Table of Contents

Cover

Title page

Copyright page

Foreword

Preface

Contributors

1 Recognition and Management of the Deteriorating Patient

LEARNING OBJECTIVES

INTRODUCTION

PREVENTION OF IN-HOSPITAL ADVERSE EVENTS

CLINICAL SIGNS OF DETERIORATION

TRACK-AND-TRIGGER SYSTEMS

EARLY WARNING SCORING SYSTEMS

ROLE OF RAPID RESPONSE TEAMS: OUTREACH AND MEDICAL EMERGENCY TEAMS

CLINICAL HANDOVER

CLASSIFICATION AND PROVISION OF CRITICAL CARE

TRAINING HEALTHCARE STAFF

CONCLUSION

2 Assessment of the Critically Ill Patient

LEARNING OBJECTIVES

INTRODUCTION

ABCDE APPROACH

INITIAL APPROACH TO THE PATIENT

ASSESSMENT OF AIRWAY

ASSESSMENT OF BREATHING

ASSESSMENT OF CIRCULATION

ASSESSMENT OF DISABILITY

EXPOSURE

CONCLUSION

3 Monitoring Respiratory Function

LEARNING OBJECTIVES

INTRODUCTION

ASSESSMENT OF THE EFFICACY OF BREATHING, WORK OF BREATHING AND ADEQUACY OF VENTILATION

COMPREHENSIVE ASSESSMENT OF THE BREATHLESS PATIENT

ASSOCIATED SYMPTOMS OF DYSPNOEA

MEASUREMENT OF PEAK EXPIRATORY FLOW RATE

PULSE OXIMETRY

ARTERIAL BLOOD GAS ANALYSIS

PRINCIPLES OF CAPNOGRAPHY

MONITORING PRIORITIES OF A VENTILATED PATIENT

MONITORING THE PATIENT RECEIVING NON-INVASIVE VENTILATION

PRINCIPLES OF MONITORING A PATIENT WITH A CHEST DRAIN

PRINCIPLES OF MONITORING THE PATIENT WITH A TEMPORARY TRACHEOSTOMY

SCENARIOS

CONCLUSION

4 Monitoring Cardiovascular Function 1: ECG Monitoring

LEARNING OBJECTIVES

INTRODUCTION

COMMON FEATURES OF A CARDIAC MONITOR

SETTING UP ECG MONITORING

POTENTIAL PROBLEMS WITH ECG MONITORING

THE ECG AND ITS RELATIONSHIP TO CARDIAC CONTRACTION

SYSTEMATIC APPROACH TO ECG INTERPRETATION

DEFINITION AND CLASSIFICATION OF CARDIAC ARRHYTHMIAS

RECOGNITION OF IMPORTANT ARRHYTHMIAS

CONCLUSION

5 Monitoring Cardiovascular Function 2: Haemodynamic Monitoring

LEARNING OBJECTIVES

INTRODUCTION

FACTORS AFFECTING TISSUE PERFUSION

SHOCK

NON-INVASIVE METHODS OF HAEMODYNAMIC MONITORING

GENERAL PRINCIPLES OF MONITORING WITH TRANSDUCERS

PRINCIPLES OF CENTRAL VENOUS PRESSURE MONITORING

PRINCIPLES OF PULMONARY ARTERY PRESSURE MONITORING

CARDIAC OUTPUT STUDIES

SCENARIOS

CONCLUSION

6 Monitoring Neurological Function

LEARNING OBJECTIVES

INTRODUCTION

DEFINITION OF CONSCIOUSNESS

AVPU ASSESSMENT

THE GLASGOW COMA SCALE

PUPILLARY ASSESSMENT

PRINCIPLES OF INTRACRANIAL PRESSURE MONITORING

METHODS OF ICP MONITORING

PRINCIPLES OF MONITORING SEDATION

MONITORING PAIN AND PAIN RELIEF

CONCLUSION

7 Monitoring Renal Function

LEARNING OBJECTIVES

INTRODUCTION

PRINCIPLES OF URINALYSIS

URINE OUTPUT MONITORING

MONITORING FLUID BALANCE

MANAGEMENT OF ACUTE RENAL FAILURE

MONITORING DURING RENAL REPLACEMENT THERAPY

CONCLUSION

8 Monitoring Gastrointestinal Function

LEARNING OBJECTIVES

INTRODUCTION

ASSESSMENT OF BOWEL FUNCTION

MONITORING STOMAS AND FISTULAS

ACUTE UPPER GASTROINTESTINAL TRACT BLEEDING

ASSESSMENT OF INTESTINAL OBSTRUCTION

PRINCIPLES OF MONITORING PANCREATIC FUNCTION

CONCLUSION

9 Monitoring Hepatic Function

LEARNING OBJECTIVES

INTRODUCTION

FUNCTIONS OF THE LIVER

