Reyes, Sheila Mae B.

BSN 4

Union Christian College

 INTENSIVE CARE UNIT

The Intensive Care Unit (ICU) is a 24-hour service department designed to deliver the
highest level of medical and nursing care for acutely and critically-ill or -injured patients
requiring extensive monitoring and intensive nursing care.

ICU has 6 Cardiac, and 6 Medical/Surgical beds; 6 Special ICU (Isolation A and B)
beds; and 4 Pediatric beds. The Telemetry unit (TLM) has five intermediate care beds. Each
room in the ICU complex, including the nearby Acute Stroke Unit, is equipped with a top-of-the-
line multiparameter physiologic monitor linked to a centralized system with dedicated
monitoring personnel. The ICU operates on a 1:1 or 1:2 nurse to patient ratio, complemented by
senior-level on-site medical house staff at all times to ensure continuous high quality patient
care.

Previously, care for critically-ill pediatric patients has involved a team of Pediatric
Intensivist Physicians. Beginning in 2007, a semi-closed two-tier ICU model engaging Adult
Intensivist Physicians (co-managing with our traditional medical specialists) has been
institutionalized with great success. An intensivist is a doctor trained in critical care who can
handle the multiple, often interrelated, problems that happen when the body is shutting down
from infection or trauma. This model is currently being adopted by more hospitals in the
Philippines.

What is an intensive care unit (ICU)?

Intensive care refers to the specialised treatment given to patients who are acutely unwell and
require critical medical care.

An intensive care unit (ICU) provides the critical care and life support for acutely ill and injured
patients.  

Unless you are an emergency admission, you will need a referral from your doctor or specialist
to be admitted to ICU.
 Who is cared for in ICU?

Patients may have a planned admission following surgery, an unexpected admission after an
accident or be admitted because of a sudden and critical deterioration to their health.

ICU teams are multi-disciplinary, made up of highly skilled intensive care nurses, doctors and
specialists trained in providing critical care for patients with a variety of medical, surgical and
trauma conditions.

Some hospital ICUs specialise in providing care for particular health conditions or injuries
including:

 major trauma

 severe burns

 respiratory failure

 organ transplants

 complex spinal surgery

 cardiothoracic surgery.

What to expect in ICU

ICU is one of the most critically functioning operational environments in a hospital.

Every ICU in a hospital has a different environment that will reflect the specialist medical and
surgical procedures they perform.

Most ICUs are fairly large sterile areas with a high concentration of specialised, technical and
monitoring equipment needed to care for critically ill patients.

The ICU environment can be confronting for some patients and visitors who may find the
activity, sounds, machines, tubes and monitors intimidating.

When you visit someone you care about in ICU it can be an uncomfortable experience –  you
may feel helpless, overwhelmed, frustrated and sad. Your feelings and apprehension are
understood by the staff that provide support for the people you care about.
Typically ICU also has a higher ratio of doctors and nurses to patients.

ICU equipment

It can be a frightening and uncertain time for you, family and friends to see people you care
about being monitored and supported by machines.  

In ICU you will see many patients connected to a heart monitor, others will be supported with
breathing assistance from artificial ventilators, be on dialysis machines and receiving a variety of
intravenous infusions via tubes and drips.

Be prepared to see lots of lines, tubes, wires and monitoring equipment. Almost all ICU
equipment uses alarms to let staff know about a change in a patient’s condition. Not all
equipment alarms signal an emergency situation.

Visitors

Every ICU has a visitor policy to ensure the wellbeing of their patients. You will need to ask
ICU hospital staff about their specific visiting hours and requirements. 

Visiting is usually restricted to people the patient considers to be immediate family. 

If you are feeling unwell or have an existing health condition you should reconsider visiting ICU
or discuss your circumstances with ICU staff before you plan to visit.

Hygiene

As intensive care patients are very vulnerable to infections, it is important that visitors wash their
hands before entering ICU to prevent transferring infection.

Mobile phones

Mobile phones should be turned off in ICU as they may interfere with vital electrical equipment
supporting patients.

Gifts
Restrictions are in place to allow easy access to vital medical equipment and to patients.

