BACHELOR OF SCIENCE IN NURSING:

NCM 106
RLE MODULE RLE UNIT WEEK
1 1 15
INTENSIVE NURSING CARE
ACUTE RESPIRATORY DISTRESS SYNDROME

ü Read course and laboratory unit objectives

ü Read study guide prior to class attendance
ü Read required learning resources; refer to course unit terminologies for jargons
ü Participate in weekly discussion board (Canvas)
ü Answer and submit course unit tasks
 

At the end of this unit, the students are expected to:

1. Discuss the disease process of acute respiratory distress syndrome and its contributing factors.
2. Map out the course of the disease based on the given clinical scenario.
3. Formulate a care plan based on identified priority problems of the patient.
4. Explain the nursing responsibilities relative to the drugs prescribed.

Berman, Snyder & Frandsen. (2016). Kozier & Erb’s Fundamentals of Nursing. (10th ed.).
Pearson

 
  
Lewis & Bucher. ((2017). Medical-Surgical Nursing: Assessment and management of Clinical
Problems. (10th ed.). C & E
Linton. (2020). Medical-Surgical Nursing. (7th ed.). ELSMoore. (2018). Brunner & Suddarth’s
Textbook of Medical-Surgical Nursing.(14th ed.). Wolters Kluwer
Silvestri, L.A. (2018). Saunders Q & A Review for the NCLEX-RN Examination, 7th ed.
Missouri: Elsevier
https://www.slideshare.net/rsmehta/3-monitoring-amp-devices-used-in-icu-ccu-53533107
https://www.slideshare.net/rsmehta/1-critical-care-53532785

INTENSIVE CARE UNIT

Defined as a “service for patients with potentially recoverable diseases who can be benefit
from more detailed observation and treatment than is generally available in standard wards
and departments” [Petros et al..,1995]

The intensive care unit is a designated area of a hospital facility that is dedicated to the care of
patients who are seriously ill.

DIFFERENT UNITS
There are variety of names depends on specific purpose and the degree of dependency of the
patient. Many different hospitals have many different terms. Frequently seen are
MICU = Medical Intensive Care Unit
SICU = Surgical Intensive Care Unit
TICU = Trauma ICU Transplant ICU
NICU = Neuro ICU or Neonatal ICU
PICU = Pediatric Intensive Care Unit
CVICU = Cardiovascular Intensive Care Unit
CTS-ICU = Cardio-thoracic Surgery Intensive Care Unit
CCU = Coronary Care Unit
CICU = Cardiac Intensive Care Unit
BICU = Burn Intensive Care Unit
RCU = Renal Care Unit

 
  
Intensive Treatment Unit - (ITU) highest level of patient dependency, most aggressive
treatment and monitoring protocols … CSU-cardiac surgery units are best example

Special Care Baby Unit (SCBU) neonatal problems often requiring IPPV and invasive
monitoring techniques

High Dependency Unit (HDU) recovering area of an operating theatre) with low level of
monitoring and high level of nursing care

The main functions of any ICU is to provide optimum life support & provide adequate
monitoring of vital functions.

ICU PATIENTS
• critical patients (multiple diagnoses, multi-organ failure, immune-compromised and
major trauma and post surgery)
• Move less
• Malnourished
• More obtunded / deaden (Glasgow coma scale)
• Heart, kidney, liver failure etc…

PREPRATION OF THE UNIT

The unit should be kept ready all the time which should include the following

1.Special bed having the following facilities

• Head board should be detachable to facilitate intubation (in case of cardio
pulmonary arrest)
• Bed should be firm and non yielding to facilitate cardiac massage
• Should have a tilting mechanism (to keep position of patient)
• Should have side rails to prevent falling (psychiatric and anxious patient)
• There should be a bed side locker an over bed table and a foot stool kept adjacent
to the bed
2.Cardiac monitor system with alarm that may be connected to the central console
3.Oxygen and suction apparatus (preferably pipe line model)
4.Resuscitation unit containing the following
• Syringes, needles, IV catheter, intravenous administration sets, blood sets, scalp
vein sets and intra venous fluid
• Spirit, swabs, adhesive plaster (micropore / transpore), torniquets and arm board

