Critical Care Applications Chapter 21

•  Critical care nursing is the nursing specialty that deals with human responses to life-threatening problems

•  Critical care is the multidisciplinary healthcare specialty that cares for patients with acute, life-threatening illness or injury

•  Critically ill patient is physically unstable with real or potential life threatening health problem requiring continuous intensive assessment and interventions

•  Critically ill patients were cared for in critical care units, but due to increased patient acuity, critical-care patients can be found in a variety of settings

•  The clinician in critical care integrates data from hemodynamic devices, mechanical ventilators, bedside testing devices, and observations from direct patient assessments to form a comprehensive picture of the patient’s status and the effects of care

•  Information technology is found in many patient care units in the critical care setting

•  Based on the sheer volume and complexity of the technology, the information management needs of the critically ill patient require different technology resources than those of other patient care areas

•  Developers of automated approaches to information management in critical care settings have incorporated complex formulas into physiologic monitors, rapidly analyzed small samples of gas or fluids, maintained near normal physiologic ranges with life supporting equipment, and stored large volumes of data that would otherwise be disorganized, lost, inaccurate or illegible

•  The advantages of these automated physiologic monitoring system resemble the advantage of electronic nursing documentation better control of patient observations to improve assessment, intervention, and evaluation of patient care

Information Technology Capabilities

•  Process, store, and integrate physiologic and diagnostic information from various sources

•  Present deviations from preset ranges by an alarm or an alert

•  Accept and store patient care documentation in a lifetime clinical repository

•  Trend data in a graphical presentation •  Provide clinical decision support through

alerts, alarms, and protocols •  Comparatively evaluate patient for

outcome analysis •  Present clinical data based on concept-

oriented views

Information Technology Applications

•  Physiologic monitors

•  Mechanical ventilators

•  CCISs

Physiologic Monitoring System

•  Used to replace manual methods of gathering patient vital sign

•  Used to improve overall patient monitoring capabilities

•  Consist of 5 basic parts

Basic Components of Physiologic Monitoring Equipment

•  Sensors

•  Signal conditioners to amplify or filter the display device

•  File to rank and order information

•  Computer processor to analyze data and direct reports

•  Evaluation or controlling component to regulate the equipment or alert the nurse

Advanced Hemodynamic Monitors monitoring system allow for calculation of Hemodynamic indices and limited data storage. Hemodynamic monitoring can be used to

Hemodynamic Monitors

•  Measure hemodynamic parameter •  Closely examine cardiovascular function •  Evaluate cardiac output and volume status •  Recognize pattern (arrhythmia analysis)

and extract feature •  Asses vascular system integrity •  Evaluate the patient’s physiologic

response to stimuli •  Continuously asses respiratory gases

(capnography)

•  Continuously evaluate blood gases and electrolyte

•  Estimate cellular oxygenation •  Continuously evaluate glucose levels •  Store waveform •  Automatically transmit selected data to a

computerized patient database

Hemodynamic Monitoring can be invasive or noninvasive. Invasive catheters are typically used to measure and monitoring various pressure and cardiac output

Noninvasive monitoring method are increasingly common and include pressure measurement using pulse oximetry technology, and measure cardiac output via Doppler. A screen from a bedside hemodynamic monitory system is shown Noninvasive

Invasive hemodynamic monitoring technique have traditionally involved use of the to measure of the pulmonary artery catheter(PAC), which was originally designed for measuring of pulmonary artery and wedge pressure.

This criticism prompted formation of the Pulmonary Artery Consensus Conferences organization (PACCO) with broad representation from professional nursing and medical societies. The PACCO determined that it is appropriate to use the PAC when either conventional hemodynamic therapies have not produced desired result or hemodynamic therapies require the monitoring provided by the PAC

An alternative means of measuring cardiac output noninvasively is provided by thoracic electrical bioimpedance. Four sensors are positioned on the side of the neck and throat. A low-amplitude, high-amplitude signal is emitted by the sensor through the thorax. The amplitude of the signal detected by the sensor is proportional to the impedance of the path traveled by the electricity through the thorax

Hemodynamic monitoring can take place at the bedside or be conducted from a remote location via telemetry.

Telemetry allows for the continuous monitoring of patient usually outside of the ICU. Physiological data are sent by a transmitter to an antenna system that is distributed around the nursing unit or institution

The patient wears the transmitter, which is attached via surface electrodes for monitoring of ECG

Computer-based hemodynamic monitoring offers the critical care nurse a wealth of information. However, the clinicians must keep in mind that the monitor and its information do not replace clinical judgment or necessarily imply quality patient care.

