ICU 2:1 is the recommended nurse-to-patient ratio in an ICU

Graphic sheet is not an essential component of critical

Interventions that should be implemented to prevent
care documentation
ventilator-associated pneumonia (VAP)?
Pulse oximetry is the most common method of
- Elevating the head of the bed to at least 30 degrees
monitoring oxygenation
- Providing oral care with chlorhexidine solution
Suctioning the airway immediately if a patient in the ICU
- Regularly changing the ventilator circuit
develops an airway obstruction
Level of consciousness is the assessment that should be
performed continuously in patients receiving sedation DIALYSIS
in the ICU.
Regular oral care with chlorhexidine solution is the most CHRONIC KIDNEY DISEASE
effective intervention for reducing the risk of VAP.
Infection is most common complication associated with  Several or gradual decrease of
central line placement FUNCTIONS OF KIDNEY:
Uncertainty about patient prognosis is the primary
source of stress for families of patients  Waste removal
VAP is the most common type of infection acquired by - form of drugs, urea, creatinine
patients  Water balance
Sterile technique is used when performing endotracheal - enough water in plasma
suctioning  Electrolyte balance
Heart failure is considered a contraindication for - potassium, phosphate, calcium
noninvasive positive pressure ventilation (NPPV)  Acid-base balance
Administering intravenous fluids is the first intervention  Hormone
when a patient develops a sudden decrease in blood - erythropoietin, vitamin D enzymes
pressure.
CHARACTERISTICS OF CKD:
Creatinine is most commonly monitored laboratory
values to assess renal function in critically ill patients  Decrease in renal function
Pneumonia is most common condition associated with  > 3 months
acute respiratory distress syndrome (ARDS)  Decline in filtration of glomerular filtration rate
Droplet transmission is the primary mode of (<90)
transmission for VAP  Decrease EPO -> decrease RBC
Ensuring a patent airway is the priority intervention = anemia, risk of bleeding
when caring for a patient with a traumatic brain injury.  Decrease vitamin D -> Hypocalcemia
Hypoglycemia requires immediate intervention. = bone problems (brittle)
Performing synchronized cardioversion is the priority  Increase renin -> Hypertension
intervention when providing care for a patient = high risk for kidney injury
experiencing a life-threatening arrhythmia.  Homeostasis -> increase waste
Monitoring cardiac output is not included in the initial = electrolyte, hormones, fluid imbalance
management of a patient with severe sepsis.
Improve gas exchange is the primary goal of mechanical CAUSE:
ventilation  HYPERTENSION
Pressure ulcers is the complication associated with - there is thickening of vessel walls called
prolonged immobilization of patients hyaline arteriosclerosis which leads to low
Sucralfate is commonly administered to prevent gastric oxygen delivery and also ischemia/necrosis
ulcers in critically ill patients where it triggers the protector Transforming
To provide specialized care for critically ill patients is the Growth Factor that activates fibrosis.
primary purpose of an intensive care unit (ICU) Glomerulus sclerosis is the process that results
Intensivist is the personnel responsible for overall to decrease GFR.
management and coordination of patient care in the
ICU
  DIABETES
- causes a lot of glucose combines with proteins
and lipids in the bloodstream which results to
nasty pro-inflammatory molecules called non-
enzymatic glycation. It affects afferent arteriole
and may result to hyaline arteriosclerosis or
atherosclerosis that will cause increased back
pressure to increase GFR which triggers the
mesangial cells to decrease the GFR.
 GLOMERULONEPHRITIS
- common in autoimmune diseases. Antibody-
antigen complex deposits in glomerular
basement membrane which results to
inflammation and destructive lesions.
 POLYCYSTIC KIDNEY DISEASE
- gene defects that causes cysts that compress
renal vessels. It leads to reduction of oxygen
level to ischemia/necrosis and reduction to GFR
which may lead to hypertension and to
decrease GFR.
 NSAIDS
- inhibits the prostaglandins I2 and E2 that helps
pump blood and have good filtration. It results
to decrease vasodilation, GBF and GFR.
 ACUTE KIDNEY INJURY
- doesn’t heal and is progressive or continuous,
or frequent acute kidney injury leads to CKD.
