Table Of Content

AACN Essentials of Critical Care Nursing Marianne Chulay, AN, ONSc, FAAN Consultant, Critical Care Nursing and Clinical Research Chapel Hill, North Carolina Suzanne M. Burns, RN, MSN, ART, ACNP, CCRN, FAAN, FCCM Professor of Nursing. Acute and Specialty Care School of Nursing Advanced Practice Nurse Level 2. Medicine/Medical Intensive Care Unit Universily of Virginia Health System Charlottesville, Virginia McGraw-Hill Medical Publishing Division New York Chicago San Francisco lisbon London Madrid Mexico City Milan New Oelh1 San Juan Seoul Singapore Sydney Toronto The McGrow·Hi/1 Companies · AACN Essentials of Critkal Care Nursing Copyright I!) 2006 by The McGra\\ -Hill Companie~. Inc. All righh reserved. Printed in the United State~ of Am.,rica. E~cept a' pcrrnitt~d under the Unit"d Stat.:' Copyright Act of 1976. no part of this publication may be repmJu~.:J ur di,tributctl in any ltmn ur by an) mean,, ur Mored in a data bu~e or retrieval ')l>tem. without the prior written ~rmio;,ion of the publi,her. 3 ~ 5 6 7 K 9 0 QPD/QPD 0 9 I! 7 ISBN 0-07-1-'4771·7 NOTICE M.:Jicin~ j, an ever-~:hanging s~:ience. A> new research anJ clinical experience broaden our knowkdge. change!'> in trt!atment and drug therapy are required. The authors and The publisher of this work ha\'C •·heckcd with 'ourccs believed to be reliable in their effons to provide information that is complete and generally in accord with the standard' accepted at the time of publication. However. in view of the possibility of human error or changes in medical sciences. neither the author' nor the publi~her nor any other par1y who ha~ been involved in the preparation or publication of this work warrant' that tbe information .:onrained herein is in .:very respect a.:cunue or complet.:. and the} di~claim all respon•ihility for any errors or omis~ion~ or for the results obtained from use of the infom1ativn contained in thi' work. Reader~ ar.: encouraged to confirm the infonnation contained herein Y.ith other snun:es. For cx.ample and in par1icular. readers are advised to check the product infom1ation :.heel included in the package of each dmg they plan to administer to be cenain that the infonnation contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindication,. for administration. This recommendation i~ of pani.:ular impor1ancc in connection with ne\\ or infrequently used drugs. Thi' book wa' 'et in Time' Ruman by Mid-Atlantic Book" and Joumab. Inc. The editor wa' Mi~hacl Brown. The production >Upef\ i~or wa~ Sherri Souffmnce. Project manag~m<!nt \loa' provided b} Jennsin S.:rvices. Quebecur World Dutlu4ue wa' pnntcr and bimler. Thi~ lxx>k i~ printed on acid-free paper. PlcJ't: tell the author and publi,her what you think ••f thi, book hy ;;ending your comment~ to nursing@mcgraw· tlill.cum. Plc.I~C put the authur and title ul th" bonk in the •utlject line. nr Library Cnngn.,..~ Catalo~:inJ!·in-Puhlication Data AACN e~'ential' of crittcal care I [cJitcd hy] Marianne Chula}. SuLanne M. Bum,.-I 't t'd. p.;wt. Include' bibliographical ref~r.!ncc' and indl.":\. ISBN 0·07· 1-'4771· 7 1, uftcnvcr) I. Intensive .:are nursint:--{)utlinc,. ~)llabi. etc. I. Title: American A"<x:iation of Critical-Care Nuf'e' e~sentiah of critical care nur-ing. II. Title: E'~ential' of critical care nursing. Ill. Chulay. Marianne. IV. Bum,, Sutanne M. V. American A~sociation of Critical-Care Nur~'- !DNLM: I. Critical Can:. 2. Criticallllne~~-nursing. 3. Nursing Care. WY 154 All I ~005] RTI20.15AI65 ~005 610.73 .6----tk:22 2005041551 To our critical care nursing colleagues around the world whose wondeiful work and efforts ensure the safe passage ofp atients through the critical care environment. Contents Contributors .. . .............................................................................................................................................X V Reviewers .. .. ............................................................................................ xvii Preface ... .• ••••.......................................................• ~ Section I. The Essentials ..................................................................................................................................................................... ! I. Assessment of Critically Ill Patients and Families ................................................................................................................. 3 Mary Fran Tracy 2. Planning Care for Critically Ill Patients and Families ................................ . .. ......................... 