Common Critical Conditions
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Transcript of Common Critical Conditions
“Never let what you cannot do
interfere with what you can do”
CRITICAL CONDITIONS
Sherry L. Knowles, RN, CCRN, CRNI
OBJECTIVES1. Recognize the signs & symptoms of several
common (critical) medical conditions.
2. Describe the current treatment modalities of those common (critical) medical conditions.
3. Discuss the overall management of select (critical) medical conditions.
4. Identify the nursing interventions of several common (critical) medical conditions.
CRITICAL CONDITIONS
Respiratory
Failure
ARDS
Acute MI
CHF
CRITICAL CONDITIONS
GI Bleed
DKA
Shock
Sepsis
DEFINITION– A respiratory system that fails to maintain
adequate gas exchange.
– Acute loss of adequate oxygenation at the tissue level.
– PaO2 < 60 mmHg and/or PaCO2 > 50 mmHg @ 21% FiO2
In chronic hypercapnia: pH < 7.35
– Respiratory failure may be evidenced by a high or low pCO2 level.
RESPIRATORY FAILURE
TYPES OF FAILURE
– Hypercapnic Respiratory Failure is ineffective ventilation (increased PaCO2), with normal oxygenation (normal alveolar-arterial O2 gradient).
– Hypoxemic Respiratory Failure is characterized by low PaO2, markedly elevated P(A-a)O2 gradient, and usually low PaCO2, reflecting adequate ventilation, but inadequate gas exchange.
RESPIRATORY FAILURE
SIGNS & SYMPTOMS– Neurological
Restlessness, Agitation, Headache Disorientation, Seizures, LOC
– Cardiovascular Heart Rate, Hypertension (early),
Hypotension (late), Chest Pain , Dysrhythmias
– Respiratory Respirations, Respiratory Effort
RESPIRATORY FAILURE
CAUSES– V/Q Mismatch
Ventilation / Perfusion Mismatch V/Q ratio = ventilation to perfusion
– Intrapulmonary ShuntPerfusion without ventilation
– Cardiac FailureMay result in pulmonary congestion
RESPIRATORY FAILURE
SIGNS & SYMPTOMS– Renal
UOP, Edema
– Gastrointestinal Bowel Sounds, Nausea/Vomiting, Abd
Distention, Bleeding
– IntegumentaryCool, clammy, pale skin, Decreased Capillary
Refill
RESPIRATORY FAILURE
TREATMENT
– Protect the AirwayIntubation (if needed)
Bronchodilators
Hydration (as appropriate)
Mucolytic (if appropriate)
RESPIRATORY FAILURE
TREATMENT– Correct the Acid-Base Imbalance
ABG’sBronchodilatorsMechanical or non-invasive ventilationTreat the Cause
– Reduce sedation– Add sedation– Bring fever down
RESPIRATORY FAILURE
TREATMENT FiO2
Ineffective with shuntingProlonged O2 > 40% may cause O2
toxicity (lung damage)Must use caution with CO2 retainers
– Chronic hypercapnia causes CO2 retainers to use hypoxic (O2) drive
– Too much O2 can depress respirations
RESPIRATORY FAILURE
NURSING INTERVENTIONS– Monitor the Patient
Monitor ABG’s Monitor respiratory status Monitor response to therapies
– Report Changes Watch for improvement Keep respiratory status well documented
– Treat Causes Antibiotics Diuretics Mucolytics
RESPIRATORY FAILURE
DEFINITION
– Syndrome that causes damage to the alveolar-capillary interface.
– Causes an acute lung injury that causes pulmonary capillary permeability and alveolar flooding.
– Characterized by non-cardiogenic pulmonary edema, respiratory distress, and hypoxemia.
