Acute Biologic Crisis

General Description: This concept in N-302 deal with clients in acute Biologic Crisis. The nurse, utilizing the nursing process, focuses in assisting and giving immediate care and attention to the client to restore life processes to a state of dynamic equilibrium.
• Attend to specific needs of patient under ABC
• Identify types of data needed for care
• Prioritize NCP
• Alleviate physiologic stressors specific to patient
• Describe and appreciate the role of a critical care nurse
The Topics
A. Concept of Critical Care Nursing
B. Application
C. Definition
 Pre-term
 Post-term
 Acute MI
 Thyroid Storms and Crisis
 Hepatic Coma
 ARDS
 Diabetic Ketoacidosis
 CVD
 End Stage Renal Stage
The Concept of Critical Care Nursing
Delivery of specialized care to critically-ill patients with life-threatening such as major surgery, trauma, infection, and shock as well as prevention of potential life-threatening conditions.
The critical care nurse is responsible for ensuring that all critically-ill patients and families receive optimal care.
Common Illnesses and Injuries seen in ICU:
1. GSW (Gunshot Wounds)
2. Traumatic Injuries (car collision & falls)
3. CV D/O (heart failure, acute coronary syndrome, unstable angina, MI)
4. Surgeries (abdominal aortic aneurysm repair and endarterectomy)
5. Renal D/O (acute and chronic renal failure)
6. GI and Hepatic D/O (acute pancreatitis, acute UGIB or Upper Gastro Intestinal Bleeding, acute liver failure)
7. Cancer (lungs, esophageal & gastric)
8. Shock due to hypovolemia
PRINCIPLES OF CRITICAL CARE NURSING
 Maintains the establishment standards of CCN practice
 Continually updates knowledge necessary for competence as an integral part of the multidisciplinary health care team, coordinates care delivered to patient and supports families within the CC environment.
 Must recognize physiologic and psychologic limitations when providing care.
 Respect the rights of patient families, colleagues in the promotion or prolongation of life by individualizing each patient situation.
 Identifies the values of patients, families, colleagues, and self and incorporate these beliefs and attitudes into situations of ethical dilemmas.
MEET the CCN
Critical Care Nurse – responsible for making sure that critically-ill patients and member receive close attention and the best care possible.
Roles of CCN
• Staff nurse
• Case Manager
• Educator
• Nurse practitioner
• Nurse researcher
• Nurse specialist
Work Area
-the CCN works wherever critically-ill patients are found.
What makes CCN special?
 Being an advocate
 Using sound clinical judgment
 Demonstrating caring practices
 Collaborating with multidisciplinary team
CLINICAL JUDGMENT – requires critical thinking skill which is a complex mixture of knowledge, intuition, logic and common sense.
Importance of Critical Thinking
 Foster understanding of issues and enables you to quickly find answers to difficult questions
 It is not a trial and error method but is strictly a scientific method.
Development of critical thinking….
 Improve with increasing clinical and scientific experience.
 Asking questions and learning is the BEST WAY.
ALWAYS ASKING QUESTIONS
First question is…
1. What is the patient’s diagnosis?
2. What are the s/sx?
3. What are the usual cause?
4. What complications can occur?
5. Include patient’s clinical findings.
6. Risk factors? Are there any significant? If so, what interventions done?
7. What are patient’s cultural beliefs? How can you best address cultural concerns?
8. Usual medications?
9. Type of monitoring needed to watch out for complications?
CRITICAL THINKING & NURSING PROCESS
Step 1: Assessment
Step 2: Planning
Step 3: Implementation
Step 4: Evaluation

The Critical Care Unit Environment
A.) Physical Environment
- Layout is modified circle that allows for direct visualization of all patients at all times.
- Patients may be separated in cubicles with glass windows for visualizations or large open area with curtains.
- Direct nurse-patient visualization vs. limited privacy and patient exposure to frequent interventions vs. sensory overload.
TECHNOLOGY in the nurse station…
- Sophisticated monitoring and even video equipment
- Readily accessible
- Constant and readily available at bedside readily available within seconds:
 Cardiac monitor
 Oxygen
 Hemodynamic monitoring equipment  Suction equipment
 Defibrillator
 Ventilators
 12-Lead ECG
 Emergency medication
 IABP (Intraarterial Blood Pressure)
 Hemofiltration/hemodialysis
 Temporary/permanent pacemakers
 Variety of pumps for infusion and enteral feedings
NEGATOSCOPE - use to view x-ray films
B.) Psychologic Environment
Patients are conforonted with advanced forms of medical and nursing therapies and frightening environment
Flashing lights
Buzzing machines
Painful procedures
Noisy, brightly lit, crowded hyperactive room

FACTORS that Precipitate STRESS in the ICU environement:
1. Sensory Deprivation & Overload
- Sounds, sights, smells, unfamiliar voices, equipment noise, continuous bright lights, frequent assessment and interventions done 24/7
- Challenge for nurses is to REDUCE NOISE.
2. Sleep Deprivation
- REM sleep, an important component for mental restoration, occurs in the last cycles of uninterrupted sleep.
- Most likely to be affected in the ICU.

