Critical Care Setting An Overview from Basic to Sensitive Outcomes

This Springer imprint is published by the registered company Springer International Publishing AG part of Springer Nature. General Intensive Care Unit - San Gerardo Hospital – ASST Monza University of Milano-Bicocca Milan, Italy.

Contributors

Intensive Care Unit, Kent and Canterbury Hospital, East Kent Hospital University and Canterbury Hospital, East Kent Hospital University Foundation Trust, Canterbury, UK. At the same time, approaches to nursing care are evolving towards the definition and evaluation of outcome-related problems, giving a new dimension and dignity to the nursing diagnosis concept.

Assessment and Monitoring in ICU

Monitoring Patients: What’s New in Intensive Care Setting?

Introduction
Instrumental Monitoring
Monitoring and Scales
Bedside Monitoring: An Overview
A New Monitoring Model

An example of the use of scales (and their variations) is functional evaluation. Monitoring can be defined in a conceptual area bounded by the level of invasiveness and objectivity of the systems we use in the world.

Table 1.1 Short history of physiological data measurements [2]

Clinical practice guidelines for the management of pain, agitation and delirium in adult patients in the intensive care unit. Evaluating the performance of six nutritional screening tools for predicting malnutrition in the elderly.

Neurological, Pain, Sedation, and Delirium Assessment

Introduction

Neurological Assessment

A patient in this state has an alternating cycle of sleep and wakefulness, can swallow and breathe, and shows a response to painful stimuli and endless movement. Patients with MCS spontaneously open their eyes and respond to visual stimuli, can consciously respond to simple commands or imitate actions, and usually do not speak and.

Pain Assessment

Some patients are unable to understand how to graphically represent the intensity of pain. 0 Does not move at all (does not necessarily mean absence of pain) or normal position (movements not directed to the pain site or not made for the purpose of protection).

Evaluation of Agitation and Sedation

The Richmond Agitation-Sedation Scale (RASS) [25] consists of one value with response options from +4 to -5. The MAAS is a valid and reliable sedation scale in mechanically ventilated patients in the surgical intensive care unit.

Table 2.7Synopsis sedation/agitation scales in ICU (www.sedaicu.it) Richmond Agitation- Sedation Scale (RASS)BloomsburySedation Score(Bloomsbury)Ramsay Sedation Scale (RSS)Motor ActivityAssessmentScale (MAAS)RikerSedation-AgitationScale (SAS)Observer’s Ass

Delirium Assessment in ICU

Risk Factors for the Development of ICU DeliriumDelirium
Detection
Prevention

The disorder develops over a short period of time (usually hours to days) and has a tendency to fluctuate over the course of D-day. Comparison of the overall pattern of unresponsiveness and the Glasgow Liege/Glasgow Coma Scale in an intensive care unit population. Delirium in mechanically ventilated patients: validity and reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).

Respiratory and Ventilatory Assessment

Introduction

Sedation and paralysis (in the earliest stages of severe ARDS) – to facilitate the patient's adaptation to MV. Non-invasive ventilation (NIV) – to prevent intubation Putting these key points into practice during the treatment of ARDS requires continuous monitoring of the patient-pulmonary ventilator interaction to prevent potential adverse effects and iatrogenic damage.

Basic Monitoring Tools .1 Pulse Oximetry.1 Pulse Oximetry

End-Tidal Carbon Dioxide (EtCO 2 ) Monitoring(EtCO2) Monitoring

Patient movements interfere with reading, and then a potential desaturation must be ruled out, distinguishing between reading artifacts and a true desaturation event. Incorrect tube placement can lead to venous stasis and lower saturation levels due to an increase in the pulsatile venous bed. Nevertheless, the measurement between hemoglobin and carboxyhemoglobin cannot be excluded, resulting in an overestimated estimate of the values.

Fig. 3.1 Relationship between capnography, airway pressure, and gas flow

Ventilator Waveform Monitoring

Pressure-Time Waveform
Flow-Time Waveform
Time-Volume Waveform
Other Advanced Respiratory Monitoring Parameters

The spring-loaded safety valve will open in the event of a power failure and/or if the inspiratory pressure exceeds 100 cmH2O. 7) The oxygen concentration inside the inspiratory pipe is measured by the O2 cell. In both controlled ventilation modes (pressure/volume) these unplanned spontaneous breaths lead to a modification of the inspiratory/. On pressure-controlled mode, the expiratory wave still remains the same (conducted by patient), while the inspiratory wave will be affected by changes.

