Assess the patient, by evaluating physical parameters (heart rate, pulse quality, mm color/moisture, CRT, extremity temperature, attitude/mentation, blood pressure, skin turgor). Assess ongoing losses, which can include vomiting, diarrhea, polyuria, third spacing, or wound loss. Assess the patient’s inputs - outputs, by evaluating urine output and serial body weights. Lab values, such as PCV/TP, lactate levels, and acid-base status, can give insight into a patient’s fluid status. Fluid therapy should also be monitored for signs of fluid overload.
Frequent auscultation of heart rate, palpation of pulse quality, blood pressure measurement and evaluation of mucous membranes color. Common arrhythmias seen in critical care include tachyarrhythmias (sinus tachycardia, VPCs, ventricular tachycardia, SVT, atrial fibrillation) and bradyarrhythmias (sinus bradycardia, AV blocks, atrial standstill, sick sinus syndrome, bundle branch blocks)Arterial blood pressure monitoring. Maintaining a systolic BP >90 mm Hg or mean BP >60 mm Hg is essential for maintaining organ perfusion. Blood pressure is most easily measured via noninvasive indirect methods, such as oscillometric or Doppler technique. Use appropriate cuff size (approximately 40% of the limb circumference) and the same limb for each measurement to ensure consistency and accuracy.
Arterial blood pressure monitoring. Maintaining a systolic BP >90 mm Hg or mean BP >60 mm Hg is essential for maintaining organ perfusion. Blood pressure is most easily measured via noninvasive indirect methods, such as oscillometric or Doppler technique. Use appropriate cuff size (approximately 40% of the limb circumference) and the same limb for each measurement to ensure consistency and accuracy.
These parameters include level of consciousness (LOC), breathing pattern, pupillary light reflexes (PLR), pupil size and location, posture, reflexes, and the use of coma scale evaluation. Evaluation of a patient’s LOC can be classified as normal/alert, dull/depressed/obtunded (slowed/inappropriate response to sensory stimuli), stuporous (unconscious but arousable to noxious stimuli) or comatose (unconscious and unresponsive). Changes in LOC can be indicative of decreased cerebral function (i.e., lack of oxygen supply, change in cerebral perfusion) and should be addressed quickly to prevent further deterioration. One of the most commonly used coma scales is the Modified Glasgow Coma Scale (MGCS). Any change in mentation (positive or negative) should be reported to the clinician and warrants intervention.
Albumin is the predominant protein within the intravascular space and is responsible for maintaining vascular integrity and colloid oncotic pressure (COP). Oncotic pull is what keeps fluids within the vascular space; without albumin, there would be increased intravascular permeability, resulting in fluids leaving the intravascular space and causing third spacing and edema. Critical patients often suffer from hypoalbuminemia, which can result in hypotension or interstitial or pulmonary edema. Nutritional support, synthetic colloids and intravenous albumin are therapies that can be used to raise albumin levels.",
parameter: "
TS > 40 g/l Albumin > 20 g/1
A common disease process in critically ill patients is acute kidney injury (AKI). Acute kidney injury (AKI) is a clinical syndrome, defined as a rapid deterioration in kidney function resulting from injury. Azotemia is recognized by abnormally high concentrations of body waste compounds within the blood, primarily blood urea nitrogen (BUN) and creatinine. Azotemia from AKI can further be grouped as prerenal, intrinsic renal, and postrenal, and is reflective of the type of AKI a patient is experiencing.
Blood glucose levels should be maintained between 65–120 mg/dL. Alterations in blood glucose (BG) can occur from many disease states/processes. Hypoglycemia can be caused by excess insulin (i.e., overdose, insulinoma), toxins (i.e., xylitol), hepatic disease, metabolic disease (i.e., hypoadrenocorticism, Fanconi syndrome), or sepsis. Hyperglycemia can be caused by lack of insulin (i.e., diabetes mellitus, DKA), neurological disorders, or renal disease.
factors include immunosuppression (i.e., leukopenia, undergoing chemotherapy), GI dysfunction (risk for bacterial translocation, aspiration, malnutrition), drug suppression, autoimmune disease processes, wound contamination, indwelling catheters/tubes/drains, infectious agents (i.e., zoonotic diseases), and nosocomial infections. Monitoring should include evaluation of white blood cells (i.e., daily CBC, daily blood smear), submission of culture and susceptibility, body temperature (monitor for fever), and daily assessment of wounds and/or insertion sites (i.e., incisions, IV catheter insertion sites) for signs of infection (discharge, odor, heat).
