GENERAL MANAGEMENT IN ICU

Outline Management

Nursing Care Infection Control Sedation and analgesia Physiotherapy (problem of immobility) Communication Monitoring

Nursing Care
Maintain ICU chart
BP, PR, RR, Temp, CVP, ABG, Ventilator settings, IO chart, Pupil size, Sedation score, IV infusion of therapeutic medication, Blood glucose level. Personal hygiene, nutrition, bowel and bladder care Nursing care of unconscious patient Administration of prescribe medication Implementation of ICU protocols Assist pt to orientate to time, place and person Reassurance especially when painful procedure is planned Frequent turning to prevent sores and DVT Limb physiotherapy to prevent disuse atrophy Chest physiotherapy

General nursing

Communication with patient

Physiotherapy

Infection Control
Prevent ventilator associated pneumonia by VAP prevention control or ventilator bundle protocol
Hand wash with soap or rub hand alcohol before and after touching patient or equipments + use disposable gown and gloves

Nosocomial infection
Aseptic technique during inserting arterial lines and central venous catheter to prevent catheter related blood stream infection

Change catheter (CBD) appropriately to prevent catheter related UTI

Sedation and Analgesia

Need sedation due to artificial ventilator or other painful procedure ex: chest tube & to avoid post-traumatic stress disorder
To facilitate patient ventilator synchrony and to reduce oxygen consumption during critical period

Use of BZD such as Midazolam is commonly use; can be use alone or combine with Morphine
Other drug: Fentanyl, Propofol and Dexmedetomidine (Precedex)

Use of muscle relaxant is UNCOMMON in ICU but it is use in mx of tetanus, uncontrolled high ICP and severe ARDS
Provide adequate pain relief for patient esp in trauma and post surgical patient.

Riker Sedation Scale

7 Dangerous Agitation Very Agitated Agitated Calm and Cooperative Sedated Very Sedated Unarousable Pulling at endotracheal tube (ETT), trying to remove catheters, climbing over bedrail, striking at staff, thrashing side-to-side. Does not calm down despite frequent verbal reminding of limits, requires physical restraints, biting ETT. Anxious or mildly agitated, attempting to sit up, calms down to verbal instructions. Calm, awakens easily, follows commands. Difficult to arouse, awakens to verbal stimuli or gentle shaking but drifts off again, follows simple commands. Arouses to physical stimuli but does not communicate or follow commands, may move spontaneously. Minimal or no response to noxious stimuli, does not communicate or follow commands.

6 5 4 3 2 1

Ramsay Sedation Scale

1 Patient is anxious and agitated or restless, or both 2 Patient is co-operative, oriented, and tranquil 3 Patient responds to commands only 4 Patient exhibits brisk response to light glabellar tap or loud auditory stimulus 5 Patient exhibits a sluggish response to light glabellar tap or loud auditory stimulus 6 Patient exhibits no response

Over sedation
Result: increased time being ventilated, an increased time in the intensive care unit, and an increased cost of care

Under sedation
Result: increased production of endogenous catecholamines increase in BP, heart rate and myocardial oxygen consumption

Complication: respiratory depression, prolong the weaning process