ICU Nursing
Intensive Care Unit (ICU) nursing is commonly referred to as
critical care nursing. Critical care nursing deals specifically with
the human response to life threatening conditions. Critical care
nursing is challenging due to the life-threatening health
situations in the ICU. Critical care nurses are often in highstress
situations which demands complex assessments, highintensity
therapies and interventions and continuous vigilance.
Acute Exacerbations of COPD
Chronic obstructive pulmonary disease (COPD), also known as
chronic obstructive lung disease (COLD), is a term used to
describe progressive lung diseases, which include emphysema,
chronic bronchitis and chronic asthma. The common symptoms
of COPD are progressive limitations of the airflow into and out
of the lungs and shortness of breath. Emphysema and chronic
bronchitis are closely related and patients with COPD may have
both, which affects lung function. Emphysema involves
destruction of the alveoli in the lungs. Chronic bronchitis is
characterized by chronic cough and mucus production.
Over a
period of time the patient experiences abnormal ventilationperfusion,
insufficient oxygenation of blood (hypoxemia),
hypoventilation and right-sided heart failure. People with COPD
have a variety of illnesses such as, atelectasis which occurs
due to the collapse of part or all of a lung by blockage of the
bronchus or bronchioles or by very shallow breathing;
bronchiectasis, which is an acquired disorder of the large
bronchi that become dilated due to destructive infections of the
lungs; congestive heart failure (CHF),a disorder in which the
heart loses its ability to pump and cor pulmonale ,where the
right ventricle gets enlarged because of pulmonary
hypertension from lung disorders. COPD symptoms, when
ignored, usually lead to hospitalization in intensive care (ICU)
units.
Nurse Interventions in Acute Exacerbations
People with chest deformities or neurologic conditions that
cause shallow breathing benefit from mechanical devices that
assist breathing, such as continuous positive airway pressure,
which delivers oxygen through a nose or face mask that
prevent airways collapse, even at the end of a breath.
Additional respiratory support can be provided with a
mechanical ventilator. The primary treatment for acute massive
atelectasis, a common complication in COPD is removal of the
underlying cause (Brooks-Brunn, 1995).
If the blockage cannot
be removed by coughing or by suctioning the airways then it
should be removed by bronchoscopy. Antibiotics are to be
given for any detected infection as in chronic atelectasis, when
infection is almost inevitable. Treatment of atelectasis due to
deficient or ineffective surfactant is done by treating the low
blood oxygen either with mechanical ventilation or positive end
expiratory pressure. For cor pulmonale, supplemental oxygen
can be administered to increase the level of oxygen in the
blood. A low salt diet is recommended. Diuretics are given to
remove excess fluid from the body. Calcium channel blockers,
intravenous prostacyclin, or the oral medication bosentan are
frequently used to treat pulmonary hypertension. Blood
thinning anticoagulants are also useful. Oxygen administration
relieves symptoms and prolongs survival. Careful intervention
is essential because progressive pulmonary hypertension and
cor pulmonale often leads to severe fluid retention, lifethreatening
shortness of breath, shock, and death.
Benzodiazepines are not recommended to relieve anxiety in
patients with COPD because they decrease respiratory drive
and compromise lung function (Brooks-Brunn, 1995). An
anxiolytic, buspirone, have been found to be safe in reducing
anxiety in COPD patients. Dyspnea is common in individuals
with chronic obstructive pulmonary disease. Respiratory
assessment of the patient should include present level of
dyspnea measured using a quantitative scale such as a visual
analogue or numeric rating scale. Usual dyspnea is measured
using a quantitative scale such as the Medical Research Council
(MRC) Dyspnea Scale.
The other assessments include Vital
signs, pulse oximetry, chest auscultation, chest wall movement
and shape/abnormalities, presence of peripheral edema,
accessory muscle use, presence of cough and/or sputum,
ability to complete a full sentence and the level of
consciousness. By doing so, nurses should be able to detect
stable and unstable dyspnea and acute respiratory failure
(American Thoracic Society, 1998). Nurses should also be able
to offer interventions for all levels of dyspnea including acute
episodes of respiratory distress which includes acceptance of
patients' self-report of present level of dyspnea, medications,
controlled oxygen therapy, secretion clearance strategies, noninvasive
and invasive ventilation modalities, energy conserving
strategies, relaxation techniques, nutritional strategies and
breathing retraining strategies. It is important for the nurses to
remain with patients during episodes of acute respiratory
distress. Nurses have to assess patients for hypoxemia/hypoxia
and administer appropriate oxygen therapy for individuals for
all levels of dyspnea. Medications include bronchodilators, beta
2 agonists, anticholinergics and methylxanthines,
corticosteroids, antibiotics, psychotropics and opioids
(
www.guidelines.gov).