DIAGNOSIS:
 Decreased GFR (normal: 125ml/min)
Diagnostic test: creatinine and cystatin C
Severity or Staging
o I – >90
o II – 60-89
o III – 30-59
o IV – 15-29
o V – <15
 Albuminuria
Diagnostic test: urine albumin to creatinine
ratio
Severity or Staging
o Mild – ACR <30
o Moderate – 30-299 (micro)
o Severe – >300 (macro)
 Renal Ultrasound
- for positive kidney disease
 Renal Biopsy + Serology
- for glomerulonephritis
Biopsy – take a piece to know presence of
glomerulonephritis
Serology – check ANA + rheumatoid arthritis to
know what kind of glomerulonephritis
 Additional Labs
- BMP + phosphate, CBC, ABG, Lipid panel
TREATMENT:
 Decrease progression of disease
Hypertension – ace inhibitors, angiotensin
receptor blocker, potassium sparing diuretics,
loop diuretics
Diabetes – insulin, anti-diabetic drugs, weight
loss
Glomerulonephritis – steroids, DMARDs (early
detection)
Polycystic Kidney Disease – renal transplant
Discontinue Nephrotoxins
 Decrease complication
- Renal placement therapy
Hyperkalemia – insulin, SABA, diuretics
PATHOPHYSIOLOGY
 Electrolyte Abnormalities
Reduction in GFR -> Less filtration of potassium
and phosphate -> Increase in potassium and
phosphate
________________
Decrease hydroxylase enzyme -> Decrease in
vitamin D production -> Hypocalcemia (reduced
calcium absorption)
 Water Imbalance
Reduction in GFR -> Decrease water filtration ->
increase in water retention (pulmonary edema,
hypertension, and peripheral edema) -> dump
protein in urine (albuminuria) -> increase
albuminuria -> decrease albumin in blood
 Uremia
-removal of waste products/drugs
Building up of urea -> azotemia:
- encephalopathy: asterixis, seizures,
comatose
- uremic pericarditis: lots of fluid and
inflammation in pericardium
- uremic frost: leaks into sweat glands that are
crystalized
- platelet dysfunction: not sticky enough that
may cause bleed
 Hormonal Imbalance
Decreased erythropoietin -> unable to stimulate
 red bone marrow -> decrease in RBC production
maturation -> anemia of chronic disease
(immature RBC)
_____________________
Reduction in GFR -> increase activity of inner
angiotensin aldosterone -> increase angiotensin
II -> increase vasoconstriction -> increase in
blood pressure
 Metabolic Acidosis
Decreased alpha intercalated cells -> decreased
secretion of protons in urine -> increase of
proton in the blood -> decrease bicarb
reabsorption -> reduces ph -> metabolic
acidosis
 Albumin Regulation
Decreased albumin in the blood -> 3rd spacing of
fluid -> liver increase protein production
(lipoprotein) -> increase in triglycerides and LR
HEMODIALYSIS
 Take blood, dialyze, clean, and remove all
wastes, then pump blood
 3 sessions per week
 3-5 hours
VASCULAR ACCESS
 Radio cephalic Fistula – vein and artery together
 Forearm Loop Graft – vein and artery with
synthetic vein artery vessel
 Central Venous Catheter – temporary
ASSESS: pale, tingling, pulse, capillary refill, pain
PRE-PROCEDURE
 Consent
 Assess access
 Vital signs, labs, weight
 Hold medications: ace inhibitors, angiotensin
receptor blocker, beta blockers, calcium
channel blockers, diuretics, vasodilators,
antibiotics, vitamin C and B, folic acid
INTRA-PROCEDURE
 Constant assessment: VS and Labs, Neuro
changes (nausea and muscle cramp)
 Machine: rate, flow, and meds (heparin,
anticoagulant (hemorrhage), protamine sulfate
POST-PROCEDURE
 Take needles out, wrap with light pressure if
site is not bleeding 30 mins, talk to physician
 Compare: VS, Labs, and Weight
 Inform date to come back and other procedures
COMPLICATIONS
 Vascular Access
- loss of access due to clots forming due to
anticoagulants, stenosis due to constrictive
clothing or jewelry or constant compression,
lifting heavy objects (>5lbs)
- thrombosis, stenosis, tear
 Infection
- access infection
- underlying infection
 Bleeding, Hemorrhage, Hypotension
- bleeding in access point
- hypotension -> change rate
administer fluids -> no response -> call
physician
 Nausea/Vomiting
- give antiemetics
 Disequilibrium Syndrome
- 1st session – cerebral edema/ increase in
intracranial pressure
- mental status – confusion, loss of
consciousness, and seizure
DELIVERY ROOM
POSTPARTUM BLEEDING
 Post Partum
- It begins immediately after the birth, and lasts
for a culturally variable length: typically for one
month or 30 days, up to 40 days, two months or
100 days.
 Bleeding
- is the loss of blood, inside or outside the body.
A hemorrhage is severe bleeding.