ARDS
CAUSES– Aspiration Injuries– Sepsis– Multiple Blood Transfusions– DIC– Shock States– Severe Pancreatitis– Embolism
ARDS
SIGNS & SYMPTOMS– Dyspnea
– Low PaO2
– Intrapulmonary ShuntingLow PaO2 despite high FiO2
– Pulmonary Crackles– Diffuse bilateral alveolar infiltrates – Low or normal PAWP
ARDS
SIGNS & SYMPTOMS– Early
Irritability, confusion, hyperventilation, tachypnea, dyspnea, tachycardia
– Late Increasing respiratory insufficiency,
pulmonary compliance ( pulmonary vascular resistance), PCO2 retention, frothy sputum, pulmonary crackles
ARDS
COMPLICATIONS– Barotrauma– Pulmonary Fibrosis– Pulmonary Emboli Cardiac Output– Renal Failure– Nosocomial Pneumonia– Sepsis– DIC
ARDS
TREATMENT– Maintain Oxygenation
BiPAP, CPAP Intubation PEEP ABG Monitoring
– Maintain Vascular Volume IVF Fluid Restriction
– Treat the Cause Antibiotics
ARDS
DEFINITION
– Infarction occurs due to mechanical obstruction of a coronary artery (or branch) caused by a thrombus, plaque rupture, coronary spasm and/or dissection.
ACUTE MI
SIGNS & SYMPTOMS
– Complains vary and may include crushing chest pain (which may or may not radiate), back, neck, jaw, teeth and/or epigastric pain, nausea/vomiting and dizziness.
– ST elevations on ECG
– Elevated cardiac enzymes
ACUTE MI
SIGNS & SYMPTOMS
PAWP, CO, SVR, dysrhythmias, S4,
cardiac failure, cardiogenic shock
– Diaphoresis, pallor, referred pains
– Diabetics and women often present abnormal symptoms
ACUTE MI
COMPLICATIONS
– Dysrhythmias, heart failure, pericarditis,
ventricular aneurysms, ventricular thrombus,
VSD, mitral regurgitation, papillary muscle (or
chordae tendineae) rupture, pericardial
effusions, pericarditis
ACUTE MI
TREATMENT
– Time Is Heart Muscle
– The goal of treatment for an AMI is to relieve pain, limit the size of the infarction and to prevent complications, primarily lethal dysrhythmias
– Prompt ECG
ACUTE MI
TREATMENT
– Usual medications include O2, NTG, MSO4, aspirin, heparin, beta-blockers, and ace inhibitors. May also include thrombolytics or Gp2a3b inhibitors
– Cardiac Catheterization (with angioplasty, atherectomy and/or stent)
– IABP, CABG, Education
ACUTE MI
TREATMENT– IWMI
Fluids InotropicsAfterload reducing medications
– AWMIDiuretics InotropicsAfterload reducing medications
ACUTE MI
NURSING INTERVENTIONS– O2
– Bedrest– Serial ECG’s– Serial cardiac enzymes
– Keep pain free (NTG. MSO4)– Aspirin, heparin, beta-blockers, ace inhibitors,
Gp2a3b inhibitors, thrombolytics, PTCA, IABP, CABG
ACUTE MI
DEFINITION
– CHF
A condition in which the heart cannot pump sufficient blood to meet the metabolic needs of the body.
Pulmonary (LVF) and/or systemic (RVF) congestion is present.
CHF
DEFINITION
– Pulmonary EdemaFluid in the alveolus that impairs gas
exchange by altering the diffusion between alveolus and capillary; acute left ventricular failure causes cardiogenic pulmonary edema.
Non-cardiogenic pulmonary edema is a synonym for Adult Respiratory Distress Syndrome (ARDS).
CHF
SIGNS & SYMPTOMS– Sympaththetic nervous system stimulation
TachycardiaVasoconstriction and increased SVR
– Renin-angiotensin-aldosterone system activationHypo perfusion to the kidneys (rennin)Vasoconstriction (angiotension)Sodium and water retention (kidneys)Ventricular dilation
– See Handout
CHF
FUNCTIONAL CLASSIFICATIONS
– Class I
– Class II
– Class III
– Class IV
CHF
COMPLICATIONS– Respiratory Failure
– Dysrhythmias
– Hypotension
– Progressive Deterioration
– Acute Renal Failure
– Fluid & Electrolyte Imbalances
CHF
TREATMENT– Improve Oxygenation
– Decrease Myocardial Oxygen Demand
– Decrease Preload
– Decrease Afterload
– Increase Contractility
– Manage Dysrhythmias
CHF
CAUSES– PUD
– Stress Ulcers
– Esophageal Varicies
– Portal Hypertension
– Mallory Weiss Syndrome
GI BLEED
SIGNS & SYMPTOMS– Hematemesis– Hematochezia BP H & H BUN– Weakness– Dizziness– Syncope
GI BLEED
TREATMENT– Hemodynamic Stabilization
Blood, IVF, NGT, antacids, H2 blockers, antibiotics, serial H & H’s and clotting factors
– Vasopressin (Pitressin)– Sengstaken-Blakemore or Minnesota Tube– Sclerotherapy– Laser Electorcautery– Surgery
GI BLEED
NURSING INTERVENTIONS– Large Bore IV’s– Type & Cross Match Blood– Serial H & H’s (q4hr)– Monitor Clotting Factors– Watch for Complications
ARF, ARDS, DIC– Maintain Tubes
NG, Blakemore or Minnesota Tube
GI BLEED
DEFINITION
– Serious or life-threatening complication usually from diabetes mellitus type I.
