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17. CCN & EDN - Transes on CCN and EDN

Bachelor of science in nursing (Far Eastern University)

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FEU DEPARTMENT OF NURSING | IN-HOUSE REVIEW

CCN & EDN |TRANSCRIBED NOTES | BATCH 2023| LECTURER: MA’AM BONGAR
CRITICAL CARE NURSING CRITICAL CARE NURSE
Specialty within nursing that deals specifically Is a licensed professional nurse who is
with human responses to life-threatening responsible for ensuring that acutely and critically
problems. ill patients and their families receive optimal care.
Critical Care Units “Cares for patients and the families of patients
CCus or ICUs - designed to meet the special with acute and unstable physiologic problems in
needs of acutely ill and critically ill patients. an environment equipped for technically
● 1800s (Florence Nightingale) - concept of advanced methods of assessing and managing
clustering the acutely ill patients. patient problems.”
● Mid 20th Century (Polio & TB pandemics) - ● Not just holistic care but also ethico-legal
technical equipment with specialized care situations.
providers. CRITICAL ASSESSMENT FRAMEWORK
● WWIII & Korean war - concepts of TRIAGE Head to toe - upon admission and first time
and specialty nursing units. encounter of the patient.
● 1950s - these concepts were being Focus - reason for hospitalization
incorporated into hospitals. ISBAR - for referral / hand off communication
● 1960s - Technological developments: more Pre Arrival Assessment
accessible monitoring of ECG, arterial and ● Prepare room before admitting (verification of
central venous pressure, ABGs; coronary functioning of equipment).
care units were developed. ● Patient data: age, gender, chief complaint,
Electronic or Virtual ICU diagnosis, pertinent history, physiologic
Designed to augment the bedside ICU team by status, invasive devices, equipment, status of
monitoring patients from a remote location. labs and diagnostic tests.
Rapid Response Team (RRT) or MET NOTE: do not transfer if unstable
Goes outside the ICU To bring rapid and Admission Quick Check
immediate care to unstable patients in non-critical • Airway
care units. • Breathing
● RRT is being called when the patient is • Circulation
• Drugs and Diagnostic Tests
having respiratory distress, hypotension
• Equipment
(inotrope), hypoglycemia → IN SHORT, there Comprehensive Admission
● Health History
are other interventions (not CPR only).
● Physical Examination - physiologic needs of
Progressive Care Units (PCU) the patient.
● High dependency units or intermediate care ● Psychosocial Assessment - (since the patient
units, or step-down units. is sedated, you are going to ask the relative)
● Transition between ICU and the general care NOTE:
or discharge. Physical: If COPD, 90 is acceptable in O2 sat
Example: Patients scheduled for interventional Partial oxygen (80-100)
cardiac procedures, awaiting heart transplant, Physiologic: Always the legal person who will
receiving stable doses of vasoactive IV drugs, or decide or be asked.
being weaned from prolonged mechanical - If a priest, contact the head of the
ventilators. congregation.
Critical Ill Patient - If abandoned, inform social service.
● Physically unstable - If an unknown cause of death is abandoned,
● At risk for serious complications and require inform the priest for investigation.
frequent and often invasive assessments. • Ongoing Assessment
● Require intensive and complicated nursing COMMON PROBLEMS OF
support and advanced biotechnology. CRITICALLY ILL PATIENT
WHO CANNOT BE ADMITTED IN ICU? NGT (GLAD) - gavage, lavage, aspiration,
● Patient who is not expected to recover from decompression.
an illness is usually NOT admitted to an ICU. NOTE: STUDY ABOUT CHEST TUBES
● ICU should not be used to manage patients Pneumothorax - 2nd to 3rd ICS
in a persistent coma. Hemothorax - 4th to 5th ICS; intermittent
● ICU care can be used to prolong the natural bubbling.
process of death. 1 way bottle - collection and water seal

BROSOTO, A.J., CAJIGAL, A.V. 1

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FEU DEPARTMENT OF NURSING | IN-HOUSE REVIEW