 Placenta accreta
- is a serious pregnancy condition that occurs
when the placenta grows too deeply into the
uterine wall.
 Complete placenta previa
- The placenta completely covers the cervix
 Partial placenta previa
- The placenta is partly over the cervix.
 Marginal placenta previa
- The placenta is near the edge of the cervix.
 Placenta abruptio
- the placenta partially or completely detaches
itself from the uterine wall before delivery.
 Hysterectomy
- is an operation to remove the uterus. This
surgery may be done for different reasons
 Laparotomy
- is a surgical incision into the abdominal cavity.
 Intrahepatic cholestasis of pregnancy
- commonly known as cholestasis of pregnancy,
is a liver condition that occurs in late pregnancy
 Eclampsia
- a condition in which one or more convulsions
occur in a pregnant woman suffering from high
blood pressure, often followed by coma and
posing a threat to the health of mother and
baby.
 Preeclampsia
- is a pregnancy complication characterized by
high blood pressure and signs of damage to
another organ system, most often the liver and
kidneys. Preeclampsia usually begins after 20
weeks of pregnancy in women whose blood
pressure had been normal.
 Thrombin
- is a coagulation factor used to stop bleeding
during surgery. Once converted from
prothrombin, thrombin converts fibrinogen to
fibrin, which, in combination with platelets from
the blood, forms a clot. red blood cells produce
thrombin through the meizothrombin pathway.
 Atony of the uterus, also called uterine atony
- is a serious condition that can occur after
childbirth. It occurs when the uterus fails to
contract after the delivery of the baby
POSTPARTUM HEMORRHAGE
 Postpartum hemorrhage (PPH) is severe
bleeding after giving birth. It's a serious and
dangerous condition. PPH usually occurs within
24 hours of childbirth, but it can happen up to
12 weeks postpartum. When the bleeding is
caught early and treated quickly, it leads to
more successful outcomes.
 Postpartum hemorrhage is when the total blood
loss is greater than 32 fluid ounces after
delivery, regardless of whether it’s a vaginal
delivery or a Cesarian section, or C-section, or
when bleeding is severe enough to cause
SYMPTOMS
symptoms of too much blood loss or a
significant change in heart rate or blood
pressure.
 Traditionally, postpartum hemorrhage (PPH)
has been defined as greater than 500 mL
estimated blood loss associated with vaginal
delivery or greater than 1000 mL estimated
blood loss associated with cesarean delivery.
 Postpartum hemorrhage occurs in about 1% to
10% of pregnancies.
CAUSE
 After the placenta is delivered, these
contractions help compress the bleeding
vessels in the area where the placenta was
attached. If the uterus does not contract
strongly enough, called uterine atony, these
blood vessels bleed freely and hemorrhage
occurs. This is the most common cause of
postpartum hemorrhage.
 The causes of postpartum hemorrhage are
called the four Ts (tone, trauma, tissue and
thrombin).
 Uterine atony: Uterine atony (or uterine
tone) refers to a soft and weak uterus after
delivery. This is when your uterine muscles
don’t contract enough to clamp the
placental blood vessels shut. This leads to a
steady loss of blood after delivery.
 Uterine trauma: Damage to your vagina,
cervix, uterus or perineum (area between
your genitals and anus) causes bleeding.
Using instruments like forceps or vacuum
extraction during delivery can increase your
risk of uterine trauma. Sometimes, a
hematoma (collection of blood) can form in
a concealed area and cause bleeding hours
or days after delivery.
 Retained placental tissue: This is when the
entire placenta doesn't separate from your
uterine wall. It’s usually caused by
conditions of the placenta that affect your
uterus’s ability to contract after delivery.
 Blood clotting condition (thrombin): If you
have a coagulation disorder or pregnancy
condition like eclampsia, it can interfere
with your body’s clotting ability. This can
make even a tiny bleed uncontrollable.
  Uncontrolled bleeding.
 Increased heart rate.
 Decrease in the red blood cell count
(hematocrit)
 Swelling and pain in tissues in the vaginal and
perineal area, if bleeding is due to a hematoma.
 Symptoms of a drop in blood
pressure like dizziness blurred vision or
feeling faint.
 Worsening abdominal or pelvic pain.
 Nausea or vomiting.
 Pale or clammy skin.
LIFE-THREATENING CONDITIONS
 can happen after giving birth include infections,
blood clots, postpartum depression and
postpartum hemorrhage. Warning signs to
watch out for include chest pain, trouble
breathing, heavy bleeding, severe headache and
extreme pain.
TYPES OF PPH
 Primary postpartum hemorrhage occurs within
the first 24 hours after delivery.
