Critical care Management in Medical Nursing
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Intensive care Early Warning Scoring (EWS) Acute Physiology and Chronic Health Evaluation (APACHE) Scoring Simplified Acute Physiological Score (SAPS) Sequential Organ Failure Assessment (SOFA)
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Critical care Management in Medical Nursing
- 1. Critical care Management in Medical Nursing Dr.Puvaneswari. K Professor Narayana Hrudayalaya College of Nursing
- 2. MEDICAL CONDITIONS CONSIDERED AS CRITICAL ANY PERSON WITH LIFE THREATENING CONDITIONS : Acute Myocardial Infarction Acute renal failure Cardiac Tamponade Severe shock Heart block
- 3. Acute Respiratory Distress Syndrome Multiple organ failure and organ dysfunction COPD Poly trauma Severe burns Poisoning
- 4. IDENTIFICATION OF PATIENT NEEDS IN MEDICAL CONDITIONS • Early Warning Scoring (EWS) • Acute Physiology and Chronic Health Evaluation (APACHE) Scoring • Simplified Acute Physiological Score (SAPS) • Sequential Organ Failure Assessment (SOFA)
- 5. • Trauma Revised Injury Severity Score (TRISS) • Nutritional assessment • Pressure area risk assessment • Sedation scoring • Glasgow coma score (GCS) • CVP monitoring
- 6. PROBLEMS FACED IN ICU MEDICAL PATIENTS • Hypoxia • Hypotension and shock • Acid base disturbance • Sepsis / Fever • Electrolyte imbalances • Pain
- 7. HYPOXIA
- 8. HYPOXIA NORMALINCREASED PaCO2 INCREASED • TYPE 11 RESPIRATORY FAILURE • COPD LOW CHEST X- RAY • CARDIOGENIC PULMONARY OEDEMA • SLEEP APNOEA • SEDATIVE OVERDOSE • CENTRAL HYPOTENSION NORMAL ABNORMAL CONSIDER PE PAOP <16 CI NORMAL PAOP >16 CI LOW ARDS RESPIRATORY ACIDOSIS PAaO2 =PAO2-PaO2
- 9. HYPOXIA MANAGEMENT COPD • Methyl Prednisolone 0.5- 2 mg/Kg Q6H • Antibiotics • Aminophylline 5mg/Kg loading .5mg/Kg /hour • Beta-2 Agonists by MDI ARDS • Diuretics • Inotropics / vasopressor – Dopamine, Dobutamine , Nor epinephrine • Sedation /Paralysis/analgesia
- 10. Cardiogenic pulmonary oedema • Morphine 2-5 mg IV • Frusemide 40mg IV • IV nitroglycerine for Ischemia • IV Nitroprusside 0.5-2 mcg/kg/min • IV Dobutamine 2.5-15 mcg/kg/min • IABP • Mechanical ventilation
- 12. HYPOTENSION FLUID RESUSCITATION HT NOT RESOLVED HT RESOLVED • CONTINUE FLUID RESUSCITATION • ASSESS THE CAUSE • ADD DOPAMINE AND NOR EPINEPHRINE VOL.PROBLEM VENT.PROBLEM PUMPING.PROBLEM • GI BLEED • DIARROHEA • SEPSIS PNUMOTHORAX PEEP ARRYTHMIA • BRADY • TACHY • ECG • ECHO • CARDIAC ENZYMES • MI • CARDIAC TAMPONADE • PUL.EMBOLISM
- 13. Hypotension and shock management • Fluid therapy- IV 1-1.5 liters or 20-40 mL/kg . • Lower volumes of crystalloid to prevent over dilution of blood and coagulation factors • Pressors – Dopamine, Dobutamine , Epinephrine, Norephinephrine, Vasopressin • IABP • Antibiotics • Treatment based on cause
- 15. LOW PH HCO3 PaCO2 HCO3 METABOLIC ACIDOSIS RESPIRATORY ACIDOSIS LOW HIGH ↓PaCO2 APPROPRIATE FOR ↓ IN HCO3 ↑ 𝐇𝐂𝐎𝟑 APPROPRIATE FOR ↑ IN PaCO2 LOW HIGH • DKA • DIARRHOEA • RENAL FAILURE • SHOCK • COPD • GBS • DRUG OVERDOSE • AIRWAY OBSTRUCTION
- 16. HIGH PH HCO3 PaCO2 HCO3 METABOLIC ALKALOSIS RESPIRATORY ALKALOSIS HIGH LOW ↑PaCO2 APPROPRIATE FOR ↓ IN HCO3 ↓ 𝐇𝐂𝐎𝟑 APPROPRIATE FOR ↓ IN PaCO2 HIGH LOW VOMITTING, DIURETIC THERAPY, EXCESS GASTRIC SUCTIONING HYPERVENTILATION, SEPTICAEMIA, RESP.ALKALOSIS
- 17. DISORDER PRIMARY ALTERATION SECONDARY RESPONSE Metabolic Acidosis in plasma HCO3 in plasma pCO2 Metabolic Alkalosis in plasma HCO3 increase in pCO2 Respiratory Acidosis in plasma pCO2 in plasma HCO3 Respiratory Alkalosis in plasma pCO2 in plasma HCO3
- 18. ACID BASE DISTURBANCE MANAGEMENT Respiratory alkalosis • Correct the underlying cause • Reassurance or sedation, rebreathing into a closed system (e.g., a paper bag) • Correction of hypocapnia ( Reset the device) Respiratory acidosis • Treat the cause . eg Bronchodilators, Respiratory stimulants • Supplemental O2 • Mechanical ventilation and NIPPV
