nursing in itu the big things that make a big...

Nursing in ITUNursing in ITUThe little things that make The little things that make a big differencea big difference

Charlotte WillettCharlotte WillettEducation SisterEducation SisterNeurocritical CareNeurocritical Care

Aims of this sessionAims of this session

To demonstrate the nurseTo demonstrate the nurse’’s contribution to the patients contribution to the patient’’s s journey through ITUjourney through ITU

To explore some elements of evidence based nursing care To explore some elements of evidence based nursing care that can make a difference to patient outcomethat can make a difference to patient outcome

To present one approach at implementing evidence based To present one approach at implementing evidence based carecare

The ITU Nurse is an essential member of The ITU Nurse is an essential member of the Critical Care teamthe Critical Care team

Nursing makes a fundamental contribution to alleviating the impact of critical illness in terms of the patient’s experience and in preventing further deterioration and complications.

The Unique role of the ITU nurseThe Unique role of the ITU nurse

Provides 24 hour patient careProvides 24 hour patient care

–– Continuity of care is achieved through Continuity of care is achieved through nurse to nurse bedside handovernurse to nurse bedside handover

–– Care is holistic and patient centredCare is holistic and patient centred

–– Involved in communication between other Involved in communication between other members of the teammembers of the team

–– Documents all episode of care on the ITU Documents all episode of care on the ITU chart and nursing noteschart and nursing notes

Makes a valued contribution to decision Makes a valued contribution to decision making in ward roundsmaking in ward rounds

Patient Safety is paramountPatient Safety is paramount

Bedside equipment is checked routinely to prevent avoidable Bedside equipment is checked routinely to prevent avoidable incidentsincidents–– Ventilator settingsVentilator settings–– Monitor alarmsMonitor alarms

Conducts thorough patient assessment using A to E approachConducts thorough patient assessment using A to E approach11

–– A=airwayA=airway–– B=breathingB=breathing–– C=circulationC=circulation–– D=disabilityD=disability–– E=everything elseE=everything else

Identifies and alerts the team to potential problemsIdentifies and alerts the team to potential problems

Protocol driven careProtocol driven care

Provides the nurse with a Provides the nurse with a framework which allows her to framework which allows her to work autonomouslywork autonomously

A multidisciplinary approach to A multidisciplinary approach to evidence based care delivery evidence based care delivery ––updated when new findings are updated when new findings are publishedpublished

NEUROSURGICAL INTENSIVETHERAPY UNIT

PATIENT MANAGEMENT PROTOCOLS

Guidelines are generalisations to support decision-making. They should always be applied in the light of individual clinical circumstances,

together with the judgement and knowledge of the responsible clinician.

Electronic version of these protocols availablePlease contact Sandra Fairley: [email protected]

In many fields of medicine the adoption of guidelines/ protocols for clinical practice has been

shown to improve outcome2

Ventilation Ventilation –– Evidence based careEvidence based care

Regular ventilator observations

Elevation of head of bed to 30–45°

Endotracheal suctioning – as patient condition demands

Humidification of inspired gas – To mobilise secretions

Management of ventilator tubing – Replace every 7 days

Ventilator Acquired Pneumonia (VAP) accounts for 45% of all infections in intensive care units in

Europe3

Oral Hygiene Oral Hygiene –– Evidence Based careEvidence Based care

Meticulous mouth care maintains oral health and helps prevent VAP

Check integrity of mouth and lips 2-4 hourly

Removal of excess oral secretions

Clean teeth with toothbrush and toothpaste

Chlorhexidine based mouthwash –evidence inconclusive

Nutrition Nutrition –– Evidence Based CareEvidence Based Care

Evidence suggests that earlier feeding results in fewer infectious complications and lower mortality4

Fine bore NG tube – strict guidance for confirmation of position

Early initiation of enteral feeding using a start-up regime

Liaison with Dietician

Gut protection for patients not absorbing feed Gut protection for patients not absorbing feed –– prevents prevents gastric ulcerationgastric ulceration

Refer all patients to dietitian

for individuallyprescribed plan

Flush tube before and after drugs and stoppages to prevent blocking

If pH > 5.5 feeding may need to be stopped for up to one hour to allow gastric pH to return to normal NB: caution with patients on insulin infusion

discuss with NIC prior to stopping feed

Reduce opiates to increase absorption if appropriate

Remember :