Patient safety checks
Patient safety checks include circuit leaks; maintenance of
positive pressure; adequate inspiratory air flow and not leaving
the patient alone. Continuous Positive Airway Pressure Oxygen
therapy is part of any ICU and requires absolute attention.
Managing the therapy involves maintenance of the desired
FIO2; level of positive airway pressure and time period for
CPAP therapy, attaching CPAP machine medical air and oxygen
gas lines to wall sources, preparation of humidification source
,selection of prescribed FIO2 on oxygen blender, turning flow
on to level above 25 litres / min., positioning of rubber
securing band behind the patient's head, centred on occiput,
positioning of face mask over the patient, adjusting the level
of positive expiratory pressure to prescribed level, adjusting
inspiratory gas flow so that minimal fluctuations are present on
pressure gauge, observing and documenting respiratory rate;
work of breathing and SpO2, increasing inspiratory flow if
respiratory work is excessive or the patient complains of
continuing dyspnea, maintaining continuous SpO2 monitoring
with alarm function in place, maintaining humidification
temperature at 36 degree C or at temperature tolerated by the
patient (American Thoracic Society, 1998).
Patient observations
include, visual check every half an hour, documentation of
respiratory rate, SpO2, nausea and vomiting, monitoring pulse
rate and rhythm; blood pressure; peripheral circulation and
proper functioning of humidification system every hour,
checking the condition of skin around and under mask and
rubber securing band, documentation of condition and
interventions, condition of conjunctivae every two hours,
auscultation of lungs for equal air entry and palpitation of
abdomen for distension every four hours (Vollman,1997).
Ventilator-Associated Pneumonia is a common nosocomial
infection in the ICU accounting for 13% to 18% of all
nosocomial infections (Rello et.al, 1996).
Infection may be even
due to improper hand washing, not changing the gloves from
patient to patient, and contamination of respiratory devices like
nebulizers, spirometers, oxygen sensors, bag-valve mask
devices, and suction catheters (Shelby Hixson, 1998). Oral care
includes brushing the patient's teeth, use of solutions and
mouthwash to cleanse the mouth, and periodical suctioning of
oral secretions. Nasal care and proper cleansing of the
nasopharynx reduces bacterial infection.
Conclusion
The ICU setting demands stressful nursing interventions and
constant monitoring of the patients especially with conditions
like COPD. Nurse interventions should be based on assessment
of dyspnea, vital signs, pulse oximetry, chest auscultation,
chest wall movement and presence of peripheral edema, cough
and/or sputum, ability to complete a full sentence and the level
of consciousness. Proper oral and nasal care reduces lung
infection.
Reference
-- American Thoracic Society (1998).Research Priorities in
Respiratory Nursing. Am. J. Respir. Crit. Care Med.158
(6): 2006-2015.
-- Brooks-Brunn, J. A (1995). Postoperative atelectasis
and pneumonia. Heart Lung 24: 94-115.
Link.Nursing care of
dyspnea: the 6th vital sign in individuals with chronic
obstructive pulmonary disease (COPD).
-- Kingston GW, Phang PT and Leathley MJ (1991).
Increased incidence of nosocomial pneumonia in
mechanically ventilated patients with subclinical
aspiration. Am J Surg 161: 589-593.
-- Metheny N (1993). Minimizing respiratory complications
of nasoenteric tube feedings: State of the science. Heart
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-- Rello J, Sonora R, Jubert P, Artigas A, Rue M, Valles J
(1996). Pneumonia in intubated patients: Role of
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154:111-115.
-- Shelby Hixson, Tracey King, Nursing Strategies to
Prevent Ventilator-Associated Pneumonia. AACN Clinical
Issues: Advanced Practice in Acute and Critical Care 9
(1).
-- Vollman, KM (1997). Prone positioning for the ARDS
patient. Dimens Crit Care Nurs 16: 184-193.
-- Zaloga GP (1991). Bedside method for placing small
bowel feeding tubes in critically ill patients: A
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