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Introduction to Critical Care

Introduction to Critical Care. Module 9. What is critical care nursing?. Life threatening Unstable Complex Specialised nursing Intensive care. Critical to success. The place of efficient and effective critical care services within the acute hospital. Audit Commission. 1999. London.

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Introduction to Critical Care

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  1. Introduction to Critical Care Module 9

  2. What is critical care nursing? • Life threatening • Unstable • Complex • Specialised nursing • Intensive care

  3. Critical to success. • The place of efficient and effective critical care services within the acute hospital.Audit Commission. 1999. London.

  4. Comprehensive Critical Care Recommendations for modernising critical care. DoH 2000. • Local management • Levels of care • Data management • Follow up • Outreach • Early warning • Staffing

  5. Supporting evidence • Sub-optimal care. • McQuillan et al, 1998. • Predicting/preventing cardiac arrest. • Schein et al, 1990. • Preventable in hospital deaths • Brennan et al, 1991, Leape et al, 1991. Wilson et al, 1995. • Late ICU referral > worse outcome. • Brennan et al, 1991, • Ward admissions to ICU mortality • Goldhill et al, 1999, • mortality after discharge from ICU. • Rowan et al, 1993.

  6. Levels of care(Department of Health, 2000. Intensive Care Society, 2002) • Level 0 Needs can be met through normal ward care. • Level 1 At risk of deterioration or recently relocated from higher levels of care. • Level 2 More detailed observation or intervention, including single organ failure, and those stepping down from higher levels of care. • Level 3 All complex patients requiring advanced respiratory support, or support for multi organ failure.

  7. Levels of care • Mr A. had a hernia repair 2 days ago, awaiting discharge. • Mrs. B took 20 paracetamol 24 hours ago, had gastric washout and charcoal. Awake but disinterested.

  8. Levels of care • Miss C. underwent emergency over sewing of a gastric ulcer 2 days ago. Now has a chest infection. • Mrs. C collapsed in the street following a cardiac arrest today. CPR given at scene. Inotropic drugs infused

  9. Levels of care • Mr. D suffered exacerbation of chronic obstructive pulmonary disease. Ventilated and sedated. Oxygen requirement = 6 (60%0. • Dr E underwent emergency abdominal surgery 24 hours ago (Aortic aneurysm rupture). In ICU. Has 4 (40%) oxygen via mask, epidural for pain relief, CVP line.

  10. What do we do at the bedside? • AWARENESS • CLINICAL JUDGEMENT • TREATMENT Bedside

  11. AWARENESS Observations and vigilance Bedside

  12. Respiratory rate Commonest physiological abnormality of patients admitted to ICU. Goldhill et al, 1999. Preceding arrest, change in Behaviour 84% Respiratory function 53% Mental function 42% Schein et al, 1990. Mortality increases with the number of abnormal physiological values 1 4.4% 2 9.2% 3 23.4% Respiratory rate Heart rate Blood pressure Conscious level Urine output Temperature SpO2 Observations Bedside

  13. KNOWLEDGE • Education • Experience • Guidelines • Policies • Procedures • Resources • MEWS Bedside

  14. TREATMENT • Simple measures • A,B,C, • Oxygen • Fluids • Getting help Bedside

  15. Sharing knowledge and skills Knowing your limits Listening to others Helping each other Communicating well Good record keeping Keeping the patient and their family informed Team work and communication

  16. Case study 1 • 42 year old man • Anterior resection for Ca rectum • 6 days later faecal peritonitis • Laparotomy and admit to ICU overnight • Transferred back to the ward at 07:00

  17. Case study 1 Leaving ICU • T 36.2, RR 16, HR 97 (SR), BP 100/62, CVP 0, • NS 120, UO 80-90, NG/drains 1L (-1400) • 3l O2 via NS, SaO2 99%

  18. Referred by pain nurse at 08:30 who called Outreach. A -  B - NS 3LO2 RR, SpO2 C - BP, HR, colour, skin temp, OU, NG loss D - irritable E - NAD High flow oxygen Fluids Get help. Readmitted to ICU Intubated and ventilated with high dose inotropes. 3rd laparotomy and tracheostomy. Slow recovery after 14 days. A. C. T!

  19. Case study 2 • 77 year old man admitted for AP resection. • 12 days post op • MEWS up to 9. • Admitted to ICU 22 hours later.

  20. Case study 2 During 22 hours • 9 entries in notes • 9 descriptions of deterioration • 4 requests for abdo and CXR • Blood transfusion • More fluids • Observe and review repeatedly • 9 hours later, mention of ICU referral • ICU involved 16 hours later (no ICU bed) • Died in ICU 7 hours after admission

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