ICU 2:1 is the recommended nurse-to-patient ratio in an ICU

Graphic sheet is not an essential component of critical

Interventions that should be implemented to prevent
care documentation
ventilator-associated pneumonia (VAP)?
Pulse oximetry is the most common method of
- Elevating the head of the bed to at least 30 degrees
monitoring oxygenation
- Providing oral care with chlorhexidine solution
Suctioning the airway immediately if a patient in the ICU
- Regularly changing the ventilator circuit
develops an airway obstruction
Level of consciousness is the assessment that should be
performed continuously in patients receiving sedation DIALYSIS
in the ICU.
Regular oral care with chlorhexidine solution is the most CHRONIC KIDNEY DISEASE
effective intervention for reducing the risk of VAP.
Infection is most common complication associated with  Several or gradual decrease of
central line placement FUNCTIONS OF KIDNEY:
Uncertainty about patient prognosis is the primary
source of stress for families of patients  Waste removal
VAP is the most common type of infection acquired by - form of drugs, urea, creatinine
patients  Water balance
Sterile technique is used when performing endotracheal - enough water in plasma
suctioning  Electrolyte balance
Heart failure is considered a contraindication for - potassium, phosphate, calcium
noninvasive positive pressure ventilation (NPPV)  Acid-base balance
Administering intravenous fluids is the first intervention  Hormone
when a patient develops a sudden decrease in blood - erythropoietin, vitamin D enzymes
pressure.
CHARACTERISTICS OF CKD:
Creatinine is most commonly monitored laboratory
values to assess renal function in critically ill patients  Decrease in renal function
Pneumonia is most common condition associated with  > 3 months
acute respiratory distress syndrome (ARDS)  Decline in filtration of glomerular filtration rate
Droplet transmission is the primary mode of (<90)
transmission for VAP  Decrease EPO -> decrease RBC
Ensuring a patent airway is the priority intervention = anemia, risk of bleeding
when caring for a patient with a traumatic brain injury.  Decrease vitamin D -> Hypocalcemia
Hypoglycemia requires immediate intervention. = bone problems (brittle)
Performing synchronized cardioversion is the priority  Increase renin -> Hypertension
intervention when providing care for a patient = high risk for kidney injury
experiencing a life-threatening arrhythmia.  Homeostasis -> increase waste
Monitoring cardiac output is not included in the initial = electrolyte, hormones, fluid imbalance
management of a patient with severe sepsis.
Improve gas exchange is the primary goal of mechanical CAUSE:
ventilation  HYPERTENSION
Pressure ulcers is the complication associated with - there is thickening of vessel walls called
prolonged immobilization of patients hyaline arteriosclerosis which leads to low
Sucralfate is commonly administered to prevent gastric oxygen delivery and also ischemia/necrosis
ulcers in critically ill patients where it triggers the protector Transforming
To provide specialized care for critically ill patients is the Growth Factor that activates fibrosis.
primary purpose of an intensive care unit (ICU) Glomerulus sclerosis is the process that results
Intensivist is the personnel responsible for overall to decrease GFR.
management and coordination of patient care in the
ICU
  DIABETES glomerulonephritis
- causes a lot of glucose combines with proteins Serology – check ANA + rheumatoid arthritis to
and lipids in the bloodstream which results to know what kind of glomerulonephritis
nasty pro-inflammatory molecules called non-  Additional Labs
enzymatic glycation. It affects afferent arteriole - BMP + phosphate, CBC, ABG, Lipid panel
and may result to hyaline arteriosclerosis or
TREATMENT:
atherosclerosis that will cause increased back
pressure to increase GFR which triggers the  Decrease progression of disease
mesangial cells to decrease the GFR. Hypertension – ace inhibitors, angiotensin
 GLOMERULONEPHRITIS receptor blocker, potassium sparing diuretics,
