ICU Flashcards

Question

SIMV ventilation mode

Answer 1

Synchronized Intermittent Mandatory Ventilation (SIMV) * SIMV = machine breaths (VT & RR or P & RR) are synchronized with patient’s spontaneous RR so as not to ‘stack’ breaths * This ventilator mode will provide a set number of breaths at a fixed tidal volume, but a patient can trigger a spontaneous breath with the volume determined by patient effort * A level of PS (5 – 8 cmH2O) added to overcome airway resistance of artificial airway * SIMV & A/C mode are similar if patient takes spontaneous breaths * SIMV is a weaning mode.

Answer 2

Continuous Positive Airway Pressure * One level of positive pressure is maintained in ventilator circuit during inspiration and expiration * Patient breathes totally spontaneously and generates his/her own VT * CPAP given through ventilator or wall circuit * CPAP is a weaning mode

Answer 3

Doctor sets RR & Vt or RR & pressure – patient doesn’t participate.

Answer 4

Adds trigger sensitivity to controlled mode, thus detects patient’s inspiratory efforts Indicated: patient with no spontaneous RR or potential loss of breathing efforts (PC mode or VC mode)

Answer 5

* Close monitoring of vital signs as this fluctuates quickly * Bolus of sedation/paralysing agent prior to handling * When a patient is turned, keep head in midline * No direct pressure to bolt, drain, shunt site * After craniotomy; bone flap removed, no direct pressure on unprotected brain * Short Rx sessions * Pre-oxygenate prior to and during treatment * Suction as needed * Not to noisy * Ventricular drains (EVD) o Check medical orders o Excessive movement/Physiotherapy (closed/raised) o If drain must be open; raise 10-20cm when pt cough * Cerebrospinal fluid leak (CSF) o CSF leak; drainage from nose or ear o Avoid nasal suction

Answer 6

* Fracture site must be supported during treatment so as not to cause further harm or injury * Avoid rotation of fractured site and be respectful of pain * avoid turning the patient directly on to right shoulder. * Avoid resistance distal to fracture site * Elevate injured limb to reduce oedema, but only to the range allowed as a result of the fracture * Do ROM exercises in a pain-free range

Answer 7

* Nebulise with mucolytic “mesna”/saline- will thin secretions 10-15 min * Suction, use saline to decrease tenacity of secretions, but don’t routinely install saline

Answer 8

* Height of bed inappropriate for patient to get into and out of * Noisy and busy- increases fear and anxiety in pt * Sleep and rest disruption as a result of health professionals coming in at different times to do treatments * Many machines and equipment in the vicinity, making it difficult for pt to move around easily * attachments to patient can restrict movement

Answer 9

* Pt cannot walk around ICU and communicate with others * Pt cannot speak to family members/health professionals effectively due to ventilator * Participating in exercise programmes may be limited due to pain and fear * Pt cannot bath, dress or eat independently

Answer 10

* Patient anxiety * Pt uses accessory muscles and nasal flaring is apparent * Very diminished breath sounds in both lungs on auscultation * High peak inspiratory pressure (PIP) * Low tidal volume readings on MV panel * Alarming from MV

Answer 11

- If gap < 2.5cm: bed rest 2-4 weeks until pain subsides then treat as stable fracture - If gap > 2.5cm: post surgery bed rest for up to 4 weeks then mobilise PWB or FWB (discuss with surgeon) - Pelvic sling: after bed rest mobilise patient PWB for 6 weeks.