CAUSES OF ACUTE LIVER FAILURE

MONITORING THE SPECIFIC COMPLICATIONS OF ALF

CONCLUSION

10 Monitoring Endocrine Function

LEARNING OBJECTIVES

INTRODUCTION

PRINCIPLES OF MONITORING PITUITARY GLAND FUNCTION

PRINCIPLES OF MONITORING THE ENDOCRINE FUNCTION OF THE PANCREAS

PRINCIPLES OF MONITORING ADRENAL GLAND FUNCTION

PRINCIPLES OF MONITORING THYROID GLAND FUNCTION

PRINCIPLES OF MONITORING PARATHYROID GLAND FUNCTION

CONCLUSION

11 Monitoring Nutritional Status

LEARNING OBJECTIVES

INTRODUCTION

IMPORTANCE OF ASSESSING NUTRITIONAL STATUS

ASSESSMENT OF THE PATIENT’S NUTRITIONAL STATUS

FACTORS THAT CAN AFFECT NUTRITIONAL STATUS

PRINCIPLES OF MONITORING ENTERAL FEEDING

PRINCIPLES OF MONITORING TPN

CONCLUSION

12 Monitoring Temperature

LEARNING OBJECTIVES

INTRODUCTION

FACTORS INFLUENCING BODY TEMPERATURE

METHODS OF MEASURING TEMPERATURE

PHYSIOLOGICAL EFFECTS OF HYPOTHERMIA

MONITORING PRIORITIES OF A PATIENT WITH HYPOTHERMIA

PHYSIOLOGICAL EFFECTS OF HYPERTHERMIA

MONITORING PRIORITIES OF A PATIENT WITH HYPERTHERMIA

CONCLUSION

13 Monitoring Pain

LEARNING OBJECTIVES

INTRODUCTION

FACTORS INFLUENCING PAIN

METHODS OF ASSESSING PAIN

CONCLUSION

14 Monitoring a Patient Receiving a Blood Transfusion

LEARNING OBJECTIVES

INTRODUCTION

BLOOD COMPONENTS AND THEIR USES

IMPORTANCE OF PATIENT IDENTIFICATION

DOCUMENTATION, TRACEABILITY AND EQUIPMENT

MONITORING PRIORITIES IN A PATIENT RECEIVING A BLOOD TRANSFUSION

ADVERSE REACTIONS TO A BLOOD TRANSFUSION

CONCLUSION

15 Monitoring the Patient with Infection and Related Systemic Inflammatory Response

LEARNING OUTCOMES

INTRODUCTION

HOW INFECTION OCCURS AND THE RELATIONSHIP BETWEEN THE INFECTIOUS AGENT AND HOST

THE BODY’S DEFENCE MECHANISMS AGAINST INFECTION

THE SYSTEMIC INFAMMATORY RESPONSE SYNDROME

MONITORING A PATIENT WITH SIRS/SEPSIS

SCENARIOS

CONCLUSION

16 Monitoring the Critically Ill, Pregnant Patient

LEARNING OUTCOMES

INTRODUCTION

RELEVANT PHYSIOLOGICAL CHANGES THAT OCCUR DURING PREGNANCY

ACUTE ILLNESSES AND DEATHS ASSOCIATED WITH PREGNANCY

MONITORING THE CRITICALLY ILL PREGNANT PATIENT

SCENARIOS

CONCLUSION

17 Monitoring the Critically Ill Child

LEARNING OUTCOMES

INTRODUCTION

AETIOLOGY OF CARDIORESPIRATORY ARREST IN CHILDREN

IMPORTANCE OF TREATING CHILDREN DIFFERENTLY

ABCDE APPROACH

CONCLUSION

18 Monitoring During Transport

LEARNING OBJECTIVES

INTRODUCTION

REASONS FOR TRANSPORT

POTENTIAL PROBLEMS AND HAZARDS ASSOCIATED WITH TRANSPORT

PATIENT MONITORING EQUIPMENT REQUIRED FOR TRANSPORT

MONITORING DURING TRANSFER

CONCLUSION

ACKNOWLEDGEMENT

19 Record Keeping

LEARNING OBJECTIVES

INTRODUCTION

IMPORTANCE OF GOOD RECORD KEEPING

COMMON DEFICIENCIES IN RECORD KEEPING

PRINCIPLES OF GOOD RECORD KEEPING

IMPORTANCE OF AUDITING RECORDS

LEGAL ISSUES ASSOCIATED WITH RECORD KEEPING

CONCLUSION

Index

This edition first published 2012 © 2012 Blackwell Publishing Ltd

Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing program has been merged with Wiley’s global Scientific, Technical and Medical business to form Wiley-Blackwell.

