask for help, simple as that
Tell it like it is!
Poor handover is one of the biggest dangers to any patient (or nurse). Information that is out of date, incorrect or, worst of all, not supplied kills as many patients worldwide as nearly any other issue.
Ask for feedback on your handover, listen to questions asked when you’ve finish handing over or during – are they highlighting gaps in your technique? Ask to practice ISBAR style handover with each other, your preceptor, Team Leader or NE. It is the one of the most important skills you will learn in ICU (more on ISBAR later)
A proper ISBAR handover protects you, the patient and the hospital and will ALWAYS get better results if requesting urgent review by any member of the multidisciplinary team in and out of ICU
Image – https://www.slhd.nsw.gov.au/BTF/ISBAR.html
The ICU has many expectations far beyond what you read here for nearly every aspect of your shift. Seek them out and familiarise yourself with the ‘ICU Minimum Standards” they can give your work better structure, protection and prompts for care. Make sure this is a priority for your first couple of shifts and a reminder from that point on
So there it is all you need to know in 25 odd minutes… if only it was that easy!
Let’s now start to s t r e t c h that out and add more to those concepts
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