- Adverse effects ff:
Irritability
Anxiety
Physical Exhaustion
Disruption of Metabolic Function
Respiratory Distress
- VISITING TIMES should balance patient and family needs while supporting adequate rest.
3. Acute Confusion
- Hallucinations (visual & auditory)
- Restlessness
- Memory impairment
- Fluctuations in the level of awareness
- Physically restrained to protect patient from harm, controls the behavior BUT increases confusion and cause a level of struggle or combativeness that necessitate sedation.
- CCN should foster reality orientation by spending time with patient and encouraging interaction with family and significant others
STRESSORS on Patient/Family
- Unfamiliar environment & faces
- Noise, light levels
- Sensory deprivation/ overload
- Interruption of sleep/ wake cycles
- Inaccessibility of family and friends
- Lack of privacy
- Lack of understanding of prognosis
- Anticipation of painful procedures
- Confusion/ disorientation
- Impaired communication r/t intubation pain
- Fear r/t death and diagnosis
- Conflict between patient/ family and staff goals
STRESSORS on the STAFF
- Expectation to self
- Expectation of peer, clinical supervisors, other health care team, member of hospital and administration
- Intricate machinery and procedures
- Closed, crowded work area
- Constant contact with seriously ill, dying patients
- Constant emergencies readiness
- Sustained high activity level
- Limited breaks away from high-stress unit
- Limited communication to patients with intubation, altered level of consciousness)
- Isolation from other nurse in the hospital
- Ethical conflicts r/t issues of resuscitation and use of life-supporting equipment
- Legal issues
- Exposure to infectious disease.
THE PRE-TERM INFANT
- Defined as a live-born infant born before the end of week 37 of gestation
- Weight of < 2,000 g ( 5 lbs 8 oz) at birth
- All such infants need neonatal intensive care from the moment of birth to give them their best chance of survival without neurologic after effects.
- lack of lung surfactant that makes them extreme vulnerable to respiratory distress syndrome or Hyaline Membrane Disease
- maturity determined by: sole creases, skull firmness, ear cartilage and neurologic findings that reveal gestation stage.

Gestational age: younger than 37 weeks
Birth weight: normal for age
Congenital malformations: possibility
Pulmonary problems: resp. distress syndrome
Hyperbilirubinemia: very strong possibility
Feeding Problems: hypoglycemia due to small stomach capacity, immature sucking reflex
Weight gain in nursery is slow.
Future retarded growth – “catch-up growth occurs”, not likey.

TERM INFANT - born after 37 weeks of gestation
Low birth-weight infants: 1,500-2,500 g
Very low birth-weight infants: 1,000-1,500 g
Extremely very low birth-weight infants: 500-1,000g
CAUSES:
• The exact cause of prematurity labor and birth is rarely known.
• There is a high correlation between low socioeconomic level and early termination of pregnancy.
• The major influencing factor in these instances appears to be inadequate nutrition before and during pregnancy, as a result of either lack of money or lack of knowledge.
• Iatrogenic causes, such as elective cesarean birth and inducement of labor.
Factors associated with PRE-TERM BIRTH
• Low-socioeconomic status
• Poor nutritional level
• Lack of prenatal acre
• Multiple pregnancies
• Prior/ previous early birth
• Race (nonwhites have a higher incidence of prematurity than whites)
• Cigarette smoking
• Age of mother ( 100 mmHg or 70 %
2.) Risk for deficient fluid volume r/t insensible water loss at birth and small stomach capacity

GOAL: Newborn will demonstrate intake of fluids meet body needs.

INTERVENTION:
• High sensible loss from large BSA composed with total weight; excretes high proportion of fluid from immature kidney function (unable to concentrate urine)
• Up to 160-200 mL IVF per kg of weight daily.
• IVF and glucose within hours after birth via infusion pump to ensure constant rate and avoid overload.
• Check IV sites of possible infiltration ( lack of SQ tissue)
• IV fluids within 27 gauge (special needle) in the periphery or umbilical venous catheter; special precaution: PORTAL HPN.
• Monitor output 24 H.

3.) Risk for imbalance nutrition r/t additional nutrients needed for groeth, possible sucking difficulty.