CCN & EDN |TRANSCRIBED NOTES | BATCH 2023| LECTURER: MA’AM BONGAR
2 way bottle - collection and water seal ● Anticipation of needs
3rd way bottle - collection, water seal, suction ● Pen and paper to communicate or ask the
(there should be bubbling). family member to interpret.
EXAMPLE: 2 way bottle then natisod ka tas Sensory Perceptual Problems
● Disorientation and confusion - inform what
nabasag → change lang. is happening.
Pero if water seal nabasag → emergency ● Environmental manipulation
● “ICU psychosis”
because it keeps the negative pressure; padded ● Sensory overload
forceps for clamping but not too long because it ● Re orientation - always explain
● Consistency on explaining
can lead to tension pneumothorax → get a gauze Immobility
with KY Jelly. ● DVT (deep vein thrombosis) - range of
motion or stockings.
Gastric emptying delayed → will just vomit. ● Skin breakdown - provide comfort and
NUTRITION clean linens.
● Methods of Nutrition Sleep Problems
● CBG - steroids (check regularly CBG) ● Address causes pain, fever, DOB, metabolic
● Monitoring for complications disturbance.
● Nutrition balance ● Clustering care - do it once when entering
● Restrictions patients room (suctioning, VS)
HAIS’s (Hospital Acquired Infections) I. Level I: ambulatory patient; can perform
● Urinary Tract Infections ADLs
o Change of urinary catheter → 7 days. II. Level II: patients with assistance; 1 or 2
contraptions
o Foley catheter → drain and check (it may III. Level III: completely assisted patient (bed
lead to ascending infection). bound)
● VAP (Ventilator Associated Pneumonia) IV. Level IV: needing biotechnology (ICU)
o Frequent suctioning (st and oral care.) How to distribute patients → if level 3, 1:2 ratio,
o Turn frequently every 2 hours
Level I (3 or more)
● Catheter related bloodstream infection
o Change it regularly based on institution BASIC ELECTROCARDIOGRAPHY
policy.
o It is because of the medication that
causes this situation.
● Surgical site infection
o Decubitus ulcer - problem for immobile
patients for some time; diabetic, obese,
too thin.
o Turning frequently depends on the
weight of the patient.
Anxiety Reduction Activities - Distraction
Patient has anxiety → limit the volume of the
● Graphic recording of the electrical activity of
monitors inside the patient's room. the heart.
● CONSTANT presence and re-assurance ● Basis of diagnosis when it comes to
● Giving preparatory information cardiovascular problems.
● DO NOT give false hopes ● SA node is the pacemaker of the heart
PAIN ● AV node - lower down heart (40 to 60)
Pharmacologic and alternative therapies ● Bundle of His - less than 40
● If it is no longer in your nursing care/domain, ● R - represents the ventricles (forceful ejection
notify the physician; blood transfusion, of blood).
medication. ● Coronaries - the one that supplies blood to
Impaired Communication the heart.
● Non - verbal cues

BROSOTO, A.J., CAJIGAL, A.V. 2

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FEU DEPARTMENT OF NURSING | IN-HOUSE REVIEW