If you are unsure what you can bring with you check with ICU staff before you plan to visit.

Patient and family support services

Counselling

Admission to ICU because of critical illness or accident can have a huge physical and emotional
impact on your life and your family.

Some ICUs have a dedicated counsellor to provide support for patients and their families. These
counsellors are highly experienced and have a thorough knowledge of ICU procedures.

Hospital counselling support services are also available at all major hospitals. 

Pastoral care

For many people, emotional and spiritual thoughts tend to surface when someone they care about
is in a critical condition in hospital. 

Many hospitals provide chaplaincy and pastoral counselling services for patients, families and
staff who need compassionate, professional and spiritual guidance and support. 

Some hospitals also have a non-denominational chapel available for times of reflection and
prayer. 

Interpreter service

An interpreter service is available for patients and families if English is not your first language.

These interpreters are specifically trained to interpret medical terms into other languages. It is
important that you use this service if you are having problems understanding doctors explaining
information or are being asked to provide consent for medical procedures.

Speak to ICU staff if you would like to use interpreting services.

 Costs of ICU

Your costs will depend on the procedures you need, time spent in ICU and the specialised care
you require.

CARDIAC MONITORING
    

A cardiac event monitor is a device that you control to record the electrical activity of your heart
(ECG). This device is about the size of a pager. It records your heart rate and rhythm.

Cardiac event monitors are used when you need long-term monitoring of symptoms that occur
less than daily.

How the Test is Performed

Each type of monitor is slightly different, but they all have sensors (called electrodes) to
record your ECG. In some models, these attach to the skin on your chest using sticky patches.
The sensors need good contact with your skin. Poor contact can cause poor results.

You should keep your skin free from oils, creams, and sweat (as much as possible). The
technician who places the monitor will perform the following to get a good ECG recording:

 Men will have the area on their chest shaved where the electrode patches will be placed.

 The area of skin where the electrodes will be attached will be cleaned with alcohol before the
sensors are attached.

You can carry or wear a cardiac event monitor up to 30 days. You carry the device in your hand,
wear on your wrist, or keep it in your pocket. Event monitors can be worn for weeks or until
symptoms occur.

There are several types of cardiac event monitors.

 Loop memory monitor. The electrodes remain attached to your chest, and the monitor
constantly records, but does not save, your ECG. When you feel symptoms, you press a button to
 activate the device. The device will then save the ECG from shortly before, during, and for a
time after your symptoms begin. Some event monitors start on their own if they detect abnormal
heart rhythms.
 Symptom event monitor. This device records your ECG only when symptoms occur, not before
they occur. You carry this device in a pocket or wear it on your wrist. When you feel symptoms,
you turn on the device and place the electrodes on your chest to record the ECG.
 Patch recorders. This monitor does not use wires or electrodes. It continuously monitors ECG
activity for 14 days using an adhesive patch that sticks to the chest.
 Implanted loop recorders. This is a small monitor that is implanted under the skin on the chest.
It can be left in place to monitor heart rhythms for 3 or more years.
While wearing the device:

 You should continue your normal activities while wearing the monitor. You may be asked to
exercise or adjust your activity level during the test.

 Keep a diary of what activities you do while wearing the monitor, how you feel, and any
symptoms you have. This will help your health care provider match symptoms with your monitor
findings.

 The monitoring station staff will tell you how to transfer data over the telephone.

 Your provider will look at the data and see if there have been any abnormal heart rhythms.

 The monitoring company or the provider who ordered the monitor may contact you if a
concerning rhythm is discovered.

While wearing the device, you may be asked to avoid certain things that can disrupt the signal
between the sensors and the monitor. These may include:

 Cell phones

 Electric blankets

 Electric toothbrushes

 High-voltage areas
 Magnets

 Metal detectors

Lead Placement for Cardiac Monitoring

Place the left arm (LA) electrode near the left shoulder, close to the junction of the left arm and
torso. Place the right leg (RL) electrode below the level of the lowest rib on the right abdominal
area. Place the left leg (LL) electrode below the level of the lowest rib on the left abdominal area.
What is an ECG?