Oral nutrition support – nutritional screening tool of > 10

Pregnancy

Transition to oral diet from NGT

At risk of re-feeding syndrome ( chronic alcoholics, unfed for >7

days, malnourished, anorexia nervosa )

Renal or liver failure

Requirements for non standard feed

Fluid restriction

Under 30 years

Under 50 kgs or over 100 kgs

Urgent referral to the dietitian

Neurocritical Care Multidisciplinary Team November 2007 , for review 2008

After 4 hrs

Is aspirate > 200mls ?( discard all aspirates )

Continue at same rate for 4 hrs then aspirate

Is aspirate > 200mls

Add Metoclopramide(10mgs / tds / IV )

Continue at same rate & aspirate after 4 hrs

Continue Metoclopramidefor 48 hrs

Is aspirate > 200mls ?

CONSIDER TPN Dietitian , pharmacist and

Consultant must all agree that it is appropriate

( order by 10.30am from pharmacy or if urgent bleep pharmacist )

Put tube on free drainagefor 24 hrs

(may need large bore tube for gastric decompression )

Consider OMEPRAZOLE

20-40mg IV daily

Are aspirates still > 200mls ?

Increase rate by 25mls / hr &

aspirate after 4 hrs Is aspirate < 200mls ?

℡

Neurocritical Care Enteral FeedingConfirm correct placement of NGT /OGT as per UCLH policy prior to use

( pH ≤ 4.5 in awake patients , x – ray confirmation for unconscious patients ) Start enteral nutrition as soon as possible, use only fine bore enteral feeding tubes

Start feeding with Fresubin Original Fibre at 25ml / hr for 4 hrs

Is abdomen distended with absent bowel sounds ?

consider abdominal X-ray

Change Metoclopramide to Erythromycin (250mgs /tds /IV)

continue for 48 hrs &aspirate 4 hrly

increase rate by 25ml every 4 hrs to maximum rate

75 mls / hr

Is aspirate > 200mls ?

Increase rate by 25 mls / hr&

aspirate after 4 hrsIs aspirate < 200 mls ?

No

Yes

Yes

No

Yes Yes

Yes

Yes

No

Yes No

Continue at maximum of 75mls / hr

& aspirate 4 hrly

Once seen by dietitian adjust rate to prescription

If aspirates > 200mls at any time return to beginning of

algorithm

Stop feed for 2 hours before and after administration Phenytoin &

adjust feed rate appropriately

Yes

No

Continue feeding at 10 mls / hr for 24 hours

&review after 24 hours

No

If bowel sounds are present recommence feeding at 25mls / hr

&return to beginning of algorithm

TUBE PLACEMENT

MUST BE CONFIRMED DAILY BY pH TESTING

( pH≤5.5)

RECORD ON OBSERVATION CHART

DVT prevention DVT prevention –– Evidence Based CareEvidence Based Care

Deep vein thrombosis prophylaxis – Anti-embolic stockings– Pneumatic calf compression– Low molecular weight heparin– Early mobilisation

Critically ill patients have an increased risk of venous thromboembolism (VTE). Incidence of

Pulmonary Embolus revealed at post mortem is as high as 27%5

Prevention of Pressure ulcersPrevention of Pressure ulcers

Assess each patient’s risk

Check pressure areas for early signs of pressure sore development

Keep skin clean and dry, move patient carefully to avoid shearing

Reposition patients 4 hourly or more frequently if required

Use of pressure relieving device – low pressure mattress

The presence of pressure ulcers has been associated with an increased risk of death in older

people in ITU6

Rehabilitation & Prevention of Rehabilitation & Prevention of Longer term complicationsLonger term complications

Work with Physiotherapist to start Work with Physiotherapist to start rehabilitation as early as clinically possible rehabilitation as early as clinically possible

Enable the patient to communicate his/ Enable the patient to communicate his/ her needsher needs

Promote normal sleep/ wake cyclesPromote normal sleep/ wake cycles

Psychological and emotional supportPsychological and emotional support

Provide support to family/ carersProvide support to family/ carers

Many Patients who survive critical illness have continuing physical and psychological

problems7

Anticipating problems post ITUAnticipating problems post ITU

ITU readmission rate in the UK = 6.5%ITU readmission rate in the UK = 6.5%

Prepare patient for transition to wardPrepare patient for transition to wardTiming of transfer Timing of transfer –– during daytimeduring daytimeStructured handover from critical care to ward staff supported Structured handover from critical care to ward staff supported by a written planby a written planOutreach Sister follow upOutreach Sister follow up

ITU WARD

Evidence based practice Evidence based practice –– Care Care Bundle approachBundle approach

A group of interventions A group of interventions applicable to a specific applicable to a specific patient grouppatient group

Each intervention must be Each intervention must be considered for every considered for every patientpatient

Maintains a consistent level Maintains a consistent level of safety and quality of of safety and quality of care care

Name ……………………………….. Hospital number ……………….