Registered office: John Wiley & Sons, Ltd, The Atrium, Southern Gate,

Chichester, West Sussex, PO19 8SQ, UK

Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK

The Atrium, Southern Gate, Chichester, West Sussex, PO19

8SQ, UK

2121 State Avenue, Ames, Iowa 50014-8300, USA

For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell.

The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

Library of Congress Cataloging-in-Publication Data

Jevon, Philip.

 Monitoring the critically ill patient / Philip Jevon and Beverley Ewens ; consulting editor, Jagtar Singh Pooni. – 3rd ed.

p. ; cm.

 Includes bibliographical references and index.

 ISBN 978-1-4443-3747-1 (pbk. : alk. paper)

 I. Ewens, Beverley. II. Title.

 [DNLM: 1. Intensive Care–methods. 2. Monitoring, Physiologic–methods. 3. Critical Illness. WX 218]

 LC classification not assigned

 616.02’8–dc23

2011034244

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

 ISBN 9781118276136 (mobi)

 ISBN 9781118276143 (epdf)

 ISBN 9781118276150 (epub)

Foreword

In the current healthcare environment, there is increased emphasis placed on the early recognition and treatment of the acute and critically ill patient. There is certainly good reason for this, with approximately 80% patients who have a cardiac arrest audited in hospital displaying adverse signs prior to collapse. It is the responsibility of every nurse to be able to effectively monitor patients and understand the significance of what the observations are communicating to them regarding the patient’s condition, and what appropriate action needs to be taken. Nurses need to understand that fast and appropriate action can save lives.

This third edition builds on the success of the first two editions. The content has been completely revised to reflect current guidelines and practice. Five new chapters have been added (blood transfusion, infection, critically ill child, blood transfusion and pregnancy) making this a comprehensive guide to monitoring the critically ill patient. This book remains a valuable guide for healthcare staff.

I congratulate the authors on their achievement and I would particularly recommend this book to nurses working in critical care, high dependency care, coronary care, theatres, A & E and the acute ward environment, especially in the ever growing Acute Cardiac, Medical and Surgical Assessment areas.

Jacqui Daly (Mrs)

RN, BSc (Hons), ENB 124,998, 927 and N-14.

Matron and Specialist Practitioner in Cardiology

Preface

When we developed the first edition of this textbook in 2002, it was with high hopes that there would be at least one more edition and, despite no longer sharing the same continent, here we are with the third.

The book has undergone a complete revision with this edition, including the addition of many new chapters as well as extensive updating of existing ones. To ensure that this edition provides the reader with contemporaneous material, an integral component of each chapter is the inclusion of best available evidence, the most current trends in clinical practice and the latest recommendations from statutory and advisory bodies. As we both continue to work within, and be enthused by, critical care nursing, we are uniquely placed to witness and contribute to developments in practice at first hand.

This text is intended to be an aid to the novice critical care or ward nurse in a culture of accelerating ward acuity, as they embrace the challenges that this varied and stimulating specialty offers. It may also serve as a revision tool for the more experienced critical care nurse, keen to update on unfamiliar aspects of monitoring, included in this book.

The worldwide movement targeting improvements in patient outcomes, through the promotion of early identification of the patient at risk, has experienced no higher profile than it does today. It has been evident in the literature for many years that simple strategies, including accurate and appropriate monitoring, interpretation of resulting data, appropriate and timely patient management, in tandem with escalation of care where necessary, is the key to early identification of the deteriorating patient. We hope that this text not only provides readers with the knowledge and skills to contribute to this process but also entices them to explore further.

This book is dedicated to all the critical care patients for whom we have had the privilege to care, past, present and in the future.