Fig. 3.4 Ventilator components. (1) Gas inlet for medical air. The connected air must have a pressure between 2 and 6.5 bar

Monitoring During Invasive Spontaneous VentilationSpontaneous Ventilation

During pressure support ventilation (PSV), the clinical goal is to best balance the use and abuse of the patient's respiratory muscles, while avoiding functional muscle failure due to excessive WOB. P0.1 The airway occlusion pressure (P0.1) is a reliable index of the patient's neuromuscular drive, which is also correlated with WOB (work of breathing). P0.1 is defined as the negative airway pressure generated during the first 100 ms of occluded inspiration. P0.1 is an estimate of neuromuscular drive, but if.

Table 3.1 Advanced ventilatory assessment parameters

Pressure and Flow Monitoring to Assess Asynchronyto Assess Asynchrony

Double trigger Double trigger [26] is defined as two ventilator breaths delivered within one inspiratory effort by the patient. Early cycling-off Premature cycling is the cause of the double-triggering asynchrony, but without switching to a secondary inspiratory cycle [26]. On PS, even with high-sensitivity trigger, the patient's neural demand is a negative deflection just before the waveform.

Table 3.3 Patient-ventilator asynchronies Kind of asynchrony Description Ineffective

Noninvasive Ventilation Monitoring and Managementand Management

Helmet CPAP

Gas-Flow Management
Basic Monitoring on CPAP: Patient and Circuit The basic monitoring of patient on a CPAP helmet should con-
Noise Reduction
Helmet Anchorage
Airway Humidification

Monitoring During Mask-PSV

A correct management of the helmet is useful to reduce claustrophobia, to maintain full visual contact and communication with healthcare providers and patient's significant others [30, 31]. These safety valves remain closed due to the pressure generated within the helmet by the PEEP. From a physical point of view, the pressure inside the helmet results in a vertical thrust of itself.

Fig. 3.12 Patient with helmet CPAP and counterweight system

Monitoring During Extracorporeal

Membrane Oxygenation (ECMO) Support 3.7.1 The Need for ECMO Support

Circuit Monitoring During ECMO

Nursing supervision is required to provide a safe and effective level of care to the patient receiving mechanical ventilation. ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, et al. Factors influencing the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative evidence synthesis.

Table 3.7 Key point for monitoring ECMO performance

Cardiovascular Assessment

Introduction

On this basis, a progressive implementation model [2] for CM monitoring in ICU was proposed, defining three levels of complexity for CM, which should be adopted on a continuum according to the patient condition.

General Considerations

Electrical Activity

Evaluation of electrical activity with a 3- or 5-channel electrocardiogram (ECG) provides simple and immediate information about the conduction of a stimulus through the heart, although a more accurate evaluation is only possible with a 12-channel ECG. In atrial fibrillation (AF), the most common arrhythmia, atrial electrical activity is disorganized and only a few electrical impulses reach the ventricular P wave present. The result of the electrical activity is the heart rate (HR), expressed as the number of QRS complexes per minute.

Pump Function Effectiveness

Cardiac Output
Arterial Pressure Monitoring
Pulmonary Artery Pressure

The lumen of the balloon inflates the balloon near the distal lumen; its occlusion stops blood flow through the pulmonary artery and provides a downward balloon pressure reading (from the PAP lumen). The measured values can also be affected by the position of the patient during the measurement due to the effects of the hydrostatic column (therefore, in a standing position, the arterial pressure measured at the height of the feet will be higher than that at the height of the neck). Avoid liquid contamination and air bubbles in the tube. Close the shut-off valve towards the patient.

Fig. 4.2Swan-Ganz catheter and wave visualization

Oxygen Transportation and Consumption

Venous oxygen saturation is defined as the percentage of venous hemoglobin saturated with oxygen; venous oxygen saturation values usually range between 60 and 80% and vary depending on the measurement area. It can be measured by drawing a sample of blood from the distal lumen of a central venous catheter (called central venous oxygen saturation—.ScvO2) in a jugular or subclavian vein or a Swan-Ganz catheter (called mixed venous oxygen saturation—SvO2). ) [27]. Decreased venous oxygen saturation (<) may be due to insufficient oxygen delivery or increased oxygen extraction at the cellular level [33].