– Results from relative or absolute insulin deficiency.
DKA
CAUSES– Type I DM– Insufficient Insulin Dosing– Poor Compliance– Malfunctioning Insulin Pump– Phenytoin (Dilantin)– Thiazide/Sulfonamide Diuretics– Stress– New Onset DM
DKA
SIGNS & SYMPTOMS – Sudden Onset (hours)
– Serum Glucose 300-800
– Ketones Strongly Positive
– Serum pH < 7.3 (Ketoacidosis)
– Fruity Acetone Breath (Ketones)
– Kussmaul Respirations
– Serum Osmolarity < 350
DKA
SIGNS & SYMPTOMS – Thirst (polydipsia)
– Dry Mouth
– Dry Skin
– Weakness
– Kussmaul Respirations
– Polyuria
DKA
– Hypotension
– Tachycardia
– Mental confusion
– Changes in LOC
– Mental confusion– Changes in LOC
TREATMENT
1. Reverse Dehydration Rapid IVF Replacement
– NS, then ½ NS
– Continue NS If Needed
Prevent Hypoglycemia
– D5½ NS when Glu 250
DKA
TREATMENT
2. Restore Normal Glucose Levels
Give Rapid Acting Insulin
Frequent Glu Monitoring (q ½ - 1 hr)
Monitor Serum and Urine Ketones
DKA
TREATMENT
3. Replenish Electrolytes
Watch for Dilution
Monitor Electrolytes Frequently
Insulin Lowers Serum K
DKA
ADDITIONAL INTERVENTIONS
– Monitor Frequent Accuchecks (q1hr)
– Monitor Serial Serum Glucose (q4hr)
– Monitor Serial Electrolytes (4hr)
– Monitor Anion Gap (q4hr)
– Monitor Serum & Urine Ketones
DKA
DEFINITION
– Inadequate perfusion to the body tissues
– Low blood pressure with impaired perfusion to the end organs
– May result in multiple organ dysfunction
SHOCK
TYPES OF SHOCK
– Hypovolemic Shock
– Cardiogenic Shock
– Distributive Shock
– Obstructive Shock
SHOCK
SIGNS & SYMPTOMSThe body attempts to compensate for shock:
1. Tachycardia Attempts to deliver more blood to the tissues
2. Vasoconstriction Attempts to maintain adequate BP in order to
adequately perfuse the body tissues3. Increased ADH Secretion
ADH makes the body hold onto water in an effort to maintain volume and thus enough blood pressure to perfuse the body tissues
SHOCK
SIGNS & SYMPTOMS– Hypovolemic Shock:
Low BP , tachycardia, orthostatic hypotension,
restlessness, confusion, agitation (or listless),
thirst, pallor, cool, clammy skin, resp. rate,
UOP, CO, PAWP, CVP, SVR,
lactate levels
SHOCK
SIGNS & SYMPTOMS– Cardiogenic Shock:
Low BP , tachycardia, restlessness, confusion,
agitation (or listless), thirst, pallor, cool,
clammy skin, resp. rate, UOP, CO,
PAWP (low with RVF), CVP, SVR,
JVD, peripheral edema, ventricular gallop,
dyspnea, pulmonary crackles, lactate levels
SHOCK
SIGNS & SYMPTOMS– Anaphylactic Shock:
Low BP , tachycardia, orthostatic hypotension,
restlessness, confusion, agitation (or listless),
thirst, pallor, warm feeling, pruritus, hives,
angioedema, bronchoconstriction, wheezing,
laryngoedema, dyspnea, cool, clammy skin,
UOP, CO, PAWP, CVP, SVR, lactate levels
SHOCK
SIGNS & SYMPTOMS– Obstructive Shock:
Low BP, tachycardia, restlessness,
confusion, agitation (or listless), pallor,
cool, clammy skin, UOP, CO,
symptoms related to cause
SHOCK
SIGNS & SYMPTOMS– Septic Shock:
