Critical Care Nursing

Kathy Booker is Director and Professor, Millikin University School of Nursing, Illinois, USA. She has held former positions as Specialty Director of the Adult Advanced Practice Program in the School of Nursing, Yale University, Connecticut, USA, and Dean of the College of Professional Studies at Millikin University. She has been certified as a Critical Care Registered Nurse (CCRN) for over twenty years, currently holding alumnus status CCRN. She practiced as a critical care RN and Clinical Nurse Specialist for over twenty-five years.

Contributors, xv Critical Care Nursing: Monitoring and Treatment for Advanced Nursing Practice, xvii
Kathy J. Booker

1 Philosophy and treatment in US critical care units, 1
Kathy J. Booker

US critical care units, 1

Organization of critical care delivery, 1

Monitoring and surveillance in critical care, 2

Surveillance, 2

Nursing certification and competency in critical care units, 3

US national critical care organizations, 4

American Association of Critical Care Nurses, 4

Society of Critical Care Medicine, 5

Acute care advanced practice nursing, 5

Clinical nurse specialists, 6

Acute care nurse practitioners, 6

Critical care and ACNP outcomes research, 7

Evolution of families in the critical care unit, 8

Progression and development of rapid response teams, 9

2 Vital measurements and shock syndromes in critically ill adults, 13
Kathy J. Booker and Laura Kierol Andrews

Monitoring basic vital signs, 13

Temperature monitoring, 14

Hypothermia, 14

Complications of cooling, 15

Hyperthermia, 17

Heatstroke management, 17

Malignant hyperthermia, 17

Heart rate monitoring, 18

Blood pressure monitoring, 19

Oscillometric blood pressure measurement, 20

Aneroid measurement, 20

Arterial pressure measurement, 20

Respiratory monitoring, 21

Capnography, 21

Shock conditions in critically ill adults, 22

Cardiogenic shock, 23

Anaphylactic shock, 24

Hypovolemic shock, 24

Sepsis syndromes, 26

SIRS, sepsis, and septic shock, 26

Monitoring and treatment priorities in sepsis syndromes, 28

Sepsis diagnosis, 28

Body temperature, 29

Cultures, 29

Intravascular catheters, 29

Other infectious complications in critically ill adults, 29

Pulmonary infections, 29

Urinary tract infections, 30

Monitoring during transport, 30

3 Monitoring for respiratory dysfunction, 35
Alexander P. Johnson and Jennifer Abraham

Acid-base disturbances & anion gap, 35

Metabolic acidosis, 35

Metabolic alkalosis, 37

Respiratory acidosis, 37

Respiratory alkalosis, 38

Mixed acid–base disorders, 38

Oxygenation, 38

Estimation of the PaO2, 38

A–a Gradient, 39

PaO2/FiO2 (P/F) ratio, 39

Acute respiratory failure, 40

Capnography, 40

Monitoring ventilation with PetCO2, 40

Monitoring blood flow, 41

Modes of mechanical ventilation, 41

Continuous positive airway pressure (CPAP) with pressure support, 41

Synchronized intermittent mandatory ventilation (SIMV), 42

Assist/control ventilation (AC), 42

Pressure control ventilation, 42

Airway pressure release ventilation (APRV), 42

Pressure-regulated volume control (PRVC), 42

Inverse ratio ventilation, 43

Oscillatory ventilation, 43

Overview of protective lung ventilation in ARDS, 43

ARDSNet protocol goals, 43

Monitoring for complications during mechanical ventilation, 43

High peak airway pressures on mechanical ventilation, 43

Response to bagging—monitoring and treatment, 44

Auto-PEEP effect, 44

Weaning from mechanical ventilation, 44

Postextubation stridor: monitoring and treatment, 46

Noninvasive positive pressure ventilation, 47

Tension pneumothorax, 47

Emergent treatment—needle thoracostomy, 47

Chest radiograph interpretation, 48

Sleep-disordered breathing in the critical care unit, 48

Obstructive sleep apnea, 50

Central sleep apnea, 50

Obesity hypoventilation syndrome, 51

CPAP and BiPAP therapy, 51

Approach to cardiogenic dyspnea in acute heart failure, 52

4 Electrocardiographic monitoring for cardiovascular dysfunction, 57
Catherine Winkler

Physiologic guidelines, 57

Goals of monitoring, 58

Post cardiopulmonary resuscitation, 59

Evidence-based treatment guidelines, 60

Acute coronary syndromes, 60

Evidence-based treatment guidelines, 62

Cardiac arrhythmias, 64

Evidence-based treatment guidelines, 65

Acute heart failure, 67

Electrolyte abnormalities, 67

Monitoring elements, 68

Evidence-based treatment guidelines, 68

Critical illnesses, 68

Evidence-based treatment guidelines, 68

Drug overdose, 69

Evidenced-based guidelines, 69

Unnecessary arrhythmia monitoring and underutilization of ischemia and QT-interval monitoring, 69

