“Never let what you cannot do

interfere with what you can do”

CRITICAL CONDITIONS

Sherry L. Knowles, RN, CCRN, CRNI

OBJECTIVES1. Recognize the signs & symptoms of several

common (critical) medical conditions.

2. Describe the current treatment modalities of those common (critical) medical conditions.

3. Discuss the overall management of select (critical) medical conditions.

4. Identify the nursing interventions of several common (critical) medical conditions.

CRITICAL CONDITIONS

Respiratory

Failure

ARDS

Acute MI

CHF

CRITICAL CONDITIONS

GI Bleed

DKA

Shock

Sepsis

DEFINITION– A respiratory system that fails to maintain

adequate gas exchange.

– Acute loss of adequate oxygenation at the tissue level.

– PaO2 < 60 mmHg and/or PaCO2 > 50 mmHg @ 21% FiO2

In chronic hypercapnia: pH < 7.35

– Respiratory failure may be evidenced by a high or low pCO2 level.

RESPIRATORY FAILURE

TYPES OF FAILURE

– Hypercapnic Respiratory Failure is ineffective ventilation (increased PaCO2), with normal oxygenation (normal alveolar-arterial O2 gradient).

– Hypoxemic Respiratory Failure is characterized by low PaO2, markedly elevated P(A-a)O2 gradient, and usually low PaCO2, reflecting adequate ventilation, but inadequate gas exchange.

RESPIRATORY FAILURE

SIGNS & SYMPTOMS– Neurological

Restlessness, Agitation, Headache Disorientation, Seizures, LOC

– Cardiovascular Heart Rate, Hypertension (early),

Hypotension (late), Chest Pain , Dysrhythmias

– Respiratory Respirations, Respiratory Effort

RESPIRATORY FAILURE

CAUSES– V/Q Mismatch

Ventilation / Perfusion Mismatch V/Q ratio = ventilation to perfusion

– Intrapulmonary ShuntPerfusion without ventilation

– Cardiac FailureMay result in pulmonary congestion

RESPIRATORY FAILURE

SIGNS & SYMPTOMS– Renal

UOP, Edema

– Gastrointestinal Bowel Sounds, Nausea/Vomiting, Abd

Distention, Bleeding

– IntegumentaryCool, clammy, pale skin, Decreased Capillary

Refill

RESPIRATORY FAILURE

TREATMENT

– Protect the AirwayIntubation (if needed)

Bronchodilators

Hydration (as appropriate)

Mucolytic (if appropriate)

RESPIRATORY FAILURE

TREATMENT– Correct the Acid-Base Imbalance

ABG’sBronchodilatorsMechanical or non-invasive ventilationTreat the Cause

– Reduce sedation– Add sedation– Bring fever down

RESPIRATORY FAILURE

TREATMENT FiO2

Ineffective with shuntingProlonged O2 > 40% may cause O2

toxicity (lung damage)Must use caution with CO2 retainers

– Chronic hypercapnia causes CO2 retainers to use hypoxic (O2) drive

– Too much O2 can depress respirations

RESPIRATORY FAILURE

NURSING INTERVENTIONS– Monitor the Patient

Monitor ABG’s Monitor respiratory status Monitor response to therapies

– Report Changes Watch for improvement Keep respiratory status well documented

– Treat Causes Antibiotics Diuretics Mucolytics

RESPIRATORY FAILURE

DEFINITION

– Syndrome that causes damage to the alveolar-capillary interface.

– Causes an acute lung injury that causes pulmonary capillary permeability and alveolar flooding.

– Characterized by non-cardiogenic pulmonary edema, respiratory distress, and hypoxemia.

ARDS

CAUSES– Aspiration Injuries– Sepsis– Multiple Blood Transfusions– DIC– Shock States– Severe Pancreatitis– Embolism

ARDS

SIGNS & SYMPTOMS– Dyspnea

– Low PaO2

– Intrapulmonary ShuntingLow PaO2 despite high FiO2

– Pulmonary Crackles– Diffuse bilateral alveolar infiltrates – Low or normal PAWP

ARDS

SIGNS & SYMPTOMS– Early

Irritability, confusion, hyperventilation, tachypnea, dyspnea, tachycardia

– Late Increasing respiratory insufficiency,

pulmonary compliance ( pulmonary vascular resistance), PCO2 retention, frothy sputum, pulmonary crackles

ARDS

COMPLICATIONS– Barotrauma– Pulmonary Fibrosis– Pulmonary Emboli Cardiac Output– Renal Failure– Nosocomial Pneumonia– Sepsis– DIC

ARDS

TREATMENT– Maintain Oxygenation

BiPAP, CPAP Intubation PEEP ABG Monitoring

– Maintain Vascular Volume IVF Fluid Restriction

– Treat the Cause Antibiotics

ARDS

DEFINITION

– Infarction occurs due to mechanical obstruction of a coronary artery (or branch) caused by a thrombus, plaque rupture, coronary spasm and/or dissection.

ACUTE MI

SIGNS & SYMPTOMS

– Complains vary and may include crushing chest pain (which may or may not radiate), back, neck, jaw, teeth and/or epigastric pain, nausea/vomiting and dizziness.

