2012 CCU Competency

2012 CCU Competency Assessment Module 2: Key Critical Thinking Check Points in Assessment: Blood Pressure Pulmonary Status Restlessness and Anxiety Introduction to Delirium Assessment.

Purpose • The first purpose of this module is to review critical thinking aspects associated with key areas of assessment. • The second purpose of this module is to introduce a new method for delirium assessment that will be implemented into CCU practice in 2012.

Blood Pressure Key Points

Mean Arterial Pressure (MAP) • Blood Pressure (MAP) = • Cardiac Output x Systemic Vascular Resistance (Afterload) • The end organs (brain and kidneys) are perfused based on the MAP. These organs will auto regulate blood flow as long as the MAP remains in a safe range.

CNEA / Key Choice Key Principles in Understanding Blood Pressure Assessment • Pulse pressure (difference between systolic and diastolic) is inversely related to arterial compliance • MAP = Calculated • SBP: Reflects LV volume and contraction • Very dynamic • Diastolic BP • Continuous / less dynamic pressure • Drives capillary opening pressure

Key Point • The kidneys are very sensitive to a drop in MAP and this is why Acute Kidney Injury (AKI) is a common and very serious complication of critical illness. • Patients who develop AKI as a complication of their critical illness have a higher mortality rate. • In a patient who is critically ill, the goal is keep the MAP > 70 mmHg.

CNEA / Key Choice MAP = CO x SVR • Low BP could be due to: • Low CO • HR too slow or too fast • Preload too low or too high • Contractility low • Low SVR • Vasodilation due to sepsis, anaphylaxis, altered neurological function, drugs

Use of Pulse Pressure • PP < 35 with tachycardia (in absence of beta blocker) • Seen with hypovolemia • Also seen with cardiogenic shock or pump failure in decompensated heart failure. • PP > 35 with tachycardia • Seen in sepsis.

Changes in Systolic Blood Pressure Correlate with Stroke Volume Variation • Remember – think LV ejection • Volume • Contractility • Volume is the first line treatment to improve stroke volume. • Then evaluate the patient’s response. • In patients with poor LV function an inotrope may be needed.

Blood Pressure: CO x SVR • BP: 88/64 • Is problem low cardiac output or low SVR? • The problem is low cardiac output. • Either hypovolemia or pump failure. • The patient’s SVR is actually high due to compensatory vasoconstriction. • How to treat? • Think volume first. • If not responsive to volume, an inotrope may be needed

CNEA / Key Choice Blood Pressure: CO x SVR • BP: 82/30 • Is problem low cardiac output or low SVR? • The primary problem is a low SVR. The pulse pressure is wider than normal. • This is an abnormal physiological response – the body should vasoconstrict in response to a decrease in stroke volume. This abnormal vasodilation is seen in conditions such as sepsis. • How to treat? • The patient is vasodilated meaning the vessel diameter is larger than normal. The patient will require a significant amount of increased fluid to fill up the larger vessels. • The patient may also need a vasopressor to help restore the normal vessel tone.

CNEA / Key Choice Key Principles in Understanding Blood Pressure • Pressure does not always = Flow • A patient can have an adequate Bp on vasopressors but not have adequate flow to the tissues. Vasopressors result in vasoconstriction that can impede flow. It is imperative that we assess our patient’s tissue perfusion in addition to the blood pressure.

Key Points • Many patients with HF have a lower systolic BP at baseline due to their decreased LV function. • ACE-I or ARBs are used in these patients not for the treatment of hypertension, but for the mortality benefits associated with these medications in clinical trials. • An ACE-I or ARB will reduce systemic vascular resistance and decrease the work load of the left ventricle. This can result in an improvement of forward flow (stroke volume). • Using an ACE-I or ARB in conjunction with diuretics is also important, because diuretics like furosemide (Lasix) will result in an activation of the renin-angiotensin-aldosterone system.

Key Points • Many CCU patients are on both an ACE-I (or ARB) and a beta blocker. The nurse often needs to use judgment in determining if the patient will tolerate all the ordered medications at the doses that are ordered. • Medications may be scheduled at different times to assess the effect of one medication before giving another medication with a similar effect. It is important to know the peak action of the medication you are assessing. • A general rule of thumb in prioritizing medications when you don’t think the patient will tolerate all ordered medications - is to give medications with a mortality benefit first. ACE-I (ARBs) and beta blockers are used for mortality benefit in most of our patients. • In a HF patient with a low EF – the ACE-I is usually the first priority. • In an acute coronary syndrome with ischemia and in any patient with ventricular arrhythmias a beta blocker is usually the first priority.