17 Mary Fran Trac_v 3. Interpretation and Management of Basic Cardiac Rhythms ...................... . . .... ·················· ..................................... 37 Carol Jacobson 4. He1nodynamic Monitoring .................................................................................................................................................. 65 Lewzna R. Miller 5. Airway and Ventilatory Management ............. .................................................................................................................. 111 Robert E. St. John 6. Pain, Sedation, and Neuromuscular Blockade Management ..... 145 Joan Michiko Ching and Suzanne M. Burns 7. Pharmacology .................................................................................................................................................................. 165 Earnest Alexander 8. Ethical and Legal Considerations. . .......................................................................................... ·············· .............. 199 Juanita Reigle Section II. Pathologic Conditions ..................................................................................................................................................2 13 9. Cardiovascular System .................................................... .. .. ........ 215 Barbara Leeper 10. Respiratory System .......................................................................................................................................................... 247 Marianne Chulay II. Multisystem Problems ....... . ············· ................................................................ ·············································· ........... 267 Ruth M. K/einpe/1 12. Neurologic Systern ............... 279 Dea Ivfahanes v vi CONTENTS 13. Hematology and Immunology Systems ........................................................................................................................... 305 Diane K. Dressler 14. Gastrointestinal System ...................................................................................................................................................... 317 Joanne Krumberger, Carol Rees Parrish, and Joe Krenitsky 15. Renal System ..................................................................................................................................................... . .. ..... 341 Carol Hinki e 16. Endocrine System ................................................................................................... . . ..................................... 357 Joanne Krumberger 17. Trauma ............................................................................................................................................................................... 371 Jamie B. Sinks and Carol A. Rauen SECTION Ill: Advanced Concepts in Caring for the Critically Ill Patient ......................................................................................................3 89 18. Advanced ECG Concepts ................................................................................................................................................... 391 Carol Jacobson 19. Advanced Cardiovascular Concepts .................................................................................................................................. .431 Barbara Leeper 20. Advanced Respiratory Concepts ....................................................................................................................................... .463 Suzanne M. Burns 21. Advanced Neurologic Concepts ........................................................................................................................................ .477 Dea Mahanes SECTION IV: Key Reference Information .............................................................................................................................................5 0 1 22. Normal Values Table ......................................................................................................................................................... 503 Marianne Chulay 23. Pharmacology Tables ........................................................................................................................................................ .505 Earnest Alexander 24. Advanced Cardiac Life Support Algorithms ...................................................................................................................... 