– ST elevations on ECG

– Elevated cardiac enzymes

ACUTE MI

SIGNS & SYMPTOMS

PAWP, CO, SVR, dysrhythmias, S4,

cardiac failure, cardiogenic shock

– Diaphoresis, pallor, referred pains

– Diabetics and women often present abnormal symptoms

ACUTE MI

COMPLICATIONS

– Dysrhythmias, heart failure, pericarditis,

ventricular aneurysms, ventricular thrombus,

VSD, mitral regurgitation, papillary muscle (or

chordae tendineae) rupture, pericardial

effusions, pericarditis

ACUTE MI

TREATMENT

– Time Is Heart Muscle

– The goal of treatment for an AMI is to relieve pain, limit the size of the infarction and to prevent complications, primarily lethal dysrhythmias

– Prompt ECG

ACUTE MI

TREATMENT

– Usual medications include O2, NTG, MSO4, aspirin, heparin, beta-blockers, and ace inhibitors. May also include thrombolytics or Gp2a3b inhibitors

– Cardiac Catheterization (with angioplasty, atherectomy and/or stent)

– IABP, CABG, Education

ACUTE MI

TREATMENT– IWMI

Fluids InotropicsAfterload reducing medications

– AWMIDiuretics InotropicsAfterload reducing medications

ACUTE MI

NURSING INTERVENTIONS– O2

– Bedrest– Serial ECG’s– Serial cardiac enzymes

– Keep pain free (NTG. MSO4)– Aspirin, heparin, beta-blockers, ace inhibitors,

Gp2a3b inhibitors, thrombolytics, PTCA, IABP, CABG

ACUTE MI

DEFINITION

– CHF

A condition in which the heart cannot pump sufficient blood to meet the metabolic needs of the body.

Pulmonary (LVF) and/or systemic (RVF) congestion is present.

CHF

DEFINITION

– Pulmonary EdemaFluid in the alveolus that impairs gas

exchange by altering the diffusion between alveolus and capillary; acute left ventricular failure causes cardiogenic pulmonary edema.

Non-cardiogenic pulmonary edema is a synonym for Adult Respiratory Distress Syndrome (ARDS).

CHF

SIGNS & SYMPTOMS– Sympaththetic nervous system stimulation

TachycardiaVasoconstriction and increased SVR

– Renin-angiotensin-aldosterone system activationHypo perfusion to the kidneys (rennin)Vasoconstriction (angiotension)Sodium and water retention (kidneys)Ventricular dilation

– See Handout

CHF

FUNCTIONAL CLASSIFICATIONS

– Class I

– Class II

– Class III

– Class IV

CHF

COMPLICATIONS– Respiratory Failure

– Dysrhythmias

– Hypotension

– Progressive Deterioration

– Acute Renal Failure

– Fluid & Electrolyte Imbalances

CHF

TREATMENT– Improve Oxygenation

– Decrease Myocardial Oxygen Demand

– Decrease Preload

– Decrease Afterload

– Increase Contractility

– Manage Dysrhythmias

CHF

CAUSES– PUD

– Stress Ulcers

– Esophageal Varicies

– Portal Hypertension

– Mallory Weiss Syndrome

GI BLEED

SIGNS & SYMPTOMS– Hematemesis– Hematochezia BP H & H BUN– Weakness– Dizziness– Syncope

GI BLEED

TREATMENT– Hemodynamic Stabilization

Blood, IVF, NGT, antacids, H2 blockers, antibiotics, serial H & H’s and clotting factors

– Vasopressin (Pitressin)– Sengstaken-Blakemore or Minnesota Tube– Sclerotherapy– Laser Electorcautery– Surgery

GI BLEED

NURSING INTERVENTIONS– Large Bore IV’s– Type & Cross Match Blood– Serial H & H’s (q4hr)– Monitor Clotting Factors– Watch for Complications

ARF, ARDS, DIC– Maintain Tubes

NG, Blakemore or Minnesota Tube

GI BLEED

DEFINITION

– Serious or life-threatening complication usually from diabetes mellitus type I.

– Results from relative or absolute insulin deficiency.

DKA

CAUSES– Type I DM– Insufficient Insulin Dosing– Poor Compliance– Malfunctioning Insulin Pump– Phenytoin (Dilantin)– Thiazide/Sulfonamide Diuretics– Stress– New Onset DM

DKA

SIGNS & SYMPTOMS – Sudden Onset (hours)

– Serum Glucose 300-800

– Ketones Strongly Positive

– Serum pH < 7.3 (Ketoacidosis)

– Fruity Acetone Breath (Ketones)

– Kussmaul Respirations

– Serum Osmolarity < 350

DKA

SIGNS & SYMPTOMS – Thirst (polydipsia)

– Dry Mouth

– Dry Skin

– Weakness

– Kussmaul Respirations

– Polyuria

DKA

– Hypotension

– Tachycardia

– Mental confusion

– Changes in LOC

– Mental confusion– Changes in LOC

TREATMENT

1. Reverse Dehydration Rapid IVF Replacement

– NS, then ½ NS

– Continue NS If Needed

Prevent Hypoglycemia

– D5½ NS when Glu 250

DKA

TREATMENT

2. Restore Normal Glucose Levels

Give Rapid Acting Insulin

Frequent Glu Monitoring (q ½ - 1 hr)

Monitor Serum and Urine Ketones

DKA

TREATMENT

3. Replenish Electrolytes

Watch for Dilution

Monitor Electrolytes Frequently

Insulin Lowers Serum K

DKA

ADDITIONAL INTERVENTIONS

– Monitor Frequent Accuchecks (q1hr)

– Monitor Serial Serum Glucose (q4hr)

– Monitor Serial Electrolytes (4hr)

– Monitor Anion Gap (q4hr)

– Monitor Serum & Urine Ketones

DKA

DEFINITION

– Inadequate perfusion to the body tissues

– Low blood pressure with impaired