Volemia

Filling Pressures: Central Venous Pressure and Pulmonary Artery Occlusion Pressureand Pulmonary Artery Occlusion Pressure
Volumetric Indicators

Extravascular lung water (EVLW) is a bedside measurement of the amount of lung water outside the vascular compartment. In practice, it is a measurement of the amount of pulmonary edema (defined as the difference between PTV and ITBV), previously assessed by radiological imaging (such as chest x-ray, computed tomography and magnetic resonance imaging) [42]. ]. A randomized controlled trial of the use of a pulmonary artery catheter in high-risk surgical patients.

Fig. 4.6 Central venous pressure waveform. Dotted line shows the ideal site for measurement

Early Mobility, Skin, and

Pressure Ulcer Risk Assessment

Introduction
Intensive Care Unit-Acquired Weakness (ICU-AW)(ICU-AW)

Prevention and Treatment of Immobility

Skin and Pressure Ulcer Risk Assessment .1 Definition.1 Definition

Epidemiology
Physiopathology and Main Risk Factors
Risk Assessment

Conclusions

If slough or eschar obscures the extent of tissue loss, it is an unstable pressure injury. Recently, the development and introduction of the COHMON index (level of consciousness, mobility, hemodynamics, oxygenation, nutrition) has opened a new opportunity in PI risk assessment. Pressure risk assessment in intensive care: a comparison of the interrater reliability of the COMHON (Conscious level, Mobility, Haemodynamics, Oxygenation, Nutrition) index with three scales.

Fig. 5.2 Assessment of patients’ readiness for mobility. Modified from Asfour [6]

Basic Care in ICU

Interventional Patient Hygiene Model: New Insights in

Critical Care Nursing, Starting from the Basics of Care

Introduction

Hospital-acquired conditions (HACs) are a set of unexpected complications that occur during a patient's stay in the hospital [3]. A specific subset of HACs are hospital-acquired infections (HAIs), defined as infections acquired by a patient during hospitalization [3]. Nursing is strongly involved in the development and thus also in the prevention of HAC and HAI [3].

From Evidence-Based Nursing

At present, the new mantra of health care is "ensure safety, be proactive." Behind this simple rule, the professionals' attention is focused on achieving the patients' health outcomes and at the same time preventing iatrogenic complications. Lots of nursing-sensitive results showed how this statement is true, and it is mainly related to the quality of basic nursing care provided (eg incidence of PU, failure to rescue rate, HAP, ventilator-associated pneumonia (VAP), CAUTI, CLABSI , patients decline, patients limitations) [4].

The Conceptual Framework

The Priorities of Intensive Care Nursing

The implementation of a nursing model is based on the fundamentals of care as the IPHM must be matched with a deep reflection about the priorities of nursing in the critical care environment. Nurses should be informed about the incidence and trends of major and minor complications that they contribute to prevention through their basic care interventions. Despite a strong rationale stemming from evidence-based nursing interventions, there are currently few published studies regarding the implementation of IPHM in clinical practice.

Potential Developments of HPIM

Currently, constipation in critically ill patients remains an open question due to the lack of studies evaluating the effectiveness of implementing bowel management protocols and significant limitations of published research, often related to small samples or inclusion criteria [45]. . Constipation in long-term ventilated patients: associated factors and impact on intensive care unit outcomes. Development of clinical practice guidelines for improving sleep in intensive care patients: a solution-focused approach.

Table 6.2 Consequences of sleep disturbance on ICU patients [53]

Eye, Mouth, Skin Care, and Bed Bath

Introduction

The Eye Care in ICU

Main Ocular Complications in ICU
Prevention and Treatment

Vision is a very important aspect of quality of life; therefore, this should never be neglected. In patients who cannot close the eyelids, are unconscious or heavily anesthetized, eye care should be performed every 2 hours (with gauze soaked in a physiological solution or specific lubricants) [13]. Once applied through the upper eyelid to the cheek, it forms a moist chamber originating from the tear fluid that maintains the integrity of the cornea [6, 20].

Oral Care in ICU

Management of Oral Hygiene

Oral health, including plaque accumulation, oral microbial flora, and local oral immunity, influences the number of organisms, including pathogens that can cause VAP, in the oral cavity. For proper oral hygiene management, oral, mucosal, and gingival assessments should be performed early in the intensive care unit and daily thereafter to plan care. Various oral hygiene procedures are described in the available literature, with protocols often contradicting each other [28].