519 Marianne Chulay 25. Guidelines for the Transfer of Critically Ill Patients .......................................................................................................... 529 Marianne Chulay 26. Hemodynamic Monitoring Troubleshooting Guide ........................................................................................................... 533 Leanna R. Miller 27. Ventilatory Troubleshooting Guide .................................................................................................................................. 539 Robert E. St. John and Suzanne M. Bums 28. Cardiac Rhythms, ECG Characteristics, and Treatment Guide ......................................................................................... 551 Carol Jacobson lndex ............................................................................................................................................................................................5 6! Contents in Detail Contributors.. .. ......................... xv Reviewers... . ............ xvii Preface ...... .................................................................................................................................................................................. xix Section I. The Essentials ...................................................................................................................................................................... ! I. Assessment of Critically Ill Patients and Families ................................................................................................................ 3 Mar_v Fran Tracy Assessment Framework 3 Prean-ival Assessment 4 I Admission Quick Check 4/ Comprehensive Admission Assessment 4/ Ongoing Assessment 4 Prearrival Assessment: Before the Action Begins 4 Admission Quick Check Assessment: The First Few Minutes 5 Airway and Breathing 6/ Circulation and Cerebral Perfusion 6/ Chief Complaint 6/ Drugs and Diagnostic Tests 6/ Equipment 7 Comprehensive Admission Assessment 7 Past Medical History 8 I Social History 8 I Physical Assessment by Body System 9 I Psychosocial Assessment 12 Ongoing Assessment 14 2. Planning Care for Critically Ill Patients and Families ......................................................................................................... 17 Mary Fran Trac.v Multidisciplinary Plan of Care and Critical Pathways 17 Prevention of Common Complications 18 Physiologic Instability 18 I Deep Venous Thrombosis IS I Hospital-Acquired infections 23 I Skin Breakdown 24 I Sleep Pattern Disturbances 24 I Psychosocial lmpact 25 Patient and Family Education 26 Assessment of Learning Readiness 26 I Strategies to Address Patient and Family Education 27 I Outcome Measurement 27 Family-Focused Care 28 Transporting the Critically Ill Patient 29 Assessment of Risk for Complications 29 I Level of Care Required During Transport 30 I Preparation 31 I Transport 31 I Inteti~cility Transfers 32 Transitioning to the Next Stage of Care 32 Supporting Patients and Families During the Dying Process 33 3. Interpretation and Management of Basic Cardiac Rhythms ............... . . ................................ 37 Carol Jacobson Basic Electrophysiology 37 vii viii CONTENTS JN DETAIL ECG Waveforms, Complexes, and Intervals 38 P Wave 38/ QRS Complex 38/ T and U Waves 381 ST Segment 381 PR lnterva! 38/ QT Interval 39 Cardiac Monitoring 39 Determination of the Hem1 Rate 42 Determination of the Cardiac Rhythm 42 Common Arrhythmias 43 Rhythms Originating in the Sinus Node 43 Sinus Bradycardia 44/ Sinus Tachycardia 44/ Sinus Arrhythmia 451 Sinus Arrest 45 Arrhythmias Originating in the Atria 45 Premature Atrial Complexes 461 Wandering Atrial Pacemaker 46/ Atrial Tachycardia 47 I Atrial Flutter 47 I Atrial Fibrillation 48 Arrhythmias Originating in the Atrioventricular Junction 49 Premature Junctional Complexes 50 I Junctional Rhythm, Accelerated Junctional Rhythm, and Junctional Tachycardia 50 Arrhythmias Originating in the Ventricles 50 Premature Ventricular Complexes 51 I Ventri<:ular Rhythm and Accelerated Ventricular Rhythm 51/ Ventricular Tachycardia 52/ Ventricular Fibrillation 53/ Ventricular Asystole 53 Atrioventricular Blocks 54 First-Degree Atrioventricular Block 54 I Second-Degree Atrioventricular Block 54/ High-Grade Atrioventricular Block 56/ Third-Degree Atrioventricular Block (Complete Block) 56 Temporary Pacing 57 Indications 57 I Trans venous Pacing 57 I Epicardial Pacing 57 I Components of a Pacing System 57 I Basics of Pacemaker Operation 58 I ECG Characteristics of Paced Rhythms 60 I Initiating Transvenous Ventricular Pacing 60 I Initiating Epicardial Pacing 60 I External (Transcutaneous) Pacemakers 60 Defibrillation and Cardioversion 60 Defibrillation 60 I Automatic External Defibrillators 61 I Cardioversion 62 4. Hemodynaznic Monitoring........................................................................................................................... . .. ................. 