Key Points • Knowing when the blood pressure is too low and establishing hold parameters for medications involves complex decision making on the part of the provider. Each patient is unique. • If a hold parameter is not indicated for a medication that affects blood pressure, and you are concerned about hypotension, please discuss with the provider. • If a hold parameter is ordered, and you are not comfortable with giving a medication within the ordered hold parameter, you must discuss this with the ordering physician or APN. It is not acceptable practice to hold a medication when the blood pressure is above the ordered hold parameter.

Key Points • Although many patients with a low EF have a low systolic blood pressure, this does not mean that hypotension does not have adverse effects. • Hypotension is dangerous! • When a patient experiences a new onset of hypotension, the physician or rounding APN needs to be notified. Although the patient does not have any complaints associated with the hypotension, it does not mean that the hypotension is benign. • If a treatment is ordered for the hypotension and the patient does not respond to the treatment, the physician or APN needs re-notified.

Rounds: Please report any ordered medications your patient is not tolerating or has not taken during rounds. This is crucial information that affects the treatment plan. The nurse at the point of care has vital assessment data that is important to share during patient care rounds. The point of care nurse assesses the patient during several hours out of 24 and is able to bring information to rounds that is not visible to those only assessing the patient at the time of rounds.

Pulmonary Assessment Key Points

Work of Breathing • A patient’s work of breathing should be easy. If a patient is working to breath (i.e. using accessory muscles) this is an urgent situation requiring intervention. An increased work of breathing should be reported (the term “increased work of breathing”) should be used in reporting your findings to a physician. • An increased work of breathing is one of the warning signs for an impending cardiac arrest. (Source: Fundamentals of Critical Care Support Course).

Dyspnea and Tachypnea • Dyspnea is a hallmark sign of HF. When assessing your patient for improvement or worsening in dyspnea it is important to consider a few things: • Is the dyspnea when lying flat (orthopnea)? • Is dyspnea at rest? • Is it with minimal activity such as talking or changing positions in bed? • Is it with the patient’s normal home activity level (and what is the patient’s normal home activity level)? • Documentation of an accurate respiratory rate is an important component of an accurate assessment. Tachypnea is not normal and may be an early indicator of a significant change in condition. This is an area for needed improvement in CCU. • For example: A HF patient had tachypnea (rate of 30-32) on daily rounds as assessed by the rounding APN. A CXR and BNPt was ordered as a result and the patient received additional diuretic therapy. The patient remained tachypneic (rate of 30-32) and BiPAP was considered. On review of documentation, it was found that the respiratory rate documented on the ICU flow during the same period of time was 20 for each assessment.

Hypoxemia • When a patient develops hypoxemia as evidenced by low oxygen saturation on pulse oximetry, the immediate response is to increase the FIO2 through the administration of oxygen. If the hypoxemia improves this means the problem was most likely due to a barrier to the diffusion of oxygen across the alveolar capillary membrane. • A barrier to the diffusion of oxygen occurs when there is a problem with the alveoli capillary membrane. This occurs for example when there is an increase in interstialfluid or fluid in the alveoli such as in pulmonary edema; or when an exudate is present such as with pneumonia. • An increase in FIO2 increases the amount of oxygen in the alveoli. Because the difference (gradient) is greater between the amount of oxygen in the alveoli compared to the amount in the venous blood it is easier for the oxygen to diffuse (move) across the membrane.

Hypoxemia as a result of a ventilation problem • When hypoxemia does not respond to an increase in FIO2 – this means there is something going on other than a simple diffusion problem. • A blood gas may be needed to determine if the patient is having a problem with ventilation. Untreated ventilation will ultimately lead to hypoxemia. However, hypoxemia is not the first indicator of a ventilation problem on the blood gas. An increase in PCO2 is the first indicator of inadequate (hypo) ventilation. Inadequate (hypoventilation) ventilation is the only cause of an elevated PCO2.