 
  
• Airways, endotracheal tubes and laryngoscopes of different sizes
• Ambu bag and suction catheters
• Oxygen cylinders special trays such as tracheostomy tray, and catheterization tray
• Drugs such as (antiarrhythmics, antiangina, antihypertensive, diuretics,
anticoagulants, antibiotics, anticonvulsants etc…
• Infusion pump

Following equipments should be easily available

• Defibrillator in working mode with electrodes and jell
• Cardiac pacemaker with pacing catheters in the sterile tray
• Mechanical ventilators (to ventilate the lungs in case of respiratory arrest)
• Facility for invasive and non invasive procedure like (CVP line, intra arterial pressure
monitor )
• Portable X-Ray machine
• ECG machine
• Oxygen therapy

Indications for admission

• Pre and post-operative patients and who underwent major surgeries.

• Craniotomy patients.
• Thoracotomy patients.
• Ultra major surgeries.
• Unstable multiple trauma patients.
• Patients with head or spine trauma requiring mechanical ventilation.
• Any surgical patient who requires continuous monitoring or continuous life support

The monitoring System

The monitor screen above the patient will display
• Blood pressure
• Central venous pressure CVP
• Heart rate
• Pulmonary artery pressure PAP
• Oxygen saturation
• Patient temperature

 
  
• Intracerebral pressure ICP
• ECG Monitoring system

INVASIVE BLOOD PRESSURE MONITORING (IBP)

• Arterial cannulation is used in patients in ICU to access arterial blood sample, for
checking ABG and for arterial pressure monitoring
• Arterial cannula is not used for intra vascular drug administration
• A saline-filled tube is used to connect the cannula to the transducer, to the display.
• It measures IBP on beat to beat basis.

CENTRAL VENOUS PRESSURE (CVP)

• The CVP cannula is inserted in to the internal or external jugular vein or subclavian vein
• The tip is situated approximately 2cm above the right atrium in the superior vena cava
• They provide access for intra venous drugs particularly which produce irritation to
peripheral veins eg-strong potassium chloride

HEART RATE
• Normal : 60 -100 beats per min
• Less than 60 : Bradycardia
• More than 100:Tachycardia

BRADYCARDIA
• Symptomatic
• Asymptomatic

SYMPTOMATIC BRADYCARDIA SIGNS AND SYMPTOMS

• Acute altered mental status
• Ongoing chest pain
• Hypotension
• Signs of shock

MANAGEMENT
• Assess ABC (airway breathing and circulation)
• Maintain patent airway
• Assist breathing
• Start oxygen

 
  
• Monitor vitals
• IV access (Atropine)

ASYMPTOMATIC
• Heart rate of less than 60
• Patient completely asymptomatic (stable)
• Requires no specific management

TACHYCARDIA Stable
• Heart rate more than 100 Treat underlying problem
• Dizziness.
• Shortness of breath.
• Lightheadedness.
• Rapid pulse rate.
• Heart palpitations -a racing, uncomfortable or irregular heartbeat
• Chest pain.
• Fainting (syncope)

MANAGEMENT
• Vagal maneuvers
• Pharmacologic ↑ Adenosine 6mg-12mg ↑ Amiodarone 150 mg slow IV
Unstable Management
• Synchronized Cardioversion 50 - 100 joules

Pulmonary artery pressure PAP

The introduction of pulmonary artery catheter (PAC) is the most popular and important
advances in monitoring.
It measures the pressure at three different places right atrium, pulmonary artery, and
pulmonary capillaries.
It measures amount of oxygen in the blood , cardiac output, PAP, PCWP & CVP It is also used
to figure out how much blood flows out of your heart overall.