INTERVENTION:
• Feeding schedule: -safety delay until infants has stabilized respiration effort, nutrition maintained by IV to prevent hypoglycemia
• May be on TPN until stable. D5 or any other hypertonic solution.
• Breast gavage, bottle feeding as soon as infant is able to tolerate to prevent deterioration of intestinal villi.
• Small frequent feedings.
• Gavage feeding:
 Gag reflex not intact until 32 weeks gestation; sucking until 34 weeks gestation; started on gavage feedings.
 Observe closely after both oral and gavage feeding for respiratory distress Be guided that babies are mouth breathers.
 Pacifiers to strengthen sucking reflex.
STAGES OF SUCKING
a.) ROOTING REFLEX.
b.) Direction to head
c.) Opens mouth to suck.
d.) Period of release
 Gavage feedings intermittently or continuously via tubes in mouth or nose (1ml/H)
 Aspirate, measure and replace sromach secretions before gavage feeding.
• Breastmilk
 Immunologic properties prevent necrotizing enterocolitis.
 Manual expression of breast milk for gavage feedings (frozen for safe transport and storage)
 May be left in room temperature for 8 hours.
 Sodium content in breast milk from pre-term birth is higher (necessary for fluid retention)
 Refrigerate or frozen, it will last for months or year.

THE POST-TERM INFANT
Born after 42 weeks AOG
Placenta loses ability to carry nutrients after 40 weeks causing post-term syndrome (skin: dry, cracked, leather-like from lack og fluid, absence of vernix, light weighted, amniotic fluid less than normal, can be meconium-stained, fingernails beyond end of fingertips, 2 week old baby alertness.
Birth of a Post-term Infant
 difficulty establishing respiration (esp. if meconium-stained)
 hypoglycemia (insufficient store of glycogen
 low SQ fat (used up in utero, protect from chilling)
 polycythemia (increase RBC, decrease plasma, hypoxia)
 elevated Hct and dehydration
ILLNESSES in the Newborn
A.) Respiration Distress Syndrome
- Also known as Hyaline Membrane Disease
- in pre-term infants, infants of diabetic mothers, infants born by CS
- pathologic feature of RDS is the hyaline-like (fibrous) membrane exudates of infant’s blood lining the terminal bronchioles, alveolar ducts, alveoli (prevent exchange of oxygen and carbon dioxide)
- low level of surfactant (lines the alveoli, reducing surface tension on expiration)
ASSESSMENT:
• Difficulty initiating response
• Low body temperature
• Nasal flaring
• Sterna and subcortical retraction
• Tachypnea (> 60 RR)
• Cyanotic mucous membranes
• Expiratory grunting (closure of epiglottis to increase pressure on alveoli in attempt to increase oxygen
• Seesaw respiration (inspiration: anterior dust wall retracts, abdomens protrude; expiration: sternum rises.)
• Heart failure – decreased urine output and edema on extremities
• Pale gray skin
• Periods of apnea
• Bradycardia
• Pneumothorax
• Fine rale and diminished breath sounds
• PO2 and O2 saturation decreases.
MANAGEMENT
• Surfactant replacement via spray through syringe or catheter in ET.
• Oxygen administration: CPAP on assisted ventilation with PEEP exerts pressure on the alveoli from collapsing.
• Indomethacin to cause closure of the PDA (posterior ductus arteriosus)
• Ventilation: I/E ratio is 1:2; O2 must be delivered with force to deliver enough O2 in a stiff noncompliant lung: fear is PNEUMOTHORAX
• Muscle relaxants: Pancuronium – abolishes spontaneous respiration to allow mechanical ventilation at lower pressure. ATROPINE and NEOSTIGMINE at BS when giving pancuronium.
Prevent of RDS
• Maintain L/S ratio 2:1
• Tocolytic: terbutalin to prevent pre-term
• Glucorticoid: betamethasone at 12 to 24 H before birth to quick formation of lecithin
B.) SUDDEN INFANT DEATH SYNDROME (SIDS)
- Often in infants of adolescent mothers, infants of closely spaced pregnancies, underweight infants and pre-term infants, twins, economically disadvantaged infants of color and infants of narcotic-dependent mothers.
Possible cause of death: LARYNGOSPASM ( make no sound as they die)
Characteristics:
 Blood-flecked sputum or vomitus on mouth or bedclothes resulting from death, NOT ITS CAUSE
 Petechiae in lungs and mild inflammation and congestion in the respiratory tract but not severe enough to cause death
 No association with suffocation from bedclothes or choking from overfeeding, underfeeding or crying.
RECOMMENDATION:
Put newborn to sleep on their back or side.