Date

Maintaining cerebral oxygen

delivery

Controlling cerebral oxygen

consumption

Controlling blood glucose

ICP/CPP targets set Not appropriate

Adequate

circulating volume

BP targets set Not appropriate

Adequate O2

CO2 control Not appropriate

Pyrexia control

Blood glucose

control


Adequate

circulating volume


Adequate O2


Pyrexia control

Blood glucose

control


Adequate

circulating volume


Adequate O2


Pyrexia control

Blood glucose

control


Adequate

circulating volume


Adequate O2


Pyrexia control

Blood glucose

control


Adequate

circulating volume


Adequate O2


Pyrexia control

Blood glucose

control

Head elevation 30– 450

HOB elevated Not appropriate





Managing sedation

Assessed need for

sedation Assessed need for

daily lightening of sedation

Assessed need for



Assessed need for



Assessed need for



Assessed need for



DVT prophylaxis

Flowtrons Antiembolic

stockings LMWH LMWH considered









Peptic ulcer prophylaxis

Fine bore feeding

tube Enteral feeding

commenced PPI commenced PPI considered

Fine bore feeding



Fine bore feeding



Fine bore feeding



Fine bore feeding



CVP / Peripheral / Arterial lines and

Surgical sites

Daily inspection of ne insertion sites, dressings as per

Trust policy

Daily inspection of urgical wound site, consider Redivac drain / clip / suture

removal as per protocol

CVP

Still required New line required Site satisfactory Dressing

Peripheral lines

Site satisfactory Dressing

Arterial line


Surgical wound

Site satisfactory Dressing Consider clips etc

CVP


Peripheral lines


Arterial line


Surgical wound


CVP


Peripheral lines


Arterial line


Surgical wound


CVP


Peripheral lines


Arterial line


Surgical wound


CVP


Peripheral lines


Arterial line


Surgical wound


Neurocritical Care Multidisciplinary Team January 2009 t

NEURO CARE BUNDLE CHECKLISTTo be completed daily on the ward round by nursing staff in conjunction with medical staff

Completed forms to be retained on the unit for audit purposes

Nursing in ITUNursing in ITUThe little things that make The little things that make a big differencea big difference

BIG

ReferencesReferences

1.1. A systematic approachA systematic approach to the acutely ill patient to the acutely ill patient [online], (2006). [online], (2006). URL: http://URL: http:// www.resus.org.uk www.resus.org.uk

2.2. Grimshaw JM. Towards effective professional practice. (1996) Grimshaw JM. Towards effective professional practice. (1996) TherapyTherapy 51(3):23351(3):233--66

3. Vincent JL, Bihari DJ, Suter PM, Bruining HA et al (1995). The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. Journal of American Medical Association 278:639–644

4.4. VALADKA AB & ANDREWS BT (2005). VALADKA AB & ANDREWS BT (2005). Neurotrauma Evidence Neurotrauma Evidence Based Answers to Common QuestionsBased Answers to Common Questions. Thieme Medical Publishers: . Thieme Medical Publishers: New YorkNew York

5.5. The Intensive Care Society (2008). The Intensive Care Society (2008). Venous Thromboprophylaxis in Venous Thromboprophylaxis in Critical Care: Standards and GuidelinesCritical Care: Standards and Guidelines ICS. LondonICS. London

6. Thomas DR, Goode PS, Tarquine PH , Allman RM (1996). Hospital acquired pressure ulcers and risk of death. Journal of American Geriatric Society. 44: 1435-40.

7.7. NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (2009). NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (2009). Rehabilitation after Critical Illness: Guideline 83. NICE. LondoRehabilitation after Critical Illness: Guideline 83. NICE. Londonn

Questions?Questions?