Pulmonary capillary wedge pressure PCWP is recorded when the balloon tipped catheter is
inflated and the tip moves along with the blood flow to occlude a small pulmonary artery
• The inflated balloon records the pressure in the pulmonary capillary
• PCWP reflects left atrial pressure
• Decreased PCWP means hypovolaemia

 
  
• Increased PCWP means increased preload caused by fluid over load

Oxygen saturation SpO2

• The pulse oximeter measures the oxygen saturation
• It is noninvasive and risk free when used properly, the pulse oximeter should be used in
all clinical settings in which there is a potential risk of arterial hypoxemia
• It provide an early and immediate warning of hypoxaemia
• If SpO2 is below 95% means the O2 delivering system is inadequate to meet the needs
of the tissue or poor cardiac output
• Start O2 if SPO2 less than 95%
Patient Temperature
• Temperature regulation is important to the survival of the patient
• Although uncommon, hypothermia below 32° C is ominous
• Ventricular irritability increases, and if the temperature decreases to 28° C cardiac
arrest is likely
• shivering can increase oxygen demand 135% to 468%,when respiratory and
cardiovascular systems may be unable to respond normally to the increased demand

Sites for monitoring body temperature

1.Oral.
2.Tympanic membrane
3.Esophageal
4.Nasopharyngeal
5.Pulmonary arterial blood
6.Rectal
7.Bladder
8.Axillary
9.Forehead

DRAINS AND TUBES

Definition
• A surgical drain is a tube used to remove pus, blood or other fluids from a wound.
• Drains inserted after surgery do not result in faster wound healing or prevent infection
but are sometimes necessary to drain body fluid which may accumulate and itself
become a focus of infection

Jackson-Pratt drain

 
  
• Jackson-Pratt drain, JP drain, or Bulb drain, is a drainage device used to pull excess
fluid from the body by constant suction.
• The device consists of a flexible plastic bulb that connects to an internal plastic drainage
tube

Penrose drain
• A Penrose drain is a surgical device placed in a wound to drain fluid.
• It consists of a soft rubber tube placed in a wound area, to prevent the build up of fluid

Corrugated Rubber Drain

• The drain is fixed by a suture at the end of the wound and a safety pin is placed through
the end to prevent the drain slipping inwards.
• Corrugated rubber drains can be used for the deep wound for drainage.

T-Tube
• T tube is a tube consisting of a stem and a cross head (thus shaped like a T ).
• The cross head is placed into the common bile duct while the stem is connected to a
small pouch (i.e. bile bag).
• It is used as a temporary post-operative drainage

Purpose of a T tube
Handling of the common bile duct in the form of dissection, dilatation, choledochotomy and
cholecystectomy can lead to spasm of the sphincter of Oddi
• This can cause back pressure and give way of sutures used to suture the
choledochotomy incision leading to a surgical calamity.
• It is used to slowing down the motility in the common bile duct as well as to reduce
spasm of the sphincter of Oddi
• The T tube should be kept for a period of 10 days allowing the patient to recover
from the stress of surgery.
• The bile should be allowed to flow out easily through the T tube. This reduces the
pressure on the suture line until the sphincter spasm disappears allowing free
egress of bile into the duodenum.

Chest Tube or Pleural drainage tube or intercostals drain

• Used to remove either air or fluid in the pleural space
• Used to drain; haemothorax, pneumothorax, chylothorax, pleural effusion and
empyema.

 
  
• Tube is inserted in to the pleural space in the 4th intercostal space

NasogastricTubes
• Naso-gastric tube passes through the nostrils (sometimes through oral cavity!) to the
stomach, to the duodenum or even jejunum
• During the insertion the tube has to point downward toward the xiphoid process
• once reach the nasopharynx, twist it to 180 degrees this minimizes the risk of tube
coiling at the pharynx
• lubricate the proximal part of the tube with lidocain jelly and push
• ask the patient to swallow, the tube is now in the stomach..