Early Stage (Hyper-dynamic, Warm Phase)
Normal BP, tachycardia, confusion, agitation (or listless), resp. rate, temp, normal color, normal or UOP, CO, normal PAWP, CO, SVR,
SHOCK
SIGNS & SYMPTOMS– Septic Shock:
Late Stage (Hypo-dynamic, Cold Phase)
Low BP, tachycardia, orthostatic hypotension, restlessness, confusion, agitation (or listless), thirst, pallor, cool, clammy skin, UOP, CO, PAWP, CVP, SVR, lactate levels
SHOCK
TREATMENTS– Hypovolemic Shock:
Volume (IVF, Blood)
– Cardiogenic Shock: CO Preload & Afterload Myocardial Demand
SHOCK
TREATMENTS– Anaphylactic Shock:
Epinephrine IVF Vasoconstrictors Support/Maintain Airway
– Obstructive Shock: Treat the Cause
SHOCK
TREATMENTS– Septic Shock:
IVF (150cc/hr or wide open)
Treat Cause (pan culture, antibiotics)
Vasoconstrictors in warm phase
Treat temp if needed
SHOCK
DEFINITION– SIRS
Systemic Inflammatory ResponseManifested by two or more of the following:
– Temp > 38C or < 36C, HR > 90/min, RR > 20/min, CO2 < 32 mmHg, WBC > 12,000 or < 4,000 or > 10% (immature) bands
– Sepsis Inadequate perfusion to the body tissues due
to bacteremia.
SEPSIS
DEFINITION– Severe Sepsis
Sepsis associated with organ dysfunction, hypo-perfusion or hypotension.
– Septic ShockSystemic response to infection.
SEPSIS
SIGNS & SYMPTOMS– Early Stage (Hyper-dynamic, Warm Phase)
Normal BP, tachycardia, confusion, agitation (or listless), resp. rate, temp, normal color, normal or UOP, CO, normal PAWP, CO, SVR,
SEPSIS
SIGNS & SYMPTOMS– Late Stage (Hypo-dynamic, Cold Phase)
Low BP, tachycardia, orthostatic hypotension, restlessness, confusion, agitation (or listless), thirst, pallor, cool, clammy skin, UOP, CO, PAWP, CVP, SVR, lactate levels
SEPSIS
COMPLICATIONS
– Acute Renal Failure
– Multiple Organ Failure
– Disseminated Intravascular Coagulation
– Death
SEPSIS
TREATMENT
1. Give IVF (150cc/hr or wide open)
2. Treat the Cause (Pan culture, antibiotics,)
3. Give Vasoconstrictors in warm phase (vasoconstrictors are contraindicated in cold phase).
4. Treat Temperature as needed
5. Consider Protein Activated C (Xigris)
SEPSIS
THE END
CRITICAL CONDITIONS
THANK YOU
CRITICAL CONDITIONS
REFERENCES
1.Johanson WG and Peters JI. "Respiratory Failure." IN: Textbook of Respiratory Medicine, Murray and Nadel, eds.; 1988. 2.Morris AH. "Acute Respiratory Failure." IN: Therapeutic Strategies in Current Therapy in Critical Care Medicine, JE Parrillo, ed.; 1987. 3.Pontoppidan H, Geffin B and Lowenstein E. Acute respiratory failure in the adult, Parts I-III. N Engl J Med 287:690-698, 743-752, 799-806, 1972. 4.Pingleton SK. Complications of acute respiratory failure. Am Rev Respir Dis 137:1463-1493, 1988. 5.Heffner JE. Tracheal intubation in mechanically ventilated patients. Clin Chest Med 9:23-35, 1988. 6.Stauffer JL. Medical Management of the Airway. Clin Chest Med 12:449-482. 7.Bone RC. Symposium on Respiratory Failure. Med Clinics of N Amer 67:551-750, 1983.