1. CARE OF CRITICALLY ILL PATIENT
Sally Aucken & Catherine Jones
Foundations of Critical Care Coourse

2. Learning Objectives
Understand common components of nursing care of critically ill patients.
Understand importance of maintaining a safe environment in critical care

3. Plan For Session
Lecture
Group work & Discussion

4. Complete safety checks as FIRST PRIORITY every shift
GOLDEN RULE NUMBER 1
Complete safety checks as FIRST PRIORITY every shift

5. NEVER leave a ventilated patient unattended
GOLDEN RULE NUMBER 2
NEVER leave a ventilated patient unattended

6. Please discuss as a group what you will need to mange in terms of (& possible solutions??!)
1. Environment – Safety checks, IC, clutter, bodies
2. Nursing Care – continuos monitoring, manage/monitor therapies, essential pt care – Continence, Skin integrity, joint care, DVT prophylaxis, eye/mouth, nutrition
3. Safety – Safety checks, medicines mgm, IC

7. What is the nurses role in critical care:
Maintaining safe environment
Continuous advanced monitoring
Continuous support
Invasive therapy and organ support
Medicines management
Communication
Documentation
Essential patient care
Continence
Skin integrity
DVT prophylaxis
Eye Care
Mouth Care
Nutrition

8. Useful Communication strategies
Lip reading – better for trachy.
Alphabet/picture boards.
Wipe board.
Closed question loops
Language Line. Translators
technology

9. Medication Management:
PROBLEMS:
Multiple infusions – Continuous & Intermittant.
Finite access
Polypharmacy & Interactions
Dynamic status of patient requires vigilance to contraindications.???
SOLUTIONS:
Double signing and checking with IV trained registered nurse
Smart Pumps
Line & Syringe labelling
Compatability chart
Robust pharmacy support
Resources: BNF, IV prep guide
If it smells funny it is funny, if it tastes like chicken it isn’t necessarily chicken!!
TOP TIP – Sign for meds as you give them….

10. Privacy & Dignity THESE PATIENTS CANNOT PROTECT THEMSELVES.
Be thoughtful:
Curtains should be closed.
Patients should not be left exposed.
Communication around & over the patient should be professional & in English.
Interventions should be explained before they are undertaken.

11. Continence Care Sgul/gicu webpage NICU – red computers
CTICU – L- Drive folder

12. Continence Care

13. Catheter Care Remove ASAP (Anuric patients don’t need a catheter)
Keep CLOSED – if necessary to disconnect use ANTT & manipulate with 2% sanicloth
Urinalysis on admission. (GICU – pregnancy test for female pts under 55years)
Urine bag stowed below bladder
No contact with the floor
Decontaminate port c 2% sanicloth prior to emptying catheter into single use container
Catheter blocked? Bladder scan before bladder flush (Uro-tainer Saline)
Change & label catheter bag every 7 days.
Clean daily with soap and water

14. Mouth Care In health – mouth lubricated by drinks/saliva
Saliva = water, antibacterial chemicals, buffers acids that demineralise teeth.
Saliva production impaired in critically ill 2ndry to reduction in cardiac output.
ETT – swallow reflex inhibited – oral secretions pool to the back of the mouth.
Endotracheal Cuff is seldom water tight – tracking and aspiration of muck – Ventilator Associated Pneumonia
Oral thrush related to antibiotic use

15. Chlorhexidine no longer recommended for general ICU population
Associated with higher mortality risk previous trials skewed by clean & scrubbed CTICU population so shouldn’y be recommended beyond cardiac population
Guidelines For Provision of Intensive Care (2015)

16. Mouth Care:
Inspect all mouth surfaces – teeth, tongue, gums, palate & lips using pen torch.
Assess saliva / dryness.
Brush Teeth once a shift (5am; 5pm.) for 2 minutes with flouride toothpaste.
Regular oral care 4 hourly
Lubricate Lips prn – remove excess from ETT
Check position of ETT before & after procedure
Protocols on different units
Standardisation of mouthcare assessment tool coming…….. Don’t hold your breath though

17. Beck Oral Assessment Scale (modified)

18. Eye Care Why is eye care important in ventilated patients?
In health – eyes are protected by eyelids, eyelashes & blinking.
Blinking – spreads lubrication; ANTIMICROBIAL.
Sedation/Paralysis – impairs blink rate & reflex.
Disease Processes – facial oedema, reduced GCS
Treatments – dry gases from oxygen (CPAP/O2 Therapy), Prone positioning, +ve pressure ventilation
Cross Infection – Incomplete lid closure + respiratory secretions/suctioning

19. Eye Care REPRESENT THREATS TO THE PATIENTS VISION
Corneal Abrasion/Ulcer = common injury – scratch to cornea – often resu;lting from exposure –
Keratitis/ Exposure Keratitis – Corneal Inflammtion & dryness due to incomplete lid closure – tears evaporate & therefore don’t spread their anti-microbial loveliness across the eye. Treatment = chloroamphenicol – Can lead to BLINDNESS
ANY SPOTS/CLOUDING OF CORNEA REPORT TO DOCS IMMEDIATELY
Chemosis/Ventilator Eye – Conjuctival Swelling & oedema causing conjuctiva to bulge out. Risk factors = +ve pressure ventilation, increased PEEP, tight tapes, generalised oedema eg SIRS, capillary leak, Low albumin. May need to surure to close..
Chicken or Egg? Chemisis impairs lid closure/Impaired lid closure can predispose to chemosis.
Conjuctivitis – VERY INFECTIOUS TO STAFF & PTS. Red & Sticky. Management = swab, chloramphenicol ointment,

20. Eye Care Protocol Assess eyes daily using local protocols
Cleanse each eye gently with sterile gauze
Ensure eyes closed – tape if incomplete eyelid closure
Simple eye ointment/Lacrilube 4 hourly

22. DVT Prophylaxis: Essential care of ventilated patient
Why are critically ill patients at risk?
Who performs VTE risk assessment?

23. NasoGastric Feeding:

25. Summary
The quality of care that you deliver will directly influence the patients experience in critical care
If in Doubt ASK!!!!!!
NMC code of conduct

26. GOLDEN RULES??
Complete safety checks as FIRST PRIORITY every shift NEVER leave a ventilated patient unattended