Endotracheal tubes
A tracheal tube is inserted into the trachea for the primary purpose of establishing and
maintaining a patent airway and to ensure the adequate exchange of oxygen and carbon
dioxide

Indications
• Assisted ventilation
• Isolate trachea to permit control of airway
• Direct route of suctioning
• Administration of medication via ETT
• Inserted ETT should lie at least 5cm above the carina
• Carina usually at the level ofT4
• The tip may change by 2cm with flexion and extension

Tracheostomy tube Indication

• Airway obstruction at or above level of larynx
• Respiratory failure
• Paralysis of muscle that effect swallowing or respiration
• The tip lies between stoma and carena
• Tip placement not effected by flexion and extension

Catheter and lines

 
  
A catheter is a hollow flexible tube that can be inserted into a body cavity, duct or vessel.
Catheters thereby allow injection of fluids , distend a passageway or provide access by
surgical instruments.
The process of inserting a catheter is called catheterization .

Catheters can be broadly classified Under these groups DIAGNOSTIC CATHETERS

• Used for Angiographs GUIDING CATHETERS
• Used for Angioplasty
• Guiding catheters are like angiography catheters only difference is that guiding
catheters are more stiffer & firm as it carries Balloon catheters, PTCA wires and stent
delivery system.
• Mild stiffness comes due to the wire braided design.

Butterfly Catheters
It is a device specialized for vein puncture: i.e for accessing a superficial vein for either
intravenous injection or for fluid maintain

Foley ’s Catheters
A Foley catheter is a thin, sterile tube inserted into the bladder to drain urine. It can be left in
place in the bladder for a period of time, it is also called an indwelling catheter
• Used to collect uncontaminated urine specimen
• Urine output monitoring
• Managing urination during surgery
• Before and after cesarean sections
• On patients who are in anesthesia or sedated

Central venous catheters

• Used in critically ill patients for venous access
• To measure central venous pressure and intravascular blood volume

Percutaneous intravascular Central catheters PICC

• It is used for long term access
• It is small in size
• It is inserted through antecubital vein
• The tip lie with in superior vena cava

Pulmonary artery catheter

 
  
• Also known as Swann-ganz catheter
• It is inserted into the pulmonary artery
• Its purpose is diagnostic, it is used to detect heart failure and monitor therapy
• The pulmonary artery catheter allows direct measurement of pressures in the right
atrium, right ventricle, pulmonary artery, and wedge pressure.

CLINICAL SCENARIO:

NURSING HEALTH HISTORY

A. Patient’s Profile
Name: Patient PIP
Birthday: September 10, 1961
Age: 62 years old
Sex: Male
Nationality: Filipino
Religion: Roman Catholic
Marital Status: Married
Address: Meycauayan, Bulacan
Date of Admission: August 20, 2020
Time of Admission: 10:00 PM

Chief Complaint: Shortness of breath

Admitting Diagnosis: Acute Respiratory Distress Syndrome

History of Present Illness

Third (3rd ) post-op day, the patient began to complain of not feeling right. One (1) hour prior to
trans out to ICU, the patient began to complain of severe shortness of breath, labored, and
unusually rapid breathing. The vital signs was taken BP 60/40, HR 160, RR 35, Temp 38.8,
and SPO2 89. ABG were ordered with the following results: PH 7.3, PCO2 46 mmHg, PO2 104
mmHg, HCO3 22. Hence, the patient was transferred to ICU.

 
  

Past Medical History

The patient has undergone Anterior colon resection for rectal polyps 3 days ago. (July 1,
2020). The patient had an uneventful post-op course with no unusual complaint in the private
ward.

Family History

(-) Hypertension
(-) Diabetes Mellitus
(-) Cancer

Personal and Social History

The patient is a 47-pack-year smoker. He consumes two (2) bottles of beer twice a week. He
prefers to eat rice, fish, and vegetables. He enjoys his leisure time in gardening. He gets along
with his neighbors pretty well. He likes going to his friends on walking. He is a sweet and loving
husband.