Answer 12

- External fixation or plates: no excessive hip external rotation; no posterior pelvic tilt for 4 weeks; hip flexion limited to 45 degrees for 4 weeks, No weight-bearing until given the “go ahead” from the surgeon - Pelvic sling: no sitting for 4 weeks - Communication with the surgeon is very important to clarify precautions

Answer 13

Calc: 1. PaO2/FiO2 will show VQ mismatch if below normal (n: >/= 400) 2. Hypoxic hypoxemia (A-a)O2 will show diffusion defect – Implies lung disease or pulmonary dysfunction as only lung disorder can produce a decrease in PaO2 o PAO2 = FiO2(PB – PH2O) – (PaCO2/RI)  PB = 625 mmHg (Jhb)  PH2O = 47 mmHg  RI=0.8 (ratio of CO2 excretion to O2 uptake) o (A – a)O2 ≤ 10 mmHg is normal when breathing spontaneously. o (A – a)O2 < 65 mmHg is normal when 100% oxygen is breathed. 3. Anaemic hypoxemia oxygen content * Oxygen content = dissolved O2 + O2 bound to Hb (n: >190, less = anaemic hyposxia) * Dissolved O2 = 0.03 x PaO2 (normally ± 3 – 4 ml/L) * O2 bound to Hb = 1.34 x Hb x SaO2 (remember to convert g/dL to g/L and % to a number) o (1.34 = the amount of O2 bound to 1g of Hb if it were 100% saturated)

Answer 14

inspiratory muscle trainer * Pt seated in 45 degree head up position * Establish pt’s baseline inspiratory muscle strength using a pressure manometer to measure maximal inspiratory pressure * Do two measurements of MIP and calculate the average of the 2 readings * Attach IMT device to ETT or tracheostomy Tube * Attach oxygen tubing to side-port of the device if indicated * Set the spring in the IMT device to 30% of the pt’s baseline MIP * The patient breaths through the device for 5 minutes twice daily- add lateral costal breathing exercises * Inspiratory resistance is increased by 10% of MIP daily as tolerated

Answer 15

inspiratory muscle trainer * Pt seated in 45 degree head up position * Establish pt’s baseline inspiratory muscle strength using a pressure manometer to measure maximal inspiratory pressure * Do two measurements of MIP and calculate the average of the 2 readings * Attach IMT device to ETT or tracheostomy Tube * Attach oxygen tubing to side-port of the device if indicated * Set the spring in the IMT device to 30% of the pt’s baseline MIP * The patient breaths through the device for 5 minutes twice daily- add lateral costal breathing exercises * Inspiratory resistance is increased by 10% of MIP daily as tolerated

Answer 16

* Cuff deflation and swallow assessment * Fenestrated tube inserted * Downsizing of the tube * Capping off * Decannulation (extubation)

Answer 17

* Ensures that the pt is given full attention and that all decisions are made together by all members of the team to ensure effective treatment * Pt has neurological problems and cardiopulmonary problems thus all members of the medical staff should make these decisions together so that there is no controversy/contradictions in treatment * Orthotist/OT to assist with splints for ankles * Pt requires adequate treatment from nurses, doctors, physios and dieticians among others in order for effective management to occur

Answer 18

* Certain level of pressure to the inspiratory circuit when patient starts to inhale. * This ‘boosts’ patient’s own respiratory efforts by increasing spontaneous VT & unloading patient’s respiratory muscles * Boost stops when inspiratory flow decreases to a certain degree as the end of inspiration is reached * Used in conjunction with all ventilation modes

Answer 19

Positive End-Expiratory Pressure * Positive pressure added to airways at end of expiration to prevent collapse of alveoli – stabilizes alveoli * PEEP increases patient’s tidal volume and functional residual capacity (FRC) - ↑ oxygenation * Used in conjunction with all ventilation modes

Answer 20

- maintain and improve ROM of affected joints – indicate outcome & time frame - maintain and improve muscle strength, including respiratory muscles – indicate outcome & time frame - maintain and improve muscular endurance, including respiratory muscles - prevent soft tissue shortening or muscle contractures – indicate which two-joint muscles (hamstrings (biceps femoris): crosses hip & knee; rectus femoris (quadriceps), semitendinosis, semimembranosus: cross hip & knee; gastrocnemius: cross knee & ankle; biceps brachi) are at risk of contracture formation - promote functional independence indicate outcome & time frame - oedema management

Answer 21

Physical Function in ICU Test - Developed as an outcome measure to evaluate and prescribe rehabilitation for patients in ICU as not able to perform 6MWT or timed-up-and-go test in ICU - Components of PFIT: o Assistance (sit to stand) o Cadence (during marching on the spot - steps/minute) o Shoulder (flexion strength - bilateral) o Knee (extension strength - bilateral) o Limitations to PFIT: The test can only be performed if the patient is able to sit in a chair, No assessment of respiratory function.

