1.subjective data-ask patient, listen, ask for help understanding pain, info from patient's family/so's

2.objective data-head to toe, Vitals, EMR trends, lab results and diagnostic tests

3.machinery-assessment the patient first, don't rely fully on machinery,

4.bedside rounding-include patient, family, and friends

LOC

orientation to Person, place, time

pupilary reac-pen light

response to painful and verbal stimuli

purposeful movement/reflexive movement

glascow coma scale, delirum scale (CAM), MMSE (dementia)

Intracranial pressure

intracranial pressure monitoring

invasive

SjvO2-O2 concentration in jugular vein

Normal-60-80%

Less than 50%-hypoxia

varies from states to state

absence of purposful movement

flaccid tone/absence of spontaneous movements

persistent deep coma

no response to pain

absence of brain stem reflexes-pupils fixed and dilated, no corneal, gag or cough reflexes, doll eyes (absence of spontaneous oculo cephalic reflexes)

Isoelectric or flat ECG

identify possible donations early

provide accurate information

work closely with organ procurement agency

respect cultural/religous beliefs

provide emotional support

vital signs-trends

assesment of chest pain (PQRST)

Heart sounds-s3 s4 can be indicative of cardiac overload

peripheral pulses

invasive monitoring-artial line to measure BP, PAP catheter to measure PAP, central venous pressure monitoring

cardiac monitoring-arrythmias

ventricular assistive devices-end stage disease/transplant candidates

early ambulation best prevention

difference in treating medical and post op

eval risk for hemorrhagic stroke

med managment options include heparin, lovenox, or fragmin

non pharm options includes teds, weight bearing and amb, no crossing legs when in bed or sitting

assess breath sounds

monitor abgs and pulse oximetry

observe res assessment-breathing effort, skin color, rate, accessory muscles

O2 by cannula, mask, mech ventilation

 narcotics depress RR, monitor closely with PCA pump, have narcan available

oral care

coughing and deep breathing

T and P 2qh for bed bound

OOB to chair ASAP-even for short interval

suctioning

incentive spirometer

ABC=awakening and breathing and trial cordination

awakening trials daily, breathing/spontaneous trials, coordination of extubation with respiratory trials

D=delirium, assess and treat early

E=early exercise and ambulation, passive to active ROM, ambulate while intubated

F=family, include and listion

medications include sedatives, anxiolytics, analgesics

sedation weaning includes short term sedatives, sedation vacations daily, assess and manage pain, assesment of delirum,

IV fluids and correct rate,

abdominal assessment

stool assessment

stress ulcer prophylaxis

feedings can be enteral or parental

if tube feed is late can hang IV dextrose 10% until feed back comes up for day

solutions with more than 10% IV dextrose require central line for infusion

TPN is an IV soltions containing 10-50% IV dextrose, amino acids, fatty acids, calories, electrolytes, added trace elements, vitamins, minerals, insulin etc

NPO for more than 5 days (Crit care, post op major surg)

severe malnutrition

burns

bowel disorders

severe acute pancreatis

acute renal failure

hepatic failure

metastic cancer-very malnourished

each bag and tubing must be changed q24 hours

Strict I and O required

monitor Blood sugar

monitor serum electrolytes

sterile dressing change to central line site q48-72 hour per facility protocol

hang only 10% dextrose only when solution is unavail (at same rate)

Infuse TPN via pump only!-no catch up in rate, monitor rate hourly

gaps in nutritional guidelines-work with registered dietician

foley catheters common-I & O, need to remove ASAP, prevent UTI's, clinical practice guidelines

Intake-PO, tube feeds, IV lines, tube feeds

Output-urine output, NG secretions, JP or hemovac

monitor fluid and electrolyte balance-skin turgor, electrolytes (K+ critical)

creatinine-A normal result is 0.7 to 1.3 mg/dL for men and 0.6 to 1.1 mg/dL for women. Women usually have a lower creatinine level than men.

This is because women usually have less muscle mass than men.

Normal BUN-8-25

BUN going up and Creatine staying normal-hypovolemia-dehydrated, not enough volume

know px's most recent blood glucose level

insulin is a high alert drug

nursing care of critical care patients and insulin protocols

freq glucose monitoring

adjust insulin dosages per protocol

hypoglycemia guidelines <70mg/dL

critically ill patients are at major risk of skin breakdown

daily head to toe assessment

TP, mattress rotation

skin care

attention to pressure points

wound assessment: wound RN consult

all px should be OOB unless contraindicated

t and p imporatant

ROM

ambulate px as ordered, esp post op patients

hazards of immobility-pnemonia, skin breakdown, PE

verbal and non verbal responses to pain

non verbal responses need to be used for unconscious or intellecutllay disabled

some patients may require referral to pain management specialists

acute delusional state

improve patient outcomes in post ICU experiences

improve team collab

standardize care process

break the cycle of over sedation and prolonged ventilation

ABCDE bundle includes

spontaneous awakening

spon breathing trial

careful sedation choice

assessment of delirium

early progressive mobility (passive ROM), active ROM, standing to ambulation

include MRSA and Cdiff

prevention is key

come from invasive procedures, poor immune system, mult IV lines, and lots of antibiotics

respiratory-require a sputum culture

blood-blood culture

urine-urine culture

monitor WBC and erythrocyte sedimentation rate (ESR)

check patients temp early in shift and prn throughout day

handwashing!

universal precautions

sterile tech when indicated

ther comm

px and family education

writing board

alphabet board

protocol for translators in facility

psychosocial

disturbed body image

patients frequenelty fearful and anxious

disturbed Self esteem

powerlessness

ICU psychosis

spirital distress

coping mechanisms

affects of family

spiritual and cultural concerns

50% of hospitalized patients are greater than 65

alert and oriented?

hearing and eyesight issues

skin, nutrition, and hydration issues

little or no reserves to heal

exacerbation of cognitive impairment in an acute setting

DNR, DNI

MOLST/ advanced directives

benefit vs burden

QOL: personal definition

HCP: only when person can't make wishes known

patient advocacy

moral distress

Cardiac arrest victims are more likely to survive if rescuers take a pause of < 10 sec. in CPR before or after defibrillating the patient(2011

General good rules with a focus on safety (prevention of needle sticks etc..)