Admission Order

The patient was transferred to ICU on Aug 20, 2020, at 10:00 pm with a chief complaint of
severe shortness of breath, labored and unusually rapid breathing. The patient was hooked to
a 500 ml bolus of normal saline. Dopamine 3-5 mcg/kg/min. Vancomycin 1 gm IV every 12
hours, Methylprednisolone 125 mg every 6 hours, Paracetamol 300mg TIV PRN for fever. The
patient was intubated and hooked to the mechanical ventilator in synchronized mandatory
ventilation mode was initiated with the following set up; FIO 90%, SIMV rate 6, Tidal volume
800 ml. Pulmonary artery catheter was inserted – PAWP was 12mm Hg,
FIO2 was increased from 90-100%, RR 16, PEEP 5cm H2 O was added.

After 2 hours ABG was done, with the following result PH 7.42, PCO2 46, PO2 75.2 mmHg,
HCO3 28.9. The ventilator setting was not changed. He was given several boluses of normal
saline and continue to receive dopamine infusion. And a portable chest x-ray was ordered.

Bedside care implemented to the patient that includes proper positioning, bedsore precaution,
turning the patient side to side at least every 2 hours, I&O monitoring, suctioning of secretions

 
  
prn, close monitoring of vital signs, LOC, and neurologic status, monitoring of fever, spasm
and hypotensive episodes.

The patient was also provided an oxygen therapy via an endotracheal tube connected to a
mechanical ventilator, cardiac monitor and pulse oximeter was attached to the patient, NGT,
and Indwelling catheter is placed to the patient.

Day 5 post-op
PEEP was increased to 10cm H2O and the Tidal Volume increased to 100. Vitals BP 130/60,
HR 120, RR 10, T 38.3. ABG result was PH 7.43, PCO2 46.2, PO2 86.8, HCO3 30.5.

After the ventilator changes, the patient’s oxygen levels gradually stabilized. The patient
weaned from ventilator support. The urinary output increased significantly after the fluid
boluses. 10 days after intubation, the patient was extubated and received oxygen by nasal
cannula.

Care of Clients

Pharma
Drug 1- Dopamine
Drug 2- Vancomycin
Drug 3 - Methylprednisolone
Drug 4 - Paracetamol

To facilitate the practice of students’ web navigation skills, the following rules must be
implemented:

1. The use of search engines (e.g. Google, Yahoo) are allowed.

2. Use navigation techniques as mentioned in the required readings.
3. Students must submit this accomplished worksheet through email or Canvas upload.

 
  

1. Conceptualize the pathophysiological alterations related to the case.

ü Trace the pathophysiological changes and highlight problems that are
experienced by the client.
ü Connect the pertinent nursing care and medical – surgical management to the
various signs and symptoms presented by the client.

     
     
1. Intrinsic  Factors     1. Patient   1. Extrinsic  Factors    

2. Make a care plan for 2 priority nursing problems identified.

3. Make a drug study of the medication prescribed to the patient to include; dosage,
action, classification, indication, contraindication, mechanism of action, common side-
effects, and nursing considerations.

 
  

Berman, Snyder & Frandsen. (2016). Kozier & Erb’s Fundamentals of Nursing. (10th ed.).
Pearson
Lewis & Bucher. ((2017). Medical-Surgical Nursing: Assessment and management of Clinical
Problems. (10th ed.). C & E
Linton. (2020). Medical-Surgical Nursing. (7th ed.). ELSMoore. (2018). Brunner & Suddarth’s
Textbook of Medical-Surgical Nursing.(14th ed.). Wolters Kluwer
Silvestri, L.A. (2018). Saunders Q & A Review for the NCLEX-RN Examination, 7th ed.
Missouri: Elsevier

https://www.slideshare.net/rsmehta/3-monitoring-amp-devices-used-in-icu-ccu-53533107
https://www.slideshare.net/rsmehta/1-critical-care-53532785
https://www.slideshare.net/AnilKumarGowda/nursing-management-of-critically-ill-patient-in-
intensive-care-units