- 19. Metabolic alkalosis • Treat the cause • Use k- sparing diuretics and Acetazolamide • Correct the deficiency (i e give chloride, water , K+) • Expand ECF Volume with N/saline and KCl . Metabolic acidosis • Accurate diagnosis and treat the cause • Oxygen administration or Intubation and Mechanical ventilation. • Replace losses (e.g. of fluids and electrolytes) ACID BASE DISTURBANCE MANAGEMENT
- 20. SEPSIS / FEVER
- 21. HISTORY AND PHYSICAL EXAMINATION SEPSIS WORKUP- CBC,LFT, CULTURE OF ALL SPECIMENS, CULTURE FROM INFLAMMED SITES , CHEST RADIOGRAPHY CULTURE +VE NARROW ANTIBIOTICS, WORK UP CULTURE – VE CONTINUE EMPIRIC ANTIBIOTICS CULTURE –VE CONTINUE ANTIBIOTICS BASED ON BEST GUESS CULTURE +VE NARROW ANTIBIOTICS REPEAT HISTORY AND PE SEPTIC WORK UP, CHANGE ALL LINES FEVER RESOLVES OCCULT INFECTIOUS CAUSE • CHOLECYSTITIS • INTRA ABDOMINAL ABSECESS NON INFECTIOUS CAUSE • DVT, • PANCREATITIS, • DRUG FEVER SOURCE ISOLATED NO SOURCE FEBRILE
- 22. SEPSIS / FEVER MANAGEMENT • Symptomatic management- Antibiotic therapy , Antifungal therapy. • Fluid resuscitation ( 20 mL/kg of isotonic crystalloid, followed by boluses of up to 1000 mL of crystalloid or 500 mL of colloid given over 30 minutes). • Vasopressors and Inotropes • Steroids • Antipyretic therapy eg acetaminophen
- 24. DIAGNOSTIC APPROACH FOR HYPERNATREMIA URINE OUTPUT URINE OSMOLALITY URINE OSMOLALITY HYPERTONIC FLUID LOSS • INSENSIBLE FLUID LOSS • GI LOSS • PRIOR RENAL LOSS DIABETIC INSIPIDUS OSMOTIC DIURESIS HIGH HIGH LOW LOW HIGH
- 25. HYPERNATREMIA MANAGEMENT • Calculate BWD= DBW- TBW • Replace BWD in addition to maintenance fluid • For oliguria/ hypotensive patient – Normal saline • For stable patients- D5W • Replace 50% BWD over 24 hours. Rest over 24-48 hours. • Follow serum sodium q6h
- 26. HYPOKALEMIA INCREASED LOSS DISTRIBUTION DEFECT AML, HYPERGLYCAEMIA, ALKALOSISURINARY SPOT K<10 URINARY SPOT K< 10 NONRENAL LOSS DIARROHOEA, BILIARY LOSS, SMALL INTESTINE FISTULAS URINARY SPOT K>20 RENAL LOSS CHECK BP HTN NORMAL BP CHECK PLASMA RENIN CHECK PLASMA HCO3 INCREASED SEC.HYPER ALDOSTER DECREASED PRIMARY HYPER ALDOSTER • VOMITTING WITH METABOLIC ALKALOSIS • DIURETICS, • NORMOTENSIVE, • HYPERALDOSTER INCREASED CHECK URINARY CI
- 27. HYPOKALEMIA MANAGEMENT • Find and Correct cause • Angiotensin-converting enzyme (ACE) inhibitors, which inhibit renal potassium excretion. • Potassium-sparing diuretics. • Syp .KCL po 40 meq. And IV 40 meq @ 10 meq/hour • Check ECG
- 28. PAIN
- 29. PAIN ASSESSMENT
- 30. Sedatives /Anxiolytics Patient controlled analgesia Epidural analgesia Narcotics Non steroidal anti inflammatory drugs
- 31. NURSES ROLE IN MANGEMENT OF PATIENTS WITH MEDICAL CONDITIONS • Assessment • Diagnosis • Planning • Implementation • Evaluation
- 32. RESPIRATORY MANAGEMENT • Oxygen therapy • Mobilisation of secretions • Ventilator support FLUID AND ELECTROLYTE MAINTENANCE • Administer IV fluids • Administer blood products • Maintenance of intake and output NUTRITIONAL MANAGEMENT • Enteral feeding with need based nutrients • Total parenteral nutrition
- 33. HYGIENIC CARE • Meeting /Assisting ADL • Back care • Special care for ventilated clients POSITIONING • Prevention of bed sore • Therpeutic positions • Safety PREVENTION OF INFECTION • Aseptic technique • Invasive site care. • Hand washing.
- 34. PREVENTION OF COMPLICATIONS • Monitoring • Early identification of warning signs • Patient safety EXERCISES • Respiratory , ROM exercises • Early mobilisation • Leg exercises FAMILY MANAGEMENT • Involve in decision making • Family coping • Transcultural and al manage