NURSING CARE OF CRITICALLY ILL PATIENT

Introduction

• Patients admitted in the intensive care unit (ICU) have life-threatening illnesses requiring a range of high-level interventions and the responses to that treatment can be unpredictable.
• Within this context of intensive care, the nursing contribution involves meticulous observation and skilled intervention, the provision of basic hygiene, nutrition and prevention of harm, as well as the provision of emotional and psychological support to both the patient and their families.

Patient Assessment

• The assessment includes –
  • The patient's history
  • Performing a physical examination (At minimum)
  • A quick assessment should be made of all catheters.
  • Review of the doctor's orders.
  • Fluid: movement of fluid and electrolytes among body compartment.
  • "Electrolyte imbalance, Dehydration, hypervolemia, hemodynamic stability (V/S)"
  • Aeration: assess the patient clinically and laboratory.
  • " Type of respiration, normal and extra breathing sounds, color of skin & mucous membrane, rate of respiration, ABGs determination is the best indicator for the patient condition.
  • Nutrition: assess the patient through physical examination and lab.
  • " Can we use the normal GI tract, what about the GI system condition, does the patient need biologic nutrition (TPN), what about vitamins and minerals supplementation".
  • Communication: Assess neurological function (GCS), look at the patient eyes, does he cooperative, does he oriented.
  • Activity: bed rest with mild activity (ADL), complete bed rest,
    Up with the help of assistant, Up in chair but cannot walk.
  • Pain: Physiological pain from the disease process, psychological pain from lone less, hopelessness', fear.

Planning Patient Care

• Planning patient care involves
  • Organize the patient problem, set priorities, and find out actual and potential problems or risk factors.
  • Development of nursing care plans.

Essential Nursing Care

Personal hygiene

• Eye care (must necessary if the patient is unconscious)
  • Use of artificial tears
  • Instill lubricating drops or ointment,
  • Apply antibiotic drops or ointments as ordered
  • Close the eyelids with tape to prevent corneal ulceration
  • Apply eye shields, or applying a moisture chamber
  • Raise the head of the bed may reduce scleral edema. (Scleral edema is common in the ventilated patient).
• Oral care
  • Perform regular oral hygiene (every 8 hourly) to prevent infection
  • Establish a scheduled, regular oral care regimen, remove plaque and cleanse the mouth without causing pain or irritation.
  • Use a non–alcohol-based mouthwash, like chlorhexidine-based mouthwash, hydrogen peroxide or other antibacterial or antifungal mouthwashes that is compatible with the patient's condition, and should not cause pain due to additives for flavor, alcohol, or strength.
  • Use toothbrushes which have soft bristles with toothpaste
  • Use foam brush instead of toothbrush in patients with bleeding disorders or a low platelet count
• Skin care
  • Turn the patient every 2 hours
  • Use special mattresses
  • Perform complete bed bath for the patient daily and whenever necessary
  • Keep the patient's clothes clean and dry
  • Keep the linen clean, dry and unwrinkled
  • Massage & lubricate the back and over the bony prominences

Adequate Nutrition and Hydration Status

• The nursing goal is to ensure that the patient is meeting its energy requirements.
• Metabolic needs in critically ill patients are much higher than in normal subjects. Basic caloric requirements are usually increased by 25% for hospital activity and stress associated with treatment.
• If the gastrointestinal tract is intact, enteral nutrition is preferred and can be provided through a feeding tube.
• Many chronically ill patients, such as those with COPD, have long-standing protein and calorie malnutrition. Initial tube feeding is started slowly,
• The nurse observes the patient for signs of intolerance, such as diarrhea and hyperosmolar dehydration. If the patient tolerates feedings, the rate is gradually increased until the desired rate is achieved.
• If tube feedings cannot be tolerated, parenteral nutrition should be considered.
• Provide the correct proportions of fats, CHO, and proteins as well as water through enteral or parenteral routes.
• Establish regular bowel elimination pattern.
• Consult dietitian for metabolic needs & recommendations.
• Administer bowel regimen medications as ordered, along with adequate hydration.
• Administer intravascular volume of fluid as ordered to maintain preload
• Administer electrolyte replacements (IV or enteral) as per physician's order.
• There are serious negative consequences of acute malnutrition including: decreased immune response, loss of function of tissues and organs and delayed wound healing.

Promote comfort

• The nursing goal for meeting the patient's comfort needs depends on what comfort need the technician is addressing.
• Comfort needs includes keeping the patient clean and dry, prevent urine scald and skin break down, seeing to the patients mental well being, Perform range of motion exercises, assessing the patient for pain and Provide proper pain management.
• It is imperative that the technician be observant of signs associated with pain. Individually these signs do not indicate pain, but collectively and given the patient recent history an assessment regarding pain should be rendered.
• Provide analgesia as appropriate, document efficacy after each dose.
• Administer sedation as indicated, if required.