CCN & EDN |TRANSCRIBED NOTES | BATCH 2023| LECTURER: MA’AM BONGAR

● Coronary angiography - check for blockage → o Normal: 60 to 100

o Duration: 0.30 to 0.44 sec
femoral or brachial or radial. ● T Wave - ventricular repolarization
Characteristics of Muscle Cells o Not above 10 mm
● Automaticity - ability to initiate impulse ● U wave
● Excitability - respond immediately to the o Very prominent → look electrolytes →
stimulus
● Conductibility - transmit an impulse hypokalemia.
● Contractility - transmit blood to different
areas.
Electrophysiology
● Polarized cells, there is no exchange of
electrolytes inside and outside → AT REST.
● Depolarized cells/stimulated cells, there is an
exchange of electrolytes inside and outside.
● Repolarization - resting
● One chaos - VFib (not enough circulation).
Step 1: Assess the P waves
ECG
● Indiscernible - not sure if P wave because
● Transformed visualization procedure
nakalubog.
● NR: consent, privacy, clipper (hair patients),
● Absent - no P wave but has QRS complex.
supine position, instruct to stay still, explain.
Step 2: Identify the rhythm
● Information that can be determined via ECG:
o Conduction disturbances ● Compare R-R or P-P Interval → use of
o Electrical effects of medications and calipers.
electrolytes.
Step 3: Count the rate
o Mass of cardiac muscle (cardiomegaly).
● Atrial: P to P
o Presence of ischemic damage
● Ventricular: R to R
o Orientation of the heart in the chest → ● Normal, Brady (long interval), Tachy (short
dextrocardia. interval).
● Formula 1: HR = 300 / no. of big square
ECG Graph Paper
between R-R
1 small square = 0.04 seconds
● Formula 2: HR = 1,500 / no. of small squares
Segment - line between two waves
between R-R
Interval - wave plus the segment
● Irregular rhythm: 6 seconds strip; number of
● P Wave - atrial depolarization
QRS complexes x 10.
o Without p wave, not sinus
Step 4: Calculate the PR Interval
o Height - 2.5mm
● Constant
o Duration - 0.10 sec
● Variable
● PR Interval
Step 5: Calculate QRS Complex
o Duration: 0.12 to 0.20 sec
● Wide and bizarre - for patient with VTach
o Short: flutter waves / AFib
Sinus Bradycardia
o More than: prolonged or identify what
● Normal in athletes (used to stretchability and
type of blockage.
does not coil back) and during sleep.
● QRS Complex - ventricular depolarization
● Vagal stimulation
o Duration: 0.04 to 0.10 sec
● Medications - decrease heart rate of px
o If near each other → the ventricles are not o Digitalis
resting; VFib/VTach. o Beta-blockers (-olol)
o Calcium-channel blockers
● ST Segment - early ventricular repolarization
● Disease conditions
o Isoelectric
o MI
o May deviate between -0.5 & + 1 mm from
o Myxedema
the baseline.
o Increased ICP
● QT Interval
● Treatment
o Ventricular activities; varies by age,
o Not required unless symptomatic.
gender, heart rate.

BROSOTO, A.J., CAJIGAL, A.V. 3

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FEU DEPARTMENT OF NURSING | IN-HOUSE REVIEW

CCN & EDN |TRANSCRIBED NOTES | BATCH 2023| LECTURER: MA’AM BONGAR
o Symptom - pacemaker or cholinergic. o K-blockers
o No symptom - do nothing • Unstable: CARDIOVERSION
Sinus Tachycardia Atrial Fibrillation
● Fever - increase metabolic rate ● finer; not align
● Shock ● RHD, Thyrotoxicosis, Heart Failure,
● Pain Myocardial Ischemia.
● Anxiety ● Treatment: (Dependent)
● Heart failure Anticoagulation (Stable)
● Hypermetabolic states o Digoxin
● Anemia o Ca channel blockers
● Treatment: Remove underlying cause o Beta-blockers
Sinus Arrhythmia o K-blockers
● Rhythm is the problem • Unstable: CARDIOVERSION
● Digitalis toxicity Premature Ventricular Contractions
● In response to respiration ● Contraction is happening in aorta
● Treatment: ● Ventricular is at rest
o Not necessary unless symptomatic ● WATCH OUT → monophasic/biphasic
(passed out, dizziness, hypotension)
o Hold Digitalis ● Amiodarone - given in Bolus
o Atropine as needed ● Treatment
Premature Atrial Contractions o May or may not be required
● P wave is the problem then bradycardia o Avoid stimulants
● “Para akong nagpapalpitate” o Stress reduction techniques
● Caffeine intake o Anti arrhythmic drugs
● Nicotine Ventricular Tachycardia
● Heart failure ● Not getting enough blood → fast contractions
● MI in attempt to eject blood
● Hypermetabolic states
● Treatment: not usually necessary ● Blood pressure of the patient is low
Atrial Tachycardia ● Treatment: (EMERGENCY)
● P wave is not distinguish o Check pulse
● Very high emotions; very excited or sad § V Tach with pulse - meds
● Caffeine § V Tach without pulse - defib /
● Tobacco cardioversion
● Sympathomimetic drugs Ventricular Fibrillation
● Treatment ● Rate is fast, more than 200
o Eliminate cause ● Treatment
o Vagal stimulation ○ Defibrillation
o Beta blockers ○ CPR
o Ca-Channel blockers ○ Anti-arrhythmics
Supraventricular Tachycardia CARDIOVERSION vs DEFIBRILLATION
● Very narrow QRS Complex Cardioversion Defibrillation
● P wave is buried in QRS; not evident
Energy delivered Escalating (50-100- 360 J (Monophasic)
● Treatment 200-300-360 J) 200 J (Biphasic)
o Stable - drugs
o Unstable - cardioversion / synchronized Cardiac Arrest no yes

