critical care nursing a holistic approach part 3

Critical Care Nursing A Holistic Approach

Part 3

The Critically Ill Pediatric PatientChapter 11

Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.

Pediatric Patients

Children are not small adults.


Vital Signs• Normals change with age• Blood pressure is the last vital sign to change in a child

with shock• Bradycardia is not well tolerated in young children and

can be precipitated by hypoxia • Tachycardia can be a nonspecific response to many

conditions• Tachypnea might indicate respiratory distress• Bradypnea may indicate respiratory arrest


Neurological• Needs to be age appropriate• Reflexes • Fontanels• Mental status

– Interaction with the environment – Knows Mom and Dad – Awake, looking around


Cardiovascular• Skin color

– Peripheral cyanosis normal for newborn only– Central cyanosis always abnormal– Mottling – take into consideration room temperature

• Capillary refill time is less then 2 seconds


Respiratory• Infants under 6 months are obligatory nose breathers• Smaller airway in diameter and length, easily occlude• Watch for retractions

– Abdominal breathing – Seesaw breathing

• Listen for sounds– Grunting – Stridor – Wheezing


Renal• Normal urine output

– Infants: 2mL/kg/hour • Decreased ability to concentrate urine

– Children: 1mL/kg/hour • Increased risk of dehydration

– Dry mucous membranes – Poor skin turgor – Sunken fontanels

The Critically Ill Pregnant WomanChapter 12


Critical Care Complications of Pregnancy• Severe preeclampsia • HELLP – Hemolysis, elevated liver enzymes and low platelets

• DIC – Disseminated intravascular coagulation • Amniotic fluid embolus • ARDS – Acute respiratory distress syndrome


Nursing Diagnoses• Anxiety, Stress related to poor/uncertain pregnancy

outcomes • Anticipatory Grieving related to threat to self • Fear related to fetal well-being • Potential Injury related to infection • Alterations in Family coping related to hospitalization• Impaired Fetal Oxygen Transport related to maternal

position, blood loss, or placental trauma

The Critically Ill Older PatientChapter 13


Physiologic Changes of the Older Adult• Many changes occur in every system• Table 13-1 is a summary of these changes

• The most troublesome changes are:– Loss of sight – Loss of hearing – Decrease in quality sleep – Cognitive changes


Medications in the Older Adult

Start Low and Go SlowStart Low and Go Slow

• Altered Drug Absorption • Altered Drug Distribution • Altered Drug Metabolism • Altered Drug Excretion

The Postanesthesia PatientChapter 14


Problems in the Postanesthesia Patient• AIRWAY! AIRWAY! AIRWAY! AIRWAY!• Hypoxemia• Hypotension • Hypertension• Cardiac dysrhythmias• Hypothermia


Malignant Hyperthermia• Rare, autosomal dominant disorder

– Assess for family history – Increase in temperature – as high as 46˚C– Unexplained tachycardia, sweating, labile BP

• Treatment– Dantrolene– Cooling of the patient – 100% oxygen


Postoperative Nursing Care

• Patient able to maintain airway• Patient’s mental status is assessed frequently until he or

she is easily aroused and back to baseline • Pain control • Management of postoperative nausea and vomiting

Interfacility Transport of the Critically Ill Patient

Chapter 15


Mode of Transport• Physician must order type of transport – The level of

transport should be the same as the level of care the patient is already receiving.

• Ambulances – BLS – ACLS

• Air transport – All ACLS – Helicopter – Fixed wing


EMTALAEmergency Medical Transfer Active Labor Act • Hospitals must provide screening exam• Patient should be stabilized prior to transport

– Medical certification that benefits outweigh risks• Receiving facility has accepted care of the patient

– Physician to physician report – Nurse to nurse report

• Transport personnel have the required training and equipment for a safe transport

critical care nursing a holistic approach part 3

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