An ECG stands for electrocardiogram. It is a tool used to detect a wide range of heart
dysrhythmias using waveforms on a monitor. It is used by healthcare providers regularly both in
the hospital and by EMS.

Why Is 12-Lead ECG Placement Important?

This is a big deal to me because I have on two occasions moved the someone else’s 12-lead ECG
placement and identified a STEMI that was not visible with the original placement. On the flip
side, recently I found a huge STEMI and when I got to the main heart hospital, the tech took my
leads, moved them down, and couldn’t see the STEMI.
It’s terrible patient care! These patients sit in the ED for hours while they wait for their lab work
to come back. Only then do they realize they’re having a heart attack. A lot of times this could be
avoided if the 12-lead was performed properly and the STEMI was identified on the first go-
around.
It takes literally less than 30 seconds to find the correct position for a 12-lead ECG
placement! By the way, did you know that if your electrodes are off by 2 centimeters that it can
completely skew your EKG morphology?

4-Lead Placement

Before we can get to placing our precordial leads, we need to know where our 4-lead goes. Ever
heard 4-leads referred to as “limb leads”? There’s a reason for that. These leads are not suppose
to go anywhere on the torso. It’s not as big of a deal if you’re only doing a 4-lead, but doing so
when you’re going to put the precordial leads on will alter the morphology of your EKG.
Limb leads can be placed on any part of the patient’s respective limbs. Just make sure the leads
are symmetrical. For example, don’t put one lead on the left shoulder and the other lead on the
right forearm. I’ve heard of one local doctor that preferred all 4 leads to be placed relatively
equal distances distally. For example, if you put leads on the wrists, then leads should also go on
the ankles. I haven’t found anything to back that, but that’s at least one professional’s theory.
The 12-lead ECG electrode placement is essential for paramedics and EMTs in both prehospital
and hospital setting as incorrect placement can lead to false diagnosis of infarction or negatively
change the EKG.

Proper 12-Lead ECG Placement

Now that we have our 4-leads straight, let’s talk about where your precordial leads will go.
Everyone slaps them on below the breast and sometimes below the entire rib cage. That is
completely unacceptable! Below is a bullet point list for each lead, a description of where they
go, and the order they should be applied.
ELECTRODE PLACEMENT

V1 4th Intercostal space to the right of the sternum

V2 4th Intercostal space to the left of the sternum

V3 Midway between V2 and V4

V4 5th Intercostal space at the midclavicular line

V5 Anterior axillary line at the same level as V4

V6 Midaxillary line at the same level as V4 and V5

RL Anywhere above the right ankle and below the torso

RA Anywhere between the right shoulder and the wrist

LL Anywhere above the left ankle and below the torso

LA Anywhere between the left shoulder and the wrist

Aside from a 12-lead ECG placement, there’s something
known as a 15-lead placement which includes placing
leads V4-V6 on the posterior side of the patient below
their left scapula (see below). When viewing the EKG
strip, V4-V6 on the strip will be referred to as V-13-15.
To clarify, leads will equal: V4=V7, V5=V8, and
V6=V9.

Lastly, a right sided 12-lead ECG placement allows you

to detect a right sided infarct. At a minimum, lead V4
should be placed on the 5th intercostal, mid-clavicular
(exact opposite of the regular left side placement) if an
inferior infarct was originally seen in leads II, III, and
AVF.

These give you more views of the heart and can help
inform your treatment plans. For instance, you never want
to give nitroglycerin if you see an inferior infarct until
after performing a right-sided EKG. You can view these
and other helpful diagrams.
 What Is the Glasgow Coma Scale?

The Glasgow Coma Scale (GCS) is the most common scoring system used to describe the
level of consciousness in a person following a traumatic brain injury. Basically, it is used to
help gauge the severity of an acute brain injury. The test is simple, reliable, and correlates
well with outcome following severe brain injury.

The GCS is a reliable and objective way of recording the initial and subsequent level of
consciousness in a person after a brain injury. It is used by trained staff at the site of an
injury like a car crash or sports injury, for example, and in the emergency department and
intensive care units.