5 Hemodynamic monitoring in critical care, 73
Kathy J. Booker

Hemodynamic monitoring overview, 73

Hemodynamic monitoring systems, 75

Pulmonary artery catheter monitoring, 75

Central venous pressure monitoring and management, 76

Central venous pressure trending limitations, 77

Arterial line monitoring and management, 78

Hemodynamic monitoring guidelines and outcomes, 78

Functional indicators of hemodynamic monitoring, 79

Perioperative optimization, 79

Transesophageal monitoring, 79

Volume responsiveness, 80

Pulse contour analysis, 81

FloTrac/Vigileo®, 82

Transpulmonary dilution techniques, 82

Passive leg raising, 83

SVV protocols for management, 84

6 Monitoring for neurologic dysfunction, 87
Janice L. Hinkle and Carey Heck

Physiological guidelines, 87

Increased intracranial pressure, 87

Decreased cerebral blood flow, 88

Cerebral response to increased intracranial pressure, 88

Rapid assessment of neurologic dysfunction in intensive care unit patients, 89

Evidence-based treatment guidelines, 90

Intracranial pressure monitoring, 93

Evidence-based treatment guidelines, 93

Measuring brain temperature, 94

Evidence-based treatment guidelines, 95

Brain tissue O2 monitoring, 95

Monitoring elements, 95

Evidence-based treatment guidelines, 95

Microdialysis, 95

Monitoring elements, 95

Evidence-based treatment guidelines, 95

Electrophysiological monitoring, 96

Monitoring elements, 96

Evidence-based treatment guidelines, 96

The BiSpectral index monitoring, 96

Monitoring elements, 96

Evidence-based treatment guidelines, 96

Transcranial Doppler ultrasonograpy, 97

Monitoring elements, 97

Evidence-based treatment guidelines, 97

Shunts, 98

Monitoring elements, 98

Evidence-based treatment guidelines, 98

Neuromuscular transmission, 98

Monitoring elements, 98

Evidence-based treatment guidelines, 98

Management of cervical stabilization devices, 98

Monitoring elements, 98

Evidence-based treatment guidelines, 99

Induced coma and sedation protocols, 100

Monitoring elements, 100

Evidence-based treatment guidelines, 100

Research-based neurologic protocols, 100

7 Monitoring for renal dysfunction, 104
Dawn Cooper

Acute kidney injury, 104

Physiological guidelines, 105

Prerenal injury, 105

Intrarenal injury, 106

Acute tubular necrosis, 107

Acute intersitial nephritis, 107

Post renal injury, 108

Monitoring elements, 108

History and physical assessment, 108

Laboratory analysis and data trending, 109

Diagnostic imaging, 111

Renal biopsy, 111

Evidenced-based treatment guidelines, 112

Prevention, 112

Hemodynamic monitoring, 112

Volume expansion, 112

Management of electrolyte and acid–base imbalance, 112

Pharmacologic interventions, 113

Prevention of radiocontrast nephropathy, 114

Nutrition, 114

Renal replacement therapy, 114

Intermittant hemodialysis, 114

Continuous renal replacement therapies, 114

Peritoneal dialysis, 115

8 Monitoring for blood glucose dysfunction in the intensive care unit, 119
Laura Kierol Andrews

Diabetes management in the ICU, 119

Effects of hyperglycemia, 119

Hyperglycemia management recommendations, 120

Glucose monitoring, 120

Carbohydrate administration, 120

Insulin therapy, 121

Hypoglycemia management, 121

9 Monitoring for hepatic and GI dysfunction, 126
Eleanor R. Fitzpatrick

Physiologic guidelines, 126

Gastrointestinal dysfunction, 126

Gastrointestinal bleeding, 128

Monitoring elements: nasogastric decompression, 128

Evidence-based treatment guidelines, 129

Gastric pH, 129

Evidence-based treatment guidelines, 130

Monitoring elements: laboratory tests for GI bleeding, 130

Evidence-based treatment guidelines, 130

Endoscopic procedures, 130

Evidence-based treatment guidelines, 131

Evidence-based treatment guidelines for stress ulcers, 132

Monitoring elements: gastric tonometry and capnometry, 133

Evidence-based treatment guidelines, 134

Radiographic diagnostics, 134

Evidence-based treatment guidelines, 135

Ultrasonography, 135