Sodium, potassium, chloride, and calcium should all be monitored and maintained within their normal ranges. Other electrolytes that should be monitored, if possible, are phosphorus and magnesium. Changes in electrolytes can manifest as changes in mentation (sodium), ECG rhythms (potassium, calcium), and acid-base status (chloride).Assessment of alveolar ventilation (venous), acid-base (venous or arterial), and oxygenation (arterial). Venous blood gas (VBG) analysis is performed when there is a need to know what a patient’s acid-base or ventilation status is. The values needed for interpretation are pH, PCO2, and HCO3.
Common diseases associated with gastrointestinal dysfunction are parvovirus, hemorrhagic gastroenteritis, ileus, foreign body obstruction, gastric ulceration, gastric atony, IBD, PLE, and secondary disease states (i.e., pancreatitis, cholangiohepatitis, hepatic lipidosis). The use of prokinetics, such as metoclopramide, can help enhance motility. Gastroprotectants (such as famotidine, pantoprazole, ondansetron, and sucralfate) can all be used to decrease acid secretions and limit the likelihood of ulceration. Antiemetics (such as maropitant) should be used to curb nausea.
Metabolic acidosis associated with poor perfusion and elevated lactate is common
Nutrition should be provided to every patient, every time, as it is necessary for recovery from all disease processes. The methods of providing nutrition in a hospital setting include enteral and parenteral nutrition. Enteral nutrition is when nutrition is provided via the GI tract. The use of nasoesophageal and nasogastric feeding tubes are minimally invasive, relatively short-term methods of providing nutritional support; bolus feeding or trickle feeding options are available. Additionally, esophagostomy tubes can be surgically placed for more long-term nutritional support. For enteral nutrition, the patient’s resting energy requirement (RER) should be calculated, and feedings should be started at 1/4 to 1/3 RER
HParameters such as respiratory rate, respiratory effort, respiratory character, lung auscultation, pulse oximetry, and venous blood gas can be used to monitor. Pulse oximetry (SpO2) is an easy, noninvasive means to measure the oxygen saturation of hemoglobin. A venous blood gas allows for measurement of CO2, which is the parameter that indicates appropriate ventilation. For patients who are not oxygenating well (i.e., SpO2 %lt; 95%), supplemental oxygen therapy may be necessary. For patients who are not ventilating well (i.e., CO2 >60 mm Hg), intubation and manual/mechanical ventilation may be necessary.
Altered volume of distribution, metabolism and excretion
Coagulation abnormalities occur in the critically ill due to disease processes affecting hemostasis. These include thrombocytopenia, von Willebrand’s, hemophilia, hepatic disease, rodenticide toxicity, or hypercoagulable states (i.e., Cushing’s, IMHA, sepsis). Evaluation of clotting times (PT, aPTT) requires specific blood draw techniques to ensure accuracy. It is also necessary to monitor for signs of hemorrhage, which include petechiae, ecchymoses, hematuria, or bleeding from incisions and wounds. In cases of severe coagulopathy, it may be indicated to implement blood component therapy (i.e., frozen plasma). Another concern in the critically ill is the development of disseminated intravascular coagulopathy (DIC).
Signs of pain can be classified as either behavioral (i.e., vocalizations, inability to rest, agitation, change in temperament, drop in activity level, insomnia, inappetence, immobility) or physiological (i.e., tachycardia, tachypnea, hypertension, hyperthermia, increased metabolic rate, decreased GI blood flow, immune suppression). Pain assessments should be included in the physical assessment of a patient. Monitoring for changes in pain using pain scoring systems is a great way to determine if pain is being managed appropriately or if additional pain relief therapies are needed. Pain, if left unidentified/untreated, leads to greater morbidity, mortality, and suffering.
If anemia is present and associated with clinical signs (tachycardia, tachypnea, lethargy, altered mentation), administration of blood component therapy (i.e., whole blood, packed red blood cells) may be warranted.
Any incision should be inspected daily for signs of infection or dehiscence; any dressings over an incision should be changed when soiled. Any wounds that have bandages should also be inspected and changed daily. IV catheter sites should be broken down, inspected and re-taped daily; any sign of infection, loss of patency, or inflammation, and the insertion site should be removed and replaced. Any tube insertion sites (i.e., feeding tubes, chest tubes, Penrose drains, etc.) should be inspected for patency and gently cared for.
Body temperature should be measured regularly in every critically ill patient. Temperature is most accurately measured via rectal thermometer, and fluctuations should be reported to the clinician.
Nursing care is everything that goes above and beyond and that might not explicitly be listed on the treatment sheet—things like giving soft/plush bedding, physical therapy for recumbent patients, warming up food, providing urinary catheter care, ensuring cleanliness/baths, giving “privacy screens” for timid patients, applying eye lubrication for patients in oxygen kennels, flushing IV catheters to ensure patency when not on IV fluids, evaluating pain scores, etc. It is our job to care for our patients and be their advocate. All patients should be handled and spoken to kindly in order to help minimize stress and anxiety that can develop in a hospital setting.