Answer 22

Chelsea Critical Care Physical Assessment Tool (CPAx) o Bedside scoring system to grade physical morbidity in the critical care population o Need hand dynamometer to assess hand grip strength o Newer tool than PFIT – validation studies underway

Answer 23

Functional Status Score for ICU (FSS-ICU) o Assesses rolling, supine to sit, SOEB, STS, walking o Out of 35

Answer 24

- check pulse oximeter has not shifted – if it has, replace and monitor sats and continue treatment if normal - if in situ – cease treatment, monitor sats, if due to treatment and they normalise continue treatment but monitor - if sats still decreased, check O2 mask in situ / ventilator still connected – correct if not - If all above is normal and sats still reduced, auscultate to see if there are breath sounds 🡪 increase FiO2 on vent, call a nurse/doctor to help

Answer 25

- pain from rib fracture = short, shallow breaths = unable to produce a vital capacity of >15ml/kg - rib fractures ↓ lung compliance - Haemopneumothorax places ↑ pressure on the lung and ↓ oxygenation and ventilation - decreases the amount of negative pressure inside the lung and .’. makes it difficult for O2 to enter the lungs .’. PaO2 could possibly be <60mmHg - Pain and fatigue of external and internal intercostal muscles will ↓ ability to inspire or expire, respectively - inability to clear secretions independently and effectively and independently due to pain, weakness, and other related causes

Answer 26

Environment - Stressful - sensory overload - disturbed sleep - lines and attachments - unable to communicate effectively Personal - depression, anxiety, and fear - loss of dignity and privacy - ↓ motivation - financial support - family support

Answer 27

Breathlessness (BORG/MRC scale) Pain – VAS Reversal of partial / complete collapse (auscultation Secretions - auscultation

Answer 28

Cognition – GCS/ICP value Muscle strength (MRC/Oxford) Breathing pattern (observed) Clearance of secretions (amount, consistency, and colour) Lung collapse – thoracic expansion and chest x-ray

Answer 29

Haematological System Response - Disseminated Intravascular Coagulation (DIC) Definition of DIC: A condition in which small blood clots develop throughout the bloodstream, blocking small blood vessels due to overactive proteins. The increased clotting depletes the platelets and clotting factors needed to control bleeding, causing excessive bleeding.

Answer 30

* Monitor platelets if less than 50 x 109/L = stop PT and consult with ICU staff * Monitor for signs for clotting and DVT (make sure pt has taken daily meds) * Monitor for bleeding from facial orifices e.g. nose * Do not palpate/handle/apply MCT too vigorously as pt’s bleed and bruise easily * MCT and PD are C/I if coughing up blood (haemoptysis) * Give slack in any lines, they may pull and rip out, which too may lead to bleeding * If any SOB/ Dizziness / Severe fatigue stop PT and allow for recovery. Apply relaxation positions and TEE ( if pt can tolerate)

Answer 31

Assessment: * Monitor any changes in platelets, PTT and INR. * Monitor for signs of bleeding at any orifices / ask ICU nurse * Monitor for signs of DVT * Monitor SOB/Dizziness and fatigue if mobilizing Treatment: * Mobilize out of bed – only if patient’s condition is stable enough * MS and ROM exercises as well as functional exercises – only if patient’s condition allows * Chest physio: MCT use vibromat if available, ACBT, and any other interventions if and when indicated. Use caution with airway suction and manual hyperinflation.

Answer 32

Humidification of MV Circuit: * Dry gas is delivered through a mechanical ventilator to the patient – increased risk of drying out the mucosal membranes and development of pulmonary infection * Humidification strategies in ICU: o Passive heat and moisture exchanger (HME - dry humidification) o Active humidification (Fisher Paykel system - heated water humidification)

ICU Flashcards

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