§ Consent Mode Synchronized Unsynchronized

§ Sedation
Atrial Flutter
Marker used R wave none
● RHD, Thyrotoxicosis, Heart Failure,
Myocardial Ischemia. Pre-medication Yes No
● Treatment: (Dependent)
Anticoagulation (Stable): Arrhythmia SVT, A. flutter, A. Pulseless V Tach, VFib
Fibrillation, VT with
o Digoxin pulse
o Ca channel blockers
o Beta-blockers

BROSOTO, A.J., CAJIGAL, A.V. 4

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FEU DEPARTMENT OF NURSING | IN-HOUSE REVIEW

CCN & EDN |TRANSCRIBED NOTES | BATCH 2023| LECTURER: MA’AM BONGAR
HEART BLOCKS ● Also base in diameter of patient’s nares
● First degree AV Block Endotracheal Tube
o Consistent in the delay ● Pinky finger is used to measure the size to
o Delay in transmission use (tube).
● Second degree AV Block ● Should not be longer 2 weeks of used
o Consistent in the delay ● Balloon - seals the airway
o Delay in transmission ● Tape - anchor the tube
o Mobitz 1 - gradual prolongation of PR ● Most late complications are caused by the
interval and there is a skip beat. cuff.
o Mobitz II - No relationship of P and QRS ● It should be placed on the top of the carina.
complex. ● Indications:
o Treatment ○ Upper airway obstruction
§ Type 1 - seldom treated, atropine. ○ Apnea
§ Type 2 - pacemaker ○ High risk for aspirations
● Complete Heart Block/Third-Degree AV ○ Respiratory distress
Block ○ Ineffective clearance of secretions.
o No specific pattern ○ Respiratory distress
o No relationship between P and QRS Tracheostomy Tube
complex. ● Long term
o Treatment ● At the bedside, have an obturator
§ Pacemaker - fixed or demand mode; ● Cuff - not to aspirate when feeding
CPR. ● Inner cannula - the one being cleaned
§ If it has a spike, the pacemaker is (sterile).
working. ● ET first before oral (not sterile)
Junctional Rhythm Fenestrated Trach Tube
● Impulses from the AV node ● Inner cannula is removed, a window
● P wave inverted or buried w/in QRS or follows (fenestration) opens the outer cannula.
QRS. ● Allows patients to breathe through the upper
● Rate slow airway.
Idioventricular Rhythm ● Used to wean patients from artificial airways.
● Impulses from the Purkinje Fibers ● Maximum of 3 times in suctioning (10-15
● Can lead to asystole secs).
ARTIFICIAL AIRWAYS Trach Button
● Facilitate mech vent ● Used to wean patients from artificial airways.
● Protect airway (prevent aspiration) ● When plugged, the patient uses the upper
● Facilitate suctioning airway.
● Relieve upper airway obstruction ● Button keeps stoma patent
● Check for depth and quality (use of ● Inner cannula can be removed for suctioning.
accessory muscles). ET Tube Sizes
● Check result of ABG ● Most adults will need an internal diameter of
Oropharyngeal Airways 7.5mm to 10 mm.
● “Oral bite block” ● Males usually require larger size than female,
● Used to prevent tongue from occluding the ● Bronchoscopy requires at least a 7.5mm
airway. internal diameter.
● 0-6 Tracheostomy vs ET Tube
● Adults: between 3 and 5 ● ET tubes can be tolerated for 10-28 days.
● Correct size: measure from corner of mouth ● A daily evaluation should be made and if the
to bottom of earlobe. artificial airway is determined to be needed
Nasopharyngeal Airways for longer, then a tracheotomy with
● “Nasal trumpet” tracheostomy should be performed.
● Prevent tongue from blocking airway Endotracheal Intubation
● Tolerated by conscious or semiconscious ● Can be done transorally or transnasally
patients. ● Transorally is usually faster and is also easier
● Base on diameter of patient’s nares to learn.
● French units (26-35)
● Measure from tip of nose to bottom of earlobe