- common in autoimmune diseases. Antibody- loop diuretics
antigen complex deposits in glomerular Diabetes – insulin, anti-diabetic drugs, weight
basement membrane which results to loss
inflammation and destructive lesions. Glomerulonephritis – steroids, DMARDs (early
 POLYCYSTIC KIDNEY DISEASE detection)
- gene defects that causes cysts that compress Polycystic Kidney Disease – renal transplant
renal vessels. It leads to reduction of oxygen Discontinue Nephrotoxins
level to ischemia/necrosis and reduction to GFR  Decrease complication
which may lead to hypertension and to - Renal placement therapy
decrease GFR. Hyperkalemia – insulin, SABA, diuretics
 NSAIDS
- inhibits the prostaglandins I2 and E2 that helps PATHOPHYSIOLOGY
pump blood and have good filtration. It results  Electrolyte Abnormalities
to decrease vasodilation, GBF and GFR. Reduction in GFR -> Less filtration of potassium
 ACUTE KIDNEY INJURY and phosphate -> Increase in potassium and
- doesn’t heal and is progressive or continuous, phosphate
or frequent acute kidney injury leads to CKD. ________________
DIAGNOSIS: Decrease hydroxylase enzyme -> Decrease in
vitamin D production -> Hypocalcemia (reduced
 Decreased GFR (normal: 125ml/min) calcium absorption)
Diagnostic test: creatinine and cystatin C  Water Imbalance
Severity or Staging Reduction in GFR -> Decrease water filtration ->
o I – >90 increase in water retention (pulmonary edema,
o II – 60-89 hypertension, and peripheral edema) -> dump
o III – 30-59 protein in urine (albuminuria) -> increase
o IV – 15-29 albuminuria -> decrease albumin in blood
o V – <15  Uremia
 Albuminuria -removal of waste products/drugs
Diagnostic test: urine albumin to creatinine Building up of urea -> azotemia:
ratio - encephalopathy: asterixis, seizures,
Severity or Staging comatose
o Mild – ACR <30 - uremic pericarditis: lots of fluid and
o Moderate – 30-299 (micro) inflammation in pericardium
o Severe – >300 (macro) - uremic frost: leaks into sweat glands that are
 Renal Ultrasound crystalized
- for positive kidney disease - platelet dysfunction: not sticky enough that
 Renal Biopsy + Serology may cause bleed
- for glomerulonephritis  Hormonal Imbalance
Biopsy – take a piece to know presence of Decreased erythropoietin -> unable to stimulate
 red bone marrow -> decrease in RBC production  Take needles out, wrap with light pressure if
maturation -> anemia of chronic disease site is not bleeding 30 mins, talk to physician
(immature RBC)  Compare: VS, Labs, and Weight
_____________________  Inform date to come back and other procedures
Reduction in GFR -> increase activity of inner
angiotensin aldosterone -> increase angiotensin COMPLICATIONS
II -> increase vasoconstriction -> increase in  Vascular Access
blood pressure - loss of access due to clots forming due to
 Metabolic Acidosis anticoagulants, stenosis due to constrictive
Decreased alpha intercalated cells -> decreased clothing or jewelry or constant compression,
secretion of protons in urine -> increase of lifting heavy objects (>5lbs)
proton in the blood -> decrease bicarb - thrombosis, stenosis, tear
reabsorption -> reduces ph -> metabolic  Infection
acidosis - access infection
 Albumin Regulation - underlying infection
Decreased albumin in the blood -> 3rd spacing of  Bleeding, Hemorrhage, Hypotension
fluid -> liver increase protein production - bleeding in access point
(lipoprotein) -> increase in triglycerides and LR - hypotension -> change rate
HEMODIALYSIS administer fluids -> no response -> call
physician
 Take blood, dialyze, clean, and remove all  Nausea/Vomiting
wastes, then pump blood - give antiemetics
 3 sessions per week  Disequilibrium Syndrome
 3-5 hours - 1st session – cerebral edema/ increase in
intracranial pressure
VASCULAR ACCESS
- mental status – confusion, loss of
 Radio cephalic Fistula – vein and artery together consciousness, and seizure
 Forearm Loop Graft – vein and artery with
DELIVERY ROOM
synthetic vein artery vessel
 Central Venous Catheter – temporary
ASSESS: pale, tingling, pulse, capillary refill, pain POSTPARTUM BLEEDING