Bev Ewens and Phil Jevon

June 2011

Contributors

Jayne Breakwell, RN, Child Dip HE, Paediatirc Sister, Paediatric Assessment Unit, Manor Hospital, Walsall Healthcare NHS Trust, Walsall, West Midlands, UK

Mandeep Dhanda,BSc (Hons), HPC registered Biomedical Scientist, Transfusion Practitioner, Blood Transfusion Department, Manor Hospital, Walsall Healthcare NHS Trust, Walsall, West Midlands, UK

Dan Higgins RGN, ENB998, ENB100, Senior Charge Nurse, Critical Care, University Hospitals Birmingham NHS Foundation Trust, Birmingham and Director, Healthcare Education & Skills Training (HEST).

1

Recognition and Management of the Deteriorating Patient

LEARNING OBJECTIVES

At the end of this chapter the reader will be able to:

discuss the importance of prevention of in-hospital adverse events

identify the clinical signs of impending or established deterioration

discuss the role of outreach and medical emergency teams

discuss the importance of education and training in relation to the deteriorating patient.

INTRODUCTION

Critically ill patients are not necessarily located within intensive care or high dependency units (ICU and HDU), but are frequently managed within ward areas. There is irrefutable evidence to confirm that early identification and timely management of the deteriorating patient, may negate the need for transfer to these units and ultimately improve outcomes (Jones et al. 2007; NICE 2007). The literature states that, antecedents to deterioration are present in up to 80% of patients before an adverse event, cardiac arrest, unplanned ICU admission or death occurs (Kause et al. 2004). This is postulated to be because of both the inability to either recognise deterioration, and/or to act on it promptly and appropriately, compounded by existing poor communication channels (Schein et al. 1990; Franklin and Matthew 1994). Nurses, by definition, are at the forefront of monitoring and recognising deteriorating patients which, in turn, relies on appropriate monitoring and accurate interpretation of findings, accompanied by timely action. If patients are permitted to progress without prompt and appropriate management, adverse events will occur with associated poor survival rates.

The aim of this chapter is to understand the recognition and management of the deteriorating patient.

PREVENTION OF IN-HOSPITAL ADVERSE EVENTS

In-hospital adverse events have been defined as an unintended injury or complication resulting in prolonged length of stay, disability or death, not attributed to the patient’s underlying disease process alone but by their health-care management (Baba-Akbari Sari et al. 2006; de Vries et al. 2007). The causes of this have been classified into three subthemes (NPSA 2007):

1. Failure to measure basic observations of vital signs

2. Lack of recognition of the importance of worsening vital signs

3. Delay in responding to deteriorating vital signs

The prevalence of adverse events has been estimated at between 3% and 17% of all hospital admissions, with resulting high human and financial costs (Baba-Akbari Sari et al. 2006). The most serious adverse events classified are unplanned admission to an ICU, cardiac arrest or death, 50% of which are estimated to be preventable (de Vries et al. 2007).

Survival to Discharge from In-Hospital Cardiopulmonary Arrest

In the UK, overall less than 20% of patients who have an in-hospital cardiopulmonary arrest survive to discharge (Meaney et al. 2010). These survival rates are also dependent upon the location and time of day at which they occur (Herlitz et al. 2002; Peberdy et al. 2008). Most of these survivors will have received prompt and effective defibrillation for a monitored and witnessed ventricular fibrillation (VF) arrest (Fig. ) or pulseless ventricular tachycardia (VT), caused by primary myocardial ischaemia (Resuscitation Council UK 2010). Survival to discharge in these patients is very good, even as high as 37%) (Meaney et al. 2010).

Lesen Sie weiter in der vollständigen Ausgabe!

Lesen Sie weiter in der vollständigen Ausgabe!

Lesen Sie weiter in der vollständigen Ausgabe!

Lesen Sie weiter in der vollständigen Ausgabe!

Lesen Sie weiter in der vollständigen Ausgabe!

Lesen Sie weiter in der vollständigen Ausgabe!

Lesen Sie weiter in der vollständigen Ausgabe!

Lesen Sie weiter in der vollständigen Ausgabe!

Lesen Sie weiter in der vollständigen Ausgabe!

Lesen Sie weiter in der vollständigen Ausgabe!

Lesen Sie weiter in der vollständigen Ausgabe!

Lesen Sie weiter in der vollständigen Ausgabe!

Lesen Sie weiter in der vollständigen Ausgabe!

Lesen Sie weiter in der vollständigen Ausgabe!

Lesen Sie weiter in der vollständigen Ausgabe!

Lesen Sie weiter in der vollständigen Ausgabe!

Lesen Sie weiter in der vollständigen Ausgabe!

Lesen Sie weiter in der vollständigen Ausgabe!

Lesen Sie weiter in der vollständigen Ausgabe!