BROSOTO, A.J., CAJIGAL, A.V. 5

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FEU DEPARTMENT OF NURSING | IN-HOUSE REVIEW

CCN & EDN |TRANSCRIBED NOTES | BATCH 2023| LECTURER: MA’AM BONGAR

● Oral reduces WOB (work of breathing) → less o eliminate work of breathing

o reduce oxygen consumption
away resistance. 2 Types of Mechanical Ventilator
● Risks of Oral ET Intubation 1. Negative Pressure - iron lung, drinker
o Limited head and neck movement. respirator, and the chest shell.
o Teeth can be chipped or dislodged. 2. Positive Pressure - force oxygen into a
o Salivation increased and swallowing was patient's lungs.
difficult. • Types
o Patient bites on it o Volume Cycled (set TV)
o Poor mouth care o Pressure Cycled (airways pressure
● Nursing Responsibilities is reached).
o Maintain correct tube placement - o Flow Cycled (pre det-Exp)
auscultation (bilateral breath sounds). o Time Cycled (I/E after set time).
o Maintain proper cuff inflation o Affected by: compliance and
o Monitor O2 and ventilation resistance.
o Maintain tube patency - change site daily. Fraction of Inspired Oxygen (FiO2)
o Assess for complications Set from .21 (21% or room air) to 1.00 (100%
o Provide oral care and skin integrity. oxygen)
o Foster comfort and communication. Tidal Volume
● Complications of ET insertion ● Amount of air delivered with each preset
o Inadvertent extubation breath.
§ Patient removal ● Dictated by the weight and patients lung
§ Accidental (movement) characteristics (compliance and resistance).
§ Signs: patient vocalization (absent Respiratory Rate
breath sounds), low pressure alarm ● Frequency of breath (f) set to be delivered by
in vent, respiratory distress (gastric the ventilator.
distention). ● Set to a near physiological rate
o Laryngeal and tracheal damage INSPIRATORY-TO-EXPIRATORY RATIO
o Laryngospasm (L:E RATIO)
o Aspiration Duration of inspiration in comparison with
o Infection expiration.
o Discomfort POSITIVE END-EXPIRATORY PRESSURE
o Sinusitis (PEEP)
o Subglottic injury ● Addition of positive pressure into the airways
MECHANICAL VENTILATION during expiration.
● O2 of at least 21% or greater is moved in and ● Measured in cm H20
out of the lungs by a mechanical ventilator, ● Pressure is applied at end expiration thus
via invasive or non-invasive means. increasing oxygenation.
● Administration or giving of additional ● Prevent the alveoli from collapsing
concentration oxygen to the patient; it is not Sensitivity
a cure to the disease but a supportive ● Determines the amount of patient effort
management needed to initiate gas flow through the
● IN: circuitry on a patient-initiated breath.
o Respiratory Failure ● Ventilator is "sensitive" to the patient's effort
o Apnea / respiratory Arrest to inspire.
o Inadequate/impaired ventilation Exhaled Tidal Volume
o Inadequate oxygenation (VQ mismatch) ● Amount of gas that comes out of the patient's
o Impaired gas exchange lungs on exhalation.
o Airway obstruction ● Indicates the patient's response to
o Acute respiratory failure (pH <7.25 with ventilation.
pCO2 >50mmHg) Exhaled Tidal Volume Peak Inspiratory
● Neurologic dysfunction Pressure (PIP)
o Central hypoventilation / frequent apnea. ● Maximum pressure that occurs during
o Patient comatose, GCS < 8 inspiration.
o Inability to protect airway ● Should never be allowed to rise above 40 cm
● Cardiac Insufficiency H20 can lead to ventilator induced lung injury.