PRE-PROCEDURE  Post Partum

- It begins immediately after the birth, and lasts
 Consent for a culturally variable length: typically for one
 Assess access month or 30 days, up to 40 days, two months or
 Vital signs, labs, weight 100 days.
 Hold medications: ace inhibitors, angiotensin  Bleeding
receptor blocker, beta blockers, calcium - is the loss of blood, inside or outside the body.
channel blockers, diuretics, vasodilators, A hemorrhage is severe bleeding.
antibiotics, vitamin C and B, folic acid  Placenta accreta
- is a serious pregnancy condition that occurs
INTRA-PROCEDURE
when the placenta grows too deeply into the
 Constant assessment: VS and Labs, Neuro uterine wall.
changes (nausea and muscle cramp)  Complete placenta previa
 Machine: rate, flow, and meds (heparin, - The placenta completely covers the cervix
anticoagulant (hemorrhage), protamine sulfate  Partial placenta previa
- The placenta is partly over the cervix.
POST-PROCEDURE  Marginal placenta previa
- The placenta is near the edge of the cervix.
 Placenta abruptio symptoms of too much blood loss or a
- the placenta partially or completely detaches significant change in heart rate or blood
itself from the uterine wall before delivery. pressure.
 Hysterectomy  Traditionally, postpartum hemorrhage (PPH)
- is an operation to remove the uterus. This has been defined as greater than 500 mL
surgery may be done for different reasons estimated blood loss associated with vaginal
 Laparotomy delivery or greater than 1000 mL estimated
- is a surgical incision into the abdominal cavity. blood loss associated with cesarean delivery.
 Intrahepatic cholestasis of pregnancy  Postpartum hemorrhage occurs in about 1% to
- commonly known as cholestasis of pregnancy, 10% of pregnancies.
is a liver condition that occurs in late pregnancy
CAUSE
 Eclampsia
- a condition in which one or more convulsions  After the placenta is delivered, these
occur in a pregnant woman suffering from high contractions help compress the bleeding
blood pressure, often followed by coma and vessels in the area where the placenta was
posing a threat to the health of mother and attached. If the uterus does not contract
baby. strongly enough, called uterine atony, these
 Preeclampsia blood vessels bleed freely and hemorrhage
- is a pregnancy complication characterized by occurs. This is the most common cause of
high blood pressure and signs of damage to postpartum hemorrhage.
another organ system, most often the liver and  The causes of postpartum hemorrhage are
kidneys. Preeclampsia usually begins after 20 called the four Ts (tone, trauma, tissue and
weeks of pregnancy in women whose blood thrombin).
pressure had been normal.  Uterine atony: Uterine atony (or uterine
 Thrombin tone) refers to a soft and weak uterus after
- is a coagulation factor used to stop bleeding delivery. This is when your uterine muscles
during surgery. Once converted from don’t contract enough to clamp the
prothrombin, thrombin converts fibrinogen to placental blood vessels shut. This leads to a
fibrin, which, in combination with platelets from steady loss of blood after delivery.
the blood, forms a clot. red blood cells produce  Uterine trauma: Damage to your vagina,
thrombin through the meizothrombin pathway. cervix, uterus or perineum (area between
 Atony of the uterus, also called uterine atony your genitals and anus) causes bleeding.
- is a serious condition that can occur after Using instruments like forceps or vacuum
childbirth. It occurs when the uterus fails to extraction during delivery can increase your
contract after the delivery of the baby risk of uterine trauma. Sometimes, a
hematoma (collection of blood) can form in
POSTPARTUM HEMORRHAGE
a concealed area and cause bleeding hours
 Postpartum hemorrhage (PPH) is severe or days after delivery.
bleeding after giving birth. It's a serious and  Retained placental tissue: This is when the
dangerous condition. PPH usually occurs within entire placenta doesn't separate from your
24 hours of childbirth, but it can happen up to uterine wall. It’s usually caused by
12 weeks postpartum. When the bleeding is conditions of the placenta that affect your
caught early and treated quickly, it leads to uterus’s ability to contract after delivery.
more successful outcomes.  Blood clotting condition (thrombin): If you
 Postpartum hemorrhage is when the total blood have a coagulation disorder or pregnancy
loss is greater than 32 fluid ounces after condition like eclampsia, it can interfere
delivery, regardless of whether it’s a vaginal with your body’s clotting ability. This can
delivery or a Cesarian section, or C-section, or make even a tiny bleed uncontrollable.
when bleeding is severe enough to cause
SYMPTOMS
  Uncontrolled bleeding. possible and replacing blood volume are the goals of
 Increased heart rate. treating postpartum hemorrhage.
 Decrease in the red blood cell count Some of the treatments used are:
(hematocrit)
 Uterine massage to help the muscles of your
 Swelling and pain in tissues in the vaginal and
uterus contract.
perineal area, if bleeding is due to a hematoma.
 Symptoms of a drop in blood  Medication to stimulate contractions.
pressure like dizziness blurred vision or
 Removing retained placental tissue from your
feeling faint.
uterus.
 Worsening abdominal or pelvic pain.
 Nausea or vomiting.  Repairing vaginal, cervical and uterine tears or
 Pale or clammy skin. lacerations.
LIFE-THREATENING CONDITIONS  Packing your uterus with sterile gauze or tying
off the blood vessels.
 can happen after giving birth include infections,
blood clots, postpartum depression and  Using a catheter or balloon to help put pressure
postpartum hemorrhage. Warning signs to on your uterine walls.
watch out for include chest pain, trouble
breathing, heavy bleeding, severe headache and  Blood transfusion., In rare cases, or when other
extreme pain. methods fail, may perform a laparotomy or
a hysterectomy
TYPES OF PPH
POTENTIAL COMPLICATIONS
 Primary postpartum hemorrhage occurs within
the first 24 hours after delivery.  Excessive blood loss can cause several
 Secondary or late postpartum hemorrhage complications like increased heart rate, rapid
occurs 24 hours to 12 weeks postpartum. breathing and decreased blood flow. These
symptoms can restrict blood flow to your liver,
DIAGNOSIS brain, heart or kidneys and lead to shock. In
some cases, Sheehan’s syndrome (a condition
 Healthcare providers diagnose postpartum
of the pituitary gland is seen after postpartum
hemorrhage through visual and physical
hemorrhage).
examinations, lab tests and a thorough review
of your health history.  Sheehan's syndrome is a condition that affects
 They may detect postpartum hemorrhage based women who lose a life-threatening amount of
on the amount of blood you’ve lost. Measuring blood in childbirth or who have severe low
the volume of collected blood and weighing the blood pressure during or after childbirth, which
blood-soaked pads or sponges from delivery is can deprive the body of oxygen. This lack of
one common way to approximate blood loss. oxygen that causes damage to the pituitary
gland is known as Sheehan's syndrome.
Other methods to diagnose PPH are:
 Continual monitoring of your pulse rate RISK FOR PPH
and blood pressure to detect problems.  Those with placental problems like placenta
 Blood tests to measure red blood cells accreta, placenta previa, placental
(hematocrit) and clotting factors. abruption and retained placenta are at the
 Ultrasound to get a detailed image of your highest risk of PPH.
uterus and other organs
 An overdistended uterus also increases the risk
TREATMENTS for PPH. This is when your uterus is
Healthcare providers treat PPH as an emergency in most overstretched from:
cases. Stopping the source of the bleeding as fast as
  Multiple pregnancies. NURSING ASSESSMENT