Treatment of Ventilation Problems • If it is determined that a patient has ventilatory failure (as evidenced by an elevated PCO2 on blood gas) then specific interventions are required. • Oxygen will not treat ventilation problems. • Effective ventilation is determined by the patients respiratory rate and tidal volume. There if ventilation is not effective, the respiratory rate or tidal volume must be corrected. • Interventions to correct ventilation problems include: • Reversal of sedation to increase rate. • Bagging patient. • BiPAP. • Intubation and mechanical ventilation.

Anxiety and restlessness Key Considerations

Anxiety and Restlessness • Anxiety and restlessness are non specific symptoms – however, they can be early warning signs of serious medical conditions. • When a patient develops anxiety or restlessness it is important to rule out any physical causes. • Pulmonary congestion in a patient (particularly if the patient is not able sit in a completely upright position) • Hypoxemia. A pulse ox should always be assessed. • Early sepsis. Tachycardia and tachypnea together indicate systemic inflammatory response. • Electrolyte imbalances. Sodium levels in particular can impact neurological functioning. • Withdrawal. Nicotine, alcohol, narcotics, benzodiazepines? • ? Obstructive shock such as tamponade, PE, or tension pneumothorax as discussed in the previous module.

Benzodiazepines • Benzodiazepines are a cause of acute delirium with the goal being to use as infrequently as possible and in as small doses as possible. • If a patient has anxiety and physical causes have been ruled out, the first line interventions should include supportive communication to discover the reasons for the anxiety, support, reassurance, and family presence at the bedside whenever possible. • Although benzodiazepines should not be the first line strategy for managing anxiety, it is important to know that they should not be withdrawn in a patient who takes them at home. Withdrawal of benzodiazepines is also cause of delirium.

Delirium Assessment An Introduction

Delirium Assessment • Currently there is no formal assessment process used for delirium screening at Aultman Hospital. • On 4/9/2012 the Heart Center Clinical Practice Committee decided to adopt the CAM-ICU delirium assessment tool for use within the Heart Center • Kim Alltop had researched and presented information on validated tools for delirium assessment. • The decision was to use the tool consistently on a) ventilated patients (in CVSICU those patients who remain intubated longer than planned post operatively), b) other critically ill patients such as those on CVVHD or IABP, and c) any patient who has a change from baseline mental status.

Level of Sedation as a Component of Delirium Assessment • An accurate assessment of the patient’s level of sedation is an important component of delirium assessment. • At Aultman Hospital we use the SAS Sedation Agitation Scale as our tool for sedation assessment. • When providing sedation for a patient it is important to do based on a goal. On the SAS scale the goal for sedation in most patients will be between a 3 and 4. • At the level of 4 the patient is calm, easily arousable, follows commands. • At the level of 3 the patient is difficult to arouse but awakens to verbal stimuli or gentle shaking, follows simple commands but drifts off again.

More on Sedation • Patient comfort is key. Patient comfort is a very high priority in the mechanically ventilated patient. At the same time it is important for nurses to know that the overuse of sedative and narcotic analgesics increase the risk of delirium. • A study by Pandharipande et al. (2006) that three important risk factors for the development of delirium were patient age > 70, severity of illness, and the dose of the sedative lorazepam (Ativan). Key Point: Non narcotic pain relievers such as acetaminophen may improve patient comfort in mechanically ventilated patients. The use of non narcotic pain relievers may decrease the needed amount of narcotic medications. Key Point: If a patient requires lorazepam for sedation and this is not a home medication, the goal is to use the smallest dose possible as infrequently as possible.

Think of delirium as end organ dysfunction in a critically ill patient. We should think of delirium much the way we think of acute kidney injury as a complication of critical illness. The key is prevention and early recognition. Delirium is not benign Delirium not only results in longer length of hospital stay, but its also increases the patient’s risk of death. (Pandharipande P et al, Anesthesiology. 2006;104:21-26)

What is Delirium • Delirium is an acute condition. It develops over hours to days. It is usually reversible if recognized and treated. • Delirium is a fluctuating condition that involves inattention. In addition to inattention the patient has some level of altered cognition or perception (clouded consciousness). • The terms “ICU psychosis” is no longer an appropriate clinical term.