The GCS measures the following functions:

Eye Opening (E)

 4 = spontaneous

 3 = to sound

 2 = to pressure

 1 = none

 NT = not testable

Verbal Response (V)

 5 = orientated

 4 = confused
 3 = words, but not coherent

 2 = sounds, but no words

 1 = none

 NT = not testable

Motor Response (M)

 6 = obeys command

 5 = localizing

 4 = normal flexion

 3 = abnormal flexion

 2 = extension

 1 = none

 NT = not testable

Clinicians use this scale to rate the best eye opening response, the best verbal response, and
the best motor response an individual makes. The final GCS score or grade is the sum of
these numbers.

Using the Glasgow Coma Scale

A patient's Glasgow Coma Score (GCS) should be documented on a coma scale chart. This
allows for improvement or deterioration in a patient's condition to be quickly and clearly
communicated.

Individual elements, as well as the sum of the score, are important. The individual elements
of a patient's GCS can be documented numerically (e.g. E2V4M6) as well as added together
 to give a total Coma Score (e.g E2V4M6 = 12). For example, a score may be expressed
as GCS 12 = E2 V4 M6 at 4:32.

Every brain injury is different, but generally, brain injury is classified as:

 Severe: GCS 8 or less

 Moderate: GCS 9-12

 Mild: GCS 13-15

Mild brain injuries can result in temporary or permanent neurological symptoms and
neuroimaging tests such as CT scan or MRI may or may not show evidence of any damage.

Moderate and severe brain injuries often result in long-term impairments

in cognition (thinking skills), physical skills, and/or emotional/behavioral functioning.

Limitations of the Glasgow Coma Scale

Factors like drug use, alcohol intoxication, shock, or low blood oxygen can alter a patient’s
level of consciousness. These factors could lead to an inaccurate score on the GCS.

Children and the Glasgow Coma Scale

The GCS is usually not used with children, especially those too young to have reliable
language skills. The Pediatric Glasgow Coma Scale, or PGCS, a modification of the scale
used on adults, is used instead. The PGCS still uses the three tests — eye, verbal, and motor
responses — and the three values are considered separately as well as together.

Here is the slightly altered grading scale for the PGCS:

Eye Opening (E)

 4 = spontaneous

 3 = to voice
 2 = to pressure

 1 = none

 NT = not testable

Verbal Response (V)

 5 = smiles, oriented to sounds, follows objects, interacts

 4 = cries but consolable, inappropriate interactions

 3 = inconsistently inconsolable, moaning

 2 = inconsolable, agitated

 1 = none

 NT = not testable

Motor Response (M)

 6 = moves spontaneously or purposefully

 5 = localizing (withdraws from touch)

 4 = normal flexion (withdraws to pain)

 3 = abnormal flexion (decorticate response)

 2 = extension (decerebrate response)

 1 = none

 NT = not testable

Pediatric brain injuries are classified by severity using the same scoring levels as adults, i.e.
8 or lower reflecting the most severe, 9-12 being a moderate injury and 13-15 indicating a
mild TBI. As in adults, moderate and severe injuries often result in significant long-term
impairments.
 REFERENCES

Cadogan, M. (2022, January 30). Retrieved from ECG Lead positioning: https://litfl.com/ecg-
lead-positioning/

Department Of Health. (n.d.). Retrieved from Intensive Care Units:

https://www.healthywa.wa.gov.au/Articles/F_I/Intensive-care-units-ICUs
Medline Plus. (2022, June 1). Retrieved from Cardiac event monitors:
https://medlineplus.gov/ency/article/007700.htm#:~:text=A%20cardiac%20event
%20monitor%20is,that%20occur%20less%20than%20daily.

Randazzo, A. (2016, June 1). Prime Medical Training. Retrieved from Guide To 12-Lead ECG
Placement: https://www.primemedicaltraining.com/12-lead-ecg-placement/

Teasdale G, A. D. (2018, February 13). Retrieved from What Is the Glasgow Coma Scale?:
https://www.brainline.org/article/what-glasgow-coma-scale