Evidence-based treatment guidelines, 135

Intraabdominal pressure management, 135

Intraabdominal pressure measurement, 136

Treatment of abdominal compartment syndrome, 137

Diagnostics for liver function, 137

Evidence-based treatment guidelines, 138

Liver support devices, 138

Evidence-based treatment guidelines, 139

Balloon tamponade therapy, 139

Evidence-based treatment guidelines, 140

ICP monitoring in acute liver failure, 140

Evidenced-based treatment guidelines, 140

Ascites management, 141

Evidence-based treatment guidelines: paracentesis, 141

Nutritional assessment and treatment, 142

Evidence-based treatment guidelines, 142

Critical monitoring in acute pancreatitis, 142

Evidence-based treatment guidelines for acute pancreatitis, 143

Monitoring elements: pancreatitis, 143

Evidence-based treatment guidelines for acute pancreatitis, 143

10 Traumatic injuries: special considerations, 146
Catherine Bond and Mary Beth Voights

Primary, secondary, and tertiary surveys, 146

Fluid resuscitation, 151

Fluid choice, 151

End points of resuscitation, 152

Intracompartmental monitoring, 152

Complications, 153

Thromboembolic events, 153

Anticoagulation, 154

Pain management, 154

Early mobilization, 154

Thoracic injury management, 154

Abdominal trauma, 155

Abdominal compartment syndrome, 158

Musculoskeletal injuries and management, 159

Ongoing hemorrhage, 160

Pelvic fractures, 161

Crush syndrome management, 161

Pain management in orthopedic injury, 162

Burns, 162

Burn classification, 162

Fluid management in burn therapy, 164

11 Oncologic emergencies in critical care, 167
Lisa M. Barbarotta

Evolution of oncology critical management, 167

Sepsis in the immunocompromised host, 167

Physiologic guidelines, 167

Assessment and monitoring in neutropenic patients, 168

Neutropenia management, 168

Evidence-based guidelines, 169

Research, 171

Stem cell transplant, 171

Infection, 172

Graft-versus-host disease, 172

Hepatic veno-occlusive disease, 173

Pulmonary complications, 174

Hematologic complications, 175

Hemorrhagic complications, 175

Thrombocytopenia, 175

Management, 176

Thrombotic microangiopathy, 177

Physiologic guidelines, 177

Management, 179

Hyperviscosity syndromes, 179

Physiologic guidelines, 179

Management, 180

Hyperleukocytosis and leukostasis, 180

Physiologic guidelines, 180

Management, 181

Tumor lysis syndrome, 181

Physiologic guidelines, 181

Treatment, 183

Management of electrolyte imbalances, 184

Hyperkalemia, 184

Hyperphosphatemia with secondary hypocalcemia, 184

Hyperuricemia, 185

Acute kidney injury, 186

Evidence-based treatment guidelines, 186

Structural emergencies, 186

Cardiac tamponade, 187

Physiologic guidelines, 187

Management, 189

Malignant airway obstruction, 189

Physiologic guidelines, 189

Management, 190

Carotid blowout syndrome, 192

Physiologic guidelines, 192

Management, 194

12 End-of-life concerns, 201
Kathy J. Booker

Introduction, 201

Assessment and communication issues, 201

Family presence, 202

Advanced directives, 202

Surrogate decision making, 202

Delivering bad news, 204

Palliative care in the ICU, 204

Symptom management, 206

Brain death, 206

13 Monitoring for overdoses, 210
Linda M. Dalessio

Introduction, 210

General management of drug overdoses, 210

Drug screening, 210

New and emerging therapies, 211

Indexing of drug and toxins seen in overdoses, 212

Acetaminophen, 213

Drug overview, 213

Symptoms of overdose, 213

Diagnostic testing and monitoring, 213

Antidotes/binding agents, 213

Salicylates and nonsteroidal anti-inflammatory drugs, 214

Drug overview, 214

Symptoms of overdose, 214

Monitoring, 214

Antidotes/binding agents/treatment, 215

Methemoglobin, 215

Drug overview, 215

Symptoms of overdose, 215

Diagnostic testing and monitoring, 216

Antidotes/binding agents/treatment, 216

Iron, 217

Drug overview, 217

Symptoms of overdose, 217

Diagnostic testing and monitoring, 217

Antidotes/binding agents/treatment, 217

Drugs of abuse, 218