What delirium is NOT! • Delirium is not dementia. • Characteristics of dementia: • Gradual onset (weeks, months, or years) • Intellectual impairment • Memory disturbance • Personality or mood change • No clouding of consciousness.

Assessment Features of Delirium • The next few slides are going to cover how a nurse can assess for delirium. • Using our SAS scoring system – delirium should be assessed for in any patients who have a sedation score of 3 or higher. Patients with a sedation score of 1 or 2 do not have a LOC high enough to warrant delirium assessment. • As you begin to incorporate the following strategies into your assessment of critically ill patients you may begin to detect delirium in your patients. • If you suspect delirium based on your assessment findings – this is a change in patient condition and reportable condition.

Delirium Features The patient must have Feature 1 and Feature 2 present to have Delirium. Feature 1 Feature 2 Feature: Inattention Assessment: The patient is asked to squeeze your hand when you say the letter A. You read the following series of letters three seconds apart. If the patient makes more than 2 errors they have inattention. The letters you read to the patient are SAVEAHAART. • Feature: Acute change in mental status or fluctuating course of mental status. • Assessment: • Is the patient different from baseline mental status? • Or – has there been any fluctuation in mental status over last 24 hours? • Note: A yes answer to either question makes the patient positive for feature 1.

Delirium Scoring To determine that a patient has delirium – they must have both features 1 and 2. And – they must have either Feature 3 or 4. Assess for Features 3 and 4 in patients who have both features 1 and 2. Note: Assess for Feature 3 before Feature 4. If Feature 3 is present the patient has delirium and there is no reason to assess for Feature 4.

Delirium Features Feature 3 Feature 4 Feature: Disorganized Thinking. Assessment: Ask the patient 4 Yes or No questions. They can answer with a head nod. Will a stone float on water? Are there fish in the sea? Does one pound weigh more than two pounds? Can you use a hammer to pound a nail? Hold up 2 fingers and ask the patient to hold up the same number of fingers. If the patient is able to do so ask him or her to hold up the same number of fingers using their other hand. Note: If the patient has more than one error when answering questions or holding up the correct number of fingers they are positive for this feature. • Feature: Current altered level of consciousness • Assessment: • Any score other than a 4 on the SAS score would mean the patient is positive for this feature.

CAM-ICU Flow Chart Feature 1. Acute change in mental status or any fluctuation over last 24 hours No Delirium No Yes Feature 2. Inattention. More than 2 errors when asked to squeeze hands with letter A when the nurse is saying these letters SAVEHAART. No Delirium No Yes Feature 3. Current altered level of consciousness. SAS score of 4 is normal. SAS other than 4 Delirium SAS = 4 More than 1 error Feature 4. Disorganized Thinking. More than one error when asked the four yes or no questions and when asked to hold up 2 fingers. No Delirium 0 or 1 error

The ABCDE Bundle to Prevent Delirium • The ABCDE Bundle is recommended to prevent delirium. This bundle supports the initiatives that are currently underway in the Heart Center Clinical Practice Committee and through the CCU Shared Decision Making Committee. • These additional initiatives include early progressive mobility and normal sleep and rest promotion. • The ABCDE Bundle includes: • A: Daily awakening (if sedation resumed it should be at ½ dose) • B: Daily spontaneous breathing trial • C: Choice and dose of sedation • D: Delirium Assessment • E: Early Mobility

To Complete This Module • Please identify one clinical goal you have in the area of assessment. • Please bring to your annual competency meeting at least one example of what you have done to meet this clinical goal or one example where you have demonstrated achievement of this goal in clinical practice. • Complete one of the your choice activities related to assessment as identified on the final slide.

Your Choice Activity: Choose One of the Activities to the Left.(your choice activity will be discussed at your competency meeting). Obtain or maintain certification as a CCRN, PCCN, and / or CMC. Submit a peer review written statement or a self reflective written statement (in your portfolio)demonstrating how you have shown clinical leadership in the area patient assessment. Read an evidence based patient education journal article on one of the forms of obstructive shock discussed in the first assessment module. Define one thing that will change your practice. Read an evidence based journal article on sedation or delirium assessment in the ICU. Define one thing that will change your practice. Attend a Heart Center Clinical Practice Committee Meeting. Literature supports that professional nurses should take ownership in validating their own competency. Source: National Education Framework Cancer Nursing, 2008

2012 CCU Competency