 Secondary or late postpartum hemorrhage
occurs 24 hours to 12 weeks postpartum.
DIAGNOSIS
 Healthcare providers diagnose postpartum
hemorrhage through visual and physical
examinations, lab tests and a thorough review
of your health history.
 They may detect postpartum hemorrhage based
on the amount of blood you’ve lost. Measuring
the volume of collected blood and weighing the
blood-soaked pads or sponges from delivery is
one common way to approximate blood loss.
Other methods to diagnose PPH are:
 Continual monitoring of your pulse rate
and blood pressure to detect problems.
 Blood tests to measure red blood cells
(hematocrit) and clotting factors.
 Ultrasound to get a detailed image of your
uterus and other organs
TREATMENTS
Healthcare providers treat PPH as an emergency in most
cases. Stopping the source of the bleeding as fast as
possible and replacing blood volume are the goals of
treating postpartum hemorrhage.
Some of the treatments used are:
 Uterine massage to help the muscles of your
uterus contract.
 Medication to stimulate contractions.
 Removing retained placental tissue from your
uterus.
 Repairing vaginal, cervical and uterine tears or
lacerations.
 Packing your uterus with sterile gauze or tying
off the blood vessels.
 Using a catheter or balloon to help put pressure
on your uterine walls.
 Blood transfusion., In rare cases, or when other
methods fail, may perform a laparotomy or
a hysterectomy
POTENTIAL COMPLICATIONS
 Excessive blood loss can cause several
complications like increased heart rate, rapid
breathing and decreased blood flow. These
symptoms can restrict blood flow to your liver,
brain, heart or kidneys and lead to shock. In
some cases, Sheehan’s syndrome (a condition
of the pituitary gland is seen after postpartum
hemorrhage).
 Sheehan's syndrome is a condition that affects
women who lose a life-threatening amount of
blood in childbirth or who have severe low
blood pressure during or after childbirth, which
can deprive the body of oxygen. This lack of
oxygen that causes damage to the pituitary
gland is known as Sheehan's syndrome.
RISK FOR PPH
 Those with placental problems like placenta
accreta, placenta previa, placental
abruption and retained placenta are at the
highest risk of PPH.
 An overdistended uterus also increases the risk
for PPH. This is when your uterus is
overstretched from:
  Multiple pregnancies. NURSING ASSESSMENT

 Having twins, triplets or more.  Assess the amount of bleeding.

 Assess maternal vital signs to establish baseline
 Birthing a large baby (9 pounds or more).
data.
 Too much amniotic fluid. - Assess for signs of shock.
- Cool, clammy skin.
 High blood pressure or preeclampsia - Pale or ashen skin.
 Infection. - Bluish tinge to lips or fingernails (or gray in the
case of dark complexions)
 Blood clotting disorders or other blood-related - Rapid pulse.
conditions. - Rapid breathing.
- Nausea or vomiting.
 Hemophilia. ...
- Enlarged pupils.
 Liver Disease. ... - Weakness or fatigue.
 Assess the condition of the uterus. (FIRM OR
 Vitamin K deficiency. ...
NOT)
 Platelet dysfunction. NURSING DIAGNOSIS
 Intrahepatic cholestasis of pregnancy (ICP).  Deficient fluid volume related to excessive
 Anemia. bleeding after birth.

 Obesity. NURSING INTERVENTIONS

 Advanced maternal age.
 A history of five or more previous deliveries.
PREVENTION
 is to identify those at high risk for postpartum
hemorrhage before delivery. This is dependent
on you sharing your complete medical history
and symptoms with your healthcare provider.
Routinely giving medications like oxytocin at the
time of delivery to help your uterus contract is
also important. Ensuring adequate iron intake
and red blood cell levels during pregnancy can
minimize the impact of postpartum hemorrhage
should it occur.
RECOVER
 is different for everyone. Recovering from a
postpartum hemorrhage depends on the
severity of blood loss and how your healthcare
provider treated it. Be sure to take care of
yourself in the days following delivery — eating
healthy, drinking lots of water and resting as
much as possible. Your healthcare provider may
recommend an iron supplement to help with
anemia.
 Save all perineal pads used during bleeding and
weigh them to determine the amount of blood
loss.
 Place the woman in a side lying position to
make sure that no blood is pooling underneath
her.
 Assess lochia frequently to determine if the
amount discharged is still within the normal
limits.
 Assess vital signs, especially the blood pressure
EVALUATION
 Maternal blood pressure is higher than 100/60
mmHg.
 Pulse rate is within the normal range of 60-100
beats per minute.
 Flow of lochia is less than a saturated pad per
hour.