Overview, 218

Symptoms of overdose, 218

Diagnostic testing, 218

Benzodiazepines, 218

Drug overview, 218

Symptoms of overdose, 218

Diagnostic testing and monitoring, 219

Antidotes/binding agents/treatments, 219

Opiods, 219

Drug overview, 219

Symptoms of overdose, 219

Diagnostic testing and monitoring, 220

Antidotes/binding agents/treatment, 220

Cocaine, 220

Drug overview, 221

Symptoms of overdose, 221

Diagnostic testing and monitoring, 221

Antidotes/binding agents/treatment, 222

Amphetamines, 222

Drug overview, 222

Symptoms of overdose, 222

Diagnostic testing and monitoring, 222

Antidotes/binding agents/treatments, 223

Phencyclidine, 223

Drug overview, 223

Symptoms of overdose, 223

Diagnostic testing and monitoring, 223

Antidotes/binding agents/treatments, 223

Barbituates, 224

Drug overview, 224

Symptoms of overdose, 224

Diagnostic testing and monitoring, 224

Antidotes/binding agents/treatments, 224

Hallucinogens, 224

Drug overview, 224

Symptoms of overdose, 225

Monitoring and treatment, 225

Club drugs/date rape drugs, 225

Drug overview, 225

Symptoms of overdose, 225

Diagnostic testing and monitoring, 226

Antidotes/binding agents/treatments, 226

Ketamine, 226

Drug overview, 226

Symptoms of overdose, 226

Diagnostic testing and monitoring, 227

Antidotes/binding agents/treatments, 227

Fake marijuana, 227

Drug overview, 227

Symptoms, 227

Diagnostic testing, 227

Antidote, 228

Dextromethorphan, 228

Drug overview, 228

Symptoms of overdose, 228

Diagnostic testing and monitoring, 228

Antidotes, 229

Bath salts, 229

Drug overview, 229

Symptoms of overdose/use, 229

Diagnostic testing and monitoring, 229

Antidotes/binding agents/treatments, 229

Skeletal muscle relaxants, 230

Drug overview, 230

Symptoms of overdose, 230

Diagnostic testing and monitoring, 230

Antidotes/binding agents/treatments, 231

Psychiatric drugs, 231

Drug overview, 231

Selective serotonin reuptake inhibitors, 231

Drug overview, 231

Symptoms, 231

Diagnostic testing and monitoring, 234

Antidotes/binding agents/treatments, 234

Monoamine oxidase inhibitors, 234

Drug overview, 234

Symptoms of overdose, 235

Diagnostic testing and monitoring, 235

Antidotes, 235

Lithium, 236

Drug overview, 236

Symptom of overdose, 236

Diagnostic testing and monitoring, 236

Antidotes/binding agents/treatments, 236

Neuroleptics, 237

Drug overview, 237

Symptoms of overdose, 237

Diagnostic testing and monitoring, 237

Antidotes/binding agents/treatments, 237

Tricyclic antidepressants, 238

Drug overview, 238

Symptoms of overdose, 238

Diagnostic testing and monitoring, 238

Antidotes/binding agents/treatments, 238

Carbon monoxide, 239

Drug overview, 239

Pharmacology, 239

Symptoms, 239

Diagnostic testing and monitoring, 239

Antidotes/binding agents/treatments, 240

Hydrocarbons and toxic inhalants, 240

Drug overview, 240

Pharmacology, 240

Diagnostic testing and monitoring, 241

Signs and symptoms, 241

Antidotes/treatment, 241

Cardiac medications, 241

Drug overview, 241

Antiarrhythmic agents, 246

Toxic alcohols, 248

Drug overview, 248

Anticholinergics/Cholinergics/Antihistamines (ACA), 251

Drug overview, 251

ACA symptoms of overdose, 252

ACA diagnostic testing and monitoring, 252

ACA antidotes/binding agents/treatment, 252

Anticonvulsants, 252

Drug overview, 252

Anticonvulsants symptoms of overdose, 253

Anticonvulsants diagnostic testing and monitoring, 253

Anticonvulsants antidotes/binding agents, 253

Common toxidromes and treatments for poisoning conditions, 253

Anticholinergic toxidrome, 255

Benzodiazepine toxidrome, 255

Cholinergic toxidrome, 256

Opioid toxidrome, 256

Sympathomimetic toxidromes, 256

Rhabdomyolysis syndromes, 257

Treatment of hyperkalemia, 257

Packidrome, 257

Alcohol withdrawal syndrome, 258

Anion and non-anion gap acidosis and osmolar anion gap, 258

Non-anion gap acidosis, 259

Osmolar gap, 259

Osmolarity corrected for elevated ETOH level, 259

Index, 264