BROSOTO, A.J., CAJIGAL, A.V. 6

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FEU DEPARTMENT OF NURSING | IN-HOUSE REVIEW

CCN & EDN |TRANSCRIBED NOTES | BATCH 2023| LECTURER: MA’AM BONGAR
Total Respiratory Rate ● Mode of weaning
● Total RR equals the number of breaths ● May be administered via a nasal or face
delivered (set rate) plus number of breaths mask.
initiated by patient. Positive End-Expiratory Pressure (PEEP) /
● Very sensitive indicator of overall respiratory Continuous Positive Airway Pressure (CPAP)
stability. ● Application of positive pressure during
MECHANICAL VENTILATOR MODES expiration alveoli kept open and collapse
● How breaths are delivered to the patient. prevented.
● Based on how much WOB the patient can ● Decreased airway resistance
perform and determined by ventilatory status, ● Used for weaning
respiratory drive and ABG's ● Disadvantage: Decreased CO, barotrauma.
● Modes of Volume Ventilation Bilevel Positive Airway Pressure (BiPAP)
● Modes of Pressure Ventilation Delivered through a tight-fitting face mask, nasal
● Dual mask.
Controlled Mandatory Ventilation (CMV) Patient - Ventilator Interaction
● Breaths are delivered at a preset Vrand rate. ● MV must recognize the patient's respiratory
● Independent of the patient's ventilatory efforts (trigger).
efforts. ● MV must be able to meet the patient's
● For anesthetized, coma, or apneic patients. demands (response).
Assist-Control Ventilation (A/C) ● MV must not interfere with the patient's
● Assist patient respiratory drive efforts (synchrony).
● Delivers a preset Vi at a preset rate IF patient MV TROUBLESHOOTING
does not initiate respirations at the set rate. ● "Is it working ?
● Patients can breathe faster than the preset o Look at the patient !!
rate but not slower. o Listen to the patient !!
● Advantage: allows some control over o Sp02, ABG, EtCO2 (end tidal Co2).
ventilation o Chest X-ray
● Disadvantage: potential for hypo or hyper- o Look at the vent
ventilation-respiratory alkalosis/ patient may A: Is the tube still in? Is it patent? Is it in the right
rely on the ventilator. position?
● For spontaneously breathing patients with B: Is the chest rising? Breath sounds present and
weakened respiratory muscles. equal? Changes in exam? Atelectasis,
Synchronized Intermittent Mandatory bronchospasm, pneumothorax, pneumonia?
Ventilation (SIMV) C: Shock? Sepsis?
● Mandates predetermined V be delivered in MV COMPLICATIONS
each minute IN SYNCHRONY with the ● Ventilator Induced Lung Injury
patient's breathing. o Oxygen toxicity
● Used to wean patients (with regular and o Barotrauma / Volutrauma
spontaneous breathing). o Pneumothorax / Subcutaneous
● Advantage: improved ventilator-patient emphysema
synchrony. ● MV COMPLICATIONS
● Disadvantage: Hypoventilation, muscle o Other Complications
fatigue. o VAP
● Disconnect the patient to the MV but the o Upright position
patient should do the effort. o Anti-PUD medications
PRESSURE VENTILATION o Suctioning
● Pressure Support Ventilation (PSV) o Oral care
● Pressure Controlled Ventilation (PCV) o Decreased organ perfusion
● Continuous positive airways pressure o UGIB
CAP (Continuous Positive Airway Pressure) o Decreased UO
o PEEP - hypotension
● The patient must have a reliable respiratory MV WEANING/EXTUBATION
drive and adequate Vt → no mandatory ● Clinical parameters
o Resolution/stabilization of disease
breaths or vent assistance is given. process.
● Patient performs all WOB o Hemodynamically stable

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FEU DEPARTMENT OF NURSING | IN-HOUSE REVIEW

CCN & EDN |TRANSCRIBED NOTES | BATCH 2023| LECTURER: MA’AM BONGAR
o Intact cough/gag reflex
o Spontaneous respirations
o Acceptable vent settings (FiO2<50%,
PEEP < 8, Рa02 > 75 mmHg, pH > 7.25).
● Weaning
o Is the cause of respiratory failure gone or
getting better?
o Is the patient well oxygenated and
ventilated?
o Can the heart tolerate the increased work
of breathing?
● General approaches
o SIMV
o СРАР
o PSV
o T-Piece
● Main Principle
o Decrease what the vent does and see if
the patient can make up the difference.
o Example
o decrease the PEEP
o decrease the rate
o Decrease FiOz
o decrease the PIP (as needed)
● Strategies to facilitate weaning
o Proper explanation
o Position for maximal ventilatory effort.
o Medications as appropriate
o Highly vigilant presence
o Avoid unnecessary exertion, procedures,
or transports.
o Maximize physical environment

BROSOTO, A.J., CAJIGAL, A.V. 8

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