Bandage / Incision or Wound Care

• Bandages are placed to protect lacerations and surgical incisions and provide minimal support. They should remain dry and clean.
• The exposed toes at the end of the bandage should be warm and not swollen. The bandage should be free of abnormal odors. The skin above the bandage should be checked for local irritation. The bandage should be evaluated if the patient is licking or chewing the bandage.
• A patient's surgical incision should be evaluated several times a day. A surgical incision may be expected to produce mild redness and swelling with no drainage from the incision site.
• All wound/incision checks should be documented in the medical record. Any abnormal findings are brought to the attention of the clinician.

Recumbent Patient Care

• Patients suffering neurological, orthopedic, or traumatic problems can be recumbent for prolonged periods of time.
• Primary nursing goals are to minimize or prevent decubitus ulcers and lung atelectasis.
• Provide pressure relief- Fleece pads or Air and water mattresses bedding
• Insure appropriate nutritional support,
• Keep the patient clean and dry
• Enhance or maintain circulation.
• Patient should be turned every 2-4 hour. Turning the patient not only prevents the formation of decubitus ulcers it aids in the prevention of atelectasis of the lungs.
• Avoid pulling or dragging the patient, rather lift and turn.
• If exercise is not contraindicated passive exercise and massage should be instituted by moving the limbs back and forth and flexing the joints. It helps to improve muscle tone and promotes circulation.
• If peripheral edema is present, massage may be helpful in reducing the edema.

Catheters care

• Common catheters are - IV catheter, Urinary catheter and Chest tube and gastric tube
• The nursing goals for catheters include:
  • Minimizing The Risk Of Infection
  • Insuring Functionality
  • Prevention Of Complications
• IV Catheters
  • IV catheter care should be performed every 48 hours or on an as needed basis.
  • The catheter dressing should be removed and the site inspected, look for signs of phlebitis, infection, and or thrombosis.
  • When signs of phlebitis or thrombosis are apparent, the catheter should be removed and a new one placed at a different site.
  • If the catheter site looks good then the site should be cleaned with an iodophor or chlorhexidine solution.
  • When the catheter site is dry, apply a small amount of Betadine or triple antibiotic ointment to a sterile gauze pad.
• Urinary Catheter Care
  • Urinary catheter care is performed every 8 hours.
  • It entails cleaning the prepuce or vulva and its surrounding area with Betadine scrub and water rinse.
  • The urinary catheter itself should be kept clean especially in the female patient where the vulva is in close proximity to the rectum.
  • The urinary catheter should be attached to a collection system. By maintaining a closed collection system you decrease the chance of a urinary tract infection (UTI).
  • Do not disconnect the urinary catheter from the collection system. Drain the system every 2-4 hours rather than hourly. Urinary collection bags may be obtained commercially or you can use an empty sterile IV bag.
  • The addition of 3% Hydrogen peroxide to the urinary collection system has been shown to decrease the incidence of UTI. Five to ten milliliters of hydrogen peroxide is added to the urinary collection system.
• Chest Drain / Gastrostomy Tube Care
  • The procedure for chest drain and gastrostomy tube care is much like IV catheter care.
  • The bandage is removed and the insertion site is inspected every 24 hours. The site is cleaned and re-bandaged.

Facilitate Communication

• Provide the patient with his or her eyeglasses or hearing aid (if applicable) before assessing the patient's ability to communicate.
• Complete explanations from staff members regarding any procedures to help decrease the patient's stress.
• The caregiver can use verbal and nonverbal communication skills.
• Nonverbal communication may include sign language, gestures, or lip reading.
• If the patient is unable to use these forms of nonverbal communication, helpful devices include pencil and paper, and picture or alphabet boards, Use erasable marker board etc.

Provide Psychological support

• Provide adequate information and explanation of all procedures before they are initiated.
• Communicate a caring and unhurried attitude to the patient.
• Patient participates in self-care and decision making related to own activities of daily living (ADLs) (e.g., turning, bathing).
• Allow the Patient to communicate with health care providers and visitors.
• Encourage patient to move in bed and attempt to meet own basic comfort/hygiene needs independently.
• Establish a daily schedule for bathing, out of bed, treatments, and so forth with patient input.
• Provide a means for patient to write notes and use visual tools to facilitate communication.
• Encourage visitor conversations with patient in normal tone of voice and subject matter.
• Teach visitors to assist with range-of-motion and other simple care delivery tasks, to facilitate normal patterns of interaction.

Psychological Support & Information to Family

• Consider the needs of the patient's family,
• Establishes open communication with the patient and family,
• Familiarize the family with the physical surroundings of ICU,
• Informing the family of the visiting hours & visitation policies,
• Provide frequent progress reports about their patient's condition.
• Encourage family participation & involvement in patient care whenever the patient's condition allows through guiding and observing the family while participating in hygienic care, feeding
• Arranges for visits proactively & encourage open visitation policies

Patient Evaluation

• As part of nursing care, nurse should constantly evaluate the patient's condition.
• The nurse should be looking to see, the therapy is improving the patient's condition or not.
• In addition, evaluation of the nursing care plans should be considered.
• It is important to remember, "If you don't look, you won't see".