Computerized monitoring and analysis of cardiac rhythm have proved reliable and effective in detecting potentially lethal heart rhythms. A key element is the systems ability to detect ventricular fibrillation and respond with an alarm.

Arrhythmic Monitors

There are two type of arrhythmic system: detection surveillance and diagnostic or interpretive.

In a detection system, the criteria for a normal ECG are programmed into the computer programmed into the computer. The computer might survey the ECG for the wave for wave amplitude and duration and for interval between waves

System Type

The program may even include an alarm response if the R-R interval is either less than or equals to two-third of the average R-R interval. Each signal may then be analyzed to determine whether the QRS duration is greater than normal

The next programmed search may be for the presence of a compensatory pause. The computer may then be programmed to store the number of PVCs per minute and sound an alarm or alert the nurse visually

The computer that support these type of ECGs are usually dedicated system.

Diagnostic system are usually capable of retrieving a patient’s previous ECGs for comparison. Beside monitoring capabilities for beginning to emerge that incorporate.

CCIS •  CCIS (Critical Care Information System): ◦  system designed to collect, store, organize, retrieve and

manipulate all data related to care of the critically ill patient. •  main purpose is the organization of a patient’s current

and historical data for use by all care providers.   integrates information from various sources such as:

bedside devices, medications, PA findings, and care plans

•  hospital infrastructure of interfaces between medical devices and the CCIS allows interaction between ICU and other departments

CCIS Components • Patient Management: ◦  ADT (Admission, Discharge, and Transfer) ◦  Prognostic scoring systems can be integrated into

CCIS:   TISS (Therapeutic Interventions Scoring System)   APACHE (Acute Physiology and Chronic Health

Evaluation System   MPM (Mortality Predictor Model)   SAP (Simplified Acute Physiology Score)   all systems are generally used to gauge the likelihood of

survival •  it can also be used to schedule patient care

activities, treatment, and diagnostic testing

•  Vital Sign Monitoring –  vital signs can be automatically acquired from

bedside instruments –  these data can then be integrated into flow

charts, along with other data such as lab results, body assessments, and problem lists

–  these can be modified and grouped according to the viewer’s specifications through the CCIS

•  Diagnostic Testing Result •  results can be displayed in flow sheets

such as laboratory, radiology, and cardiology results

•  Clinical documentation to support the process of

physical assessment findings

–  Eases data collection in critical care environments,

which need constant updates on health status

–  flow sheets can also be organized by body systems

–  all disciplines of care providers can add input and

provide patient assessments

–  alerts automatically generated for patients at high risk

for falls, pressure ulcers, and other factors

–  Calculations regarding physiological indices

  Decision Support ◦  CCIS can provide alerts and reminders to guide

care ◦  Point-of-care access to knowledge bases such as

guidelines of care, drug information, procedures and policies

  Medication Management ◦  barcode scanning and electronic medication

administration can help facilitate medication administration ◦  can support five rights instantly by scanning and

viewing (right drug, right patient, right dose, frequency and route) ◦  Calculations of dosages and flow rates

  Interdisciplinary plans of care ◦  CCIS meets the flexibility needs of every

discipline ◦  special flow sheets with required treatments and

responses can be incorporated ◦  workflow management tools that push when tasks

need to be done, and alerts when they finish or fail   Provider Order Entry ◦  provider order entry can help clinicians improve

communication, streamline processes, facilitate care ◦  can guide the entire clinical team towards a

common goal thru interdisciplinary plans of care

Future Developments   adoption of a standard interface language   standardized vocabularies so that lifetime records can

be created for patients and these records in turn can be used for trending patient populations

  CCISs have been discussed to assist in diagnosis thru the use of neural networks. These are computer simulations of the brain that are capable of converting incoming into outgoing activities

  Diagnostic data and relationship mapping can be integrated into CCIS to recognize patterns or symptoms, signs and lab results

  Wireless capability to address the ongoing trend of shorter stays in the ICU

Summary

•  Critical care nursing is a specialty dealing with human responses to life-threatening problems

•  Complexities of patient care have resulted in development of technology that enables nurses to deliver that care efficiently

The finding are then compared to predetermined diagnostic specifications. Evaluation of these parameter is based on an arithmetic comparison of the patient’s signal to a “normal” signal.