65 Lemma R. Miller Hemodynamic Parameters 65 Cardiac Output 65/ Components of Cardiac Output/Cardiac Index 67 I Stroke Volume and Stroke Volume Index 68 I Factors Affc~.:ting Stroke Volume/Stroke Volume Index 68 Basic Components of Hemodynamic Monitoring Systems 72 Pulmonary Artery Catheter 721 Arterial Catheter 72 I Pressure Tubing 721 Pressure Transducer 73 I Pressure Amplifier 74/ Pressure Bag and Flush Device 74/ Alarms 74 Obtaining Accurate Hemodynamic Values 74 Zeroing the Transducer 74/ Leveling the Transducer to the Catheter Tip 75/ Calibration of the Transducer/Amplifier System77/ Ensuring Accurate Waveform Transmission 77 Insertion and Removal of Catheters 77 Pulmonary Artery Catheters 77 I Arterial Catheters 80 Obtaining and Interpreting Hemodynamic Waveforms 84 Patient Positioning 84 I Interpretation 84 I Artifacts in Hemodynamic Waveforms: Respiratory Influence 91/ Cardiac Output 92 Continuous Mixed Venous Oxygen Monitoring 97 Svo Monitoring Principles 97 I Selected Examples of Clinical Applications 98 2 Right Ventricular Ejection Fraction Catheters 99 Monitoring Prindp!es 99/ Troubleshooting 99 Minimally Invasive Hemodynamic Monitoring I 00 Thoracic Bioimpedance I 00 I Esophageal Doppler Cardiac Output I 00 I Carbon Dioxide Rebreathing JOO I Gastric Tonometry 100 I Sublingual Capnometry lOI Application of Hemodynamic Parameters l 02 Low Cardiac Output States I0 2 I High Cardiac Output States I0 6 COfHENTS IN DETAIL ix 5 ..A .irway and Ventilatory Manage1nent ........................................................................................................................... Ill Robert E. St. John Respiratory Assessment Techniques. Diagnostic Tests. and Monitoring Systems 111 Arterial Blood Gas Monitoring Ill I Analysis 112 I Venous Blood Gas Monitoring 116 I Pulse Oximetry 116 I Assessing Pulmonary Function I 18 Airway Management 118 Oropharyngeal Airway 118/ Nasopharyngeal Airway 120 I Artiflcial Airways 120 Oxygen Therapy 125 Complications 125 I Oxygen Delivery 127 Basic Ventilatory Management 129 Indications 129 I General Principles 129 I Modes 132 I Complic<Hions ! 35 I Weaning From Short-Term Mechanical Ventilation 136/ Troubleshooting Ventilators 138/ Communication 139 I Principles of Management 141 6. Pain, Sedation, and Neuromuscular Blockade Management ........................................................................................... 145 Joan Michiko Ching and Suzanne M. Bums Physiologic Mechanisms of Pain 145 Peripheral Mechanisms 145/ Spinal Cord Integration 147/ Central Proces~ing 147 Responses to Pain 147 Pain Assessment 148 A Multilevel Approach to Pain Management 148 Nonsteroidal Anti-Inflammatory DIUgs 149 Side Effects !50 Opioids !50 Side Effects 1S O I Intravenous Opioids 151 I Patient-Controlled Analgesia 1S ! I Switching From IV to Oral Opioid Analgesia 152 Epidural Analgesia 153 Epidural Opioids 153/ Epidural Local Anesthetics 154 Cutaneous Stimulation 155 Distraction 155 Imagery 155 Relaxation and Sedation Techniques 155 Deep Breathing and Progressive Relaxation 156/ Presence 156 Special Considerations for Pain Management in the Elderly 156 Assessment 157 /Interventions 157 Sedation J 57 Reasons for Sedation 157/ Drugs for Sedation 158/ Goals of Sedation. Monitoring, <md Management 159/ Sedation Scales: Goals and Monitoring 159 I Sedation Management 159 Neuromuscular Blockade 159 Neuromuscular Blocking Agents 160 I Monitoring and Management 161 7. Pharmacology ................................................................................................................................................................. 165 Earnest Alexander Medication Administration Methods 165 Intravenous 165/ Intramuscular or Subcutaneous 165 I Sublingual 166/ Intranasal 166/ Transdennal 166 Central Nervous System Pharmacology 167 Sedatives 167 I Analgesics 170 I Neuromuscular Blocking Agents 171 I Anticonvulsants 173 Cardiovascular System Pharmacology J 76 Miscellaneous Agents 176/ Parenteral Vasodilators 177 I Antiarrhythmics J 80 I Thrombolytic Agents 182/ Vasoconstricting Agents 183 /Inotropic Agents 184 I Activated Protein C 18 5 Anti-Infective Pharmacology 185 Aminoglycosides 185 I Vancomycin 186/ Other Antibiotics 186