 Having twins, triplets or more.  Assess the amount of bleeding.

 Assess maternal vital signs to establish baseline
 Birthing a large baby (9 pounds or more).
data.
 Too much amniotic fluid. - Assess for signs of shock.
- Cool, clammy skin.
 High blood pressure or preeclampsia - Pale or ashen skin.
 Infection. - Bluish tinge to lips or fingernails (or gray in the
case of dark complexions)
 Blood clotting disorders or other blood-related - Rapid pulse.
conditions. - Rapid breathing.
- Nausea or vomiting.
 Hemophilia. ...
- Enlarged pupils.
 Liver Disease. ... - Weakness or fatigue.
 Assess the condition of the uterus. (FIRM OR
 Vitamin K deficiency. ...
NOT)
 Platelet dysfunction. NURSING DIAGNOSIS
 Intrahepatic cholestasis of pregnancy (ICP).  Deficient fluid volume related to excessive
 Anemia. bleeding after birth.

 Obesity. NURSING INTERVENTIONS

 Advanced maternal age.  Save all perineal pads used during bleeding and
weigh them to determine the amount of blood
 A history of five or more previous deliveries. loss.
PREVENTION  Place the woman in a side lying position to
 is to identify those at high risk for postpartum make sure that no blood is pooling underneath
hemorrhage before delivery. This is dependent her.
on you sharing your complete medical history  Assess lochia frequently to determine if the
and symptoms with your healthcare provider. amount discharged is still within the normal
Routinely giving medications like oxytocin at the limits.
time of delivery to help your uterus contract is
also important. Ensuring adequate iron intake  Assess vital signs, especially the blood pressure
and red blood cell levels during pregnancy can EVALUATION
minimize the impact of postpartum hemorrhage
should it occur.  Maternal blood pressure is higher than 100/60
mmHg.
RECOVER
 Pulse rate is within the normal range of 60-100
 is different for everyone. Recovering from a
beats per minute.
postpartum hemorrhage depends on the
severity of blood loss and how your healthcare  Flow of lochia is less than a saturated pad per
provider treated it. Be sure to take care of hour.
yourself in the days following delivery — eating
healthy, drinking lots of water and resting as
much as possible. Your healthcare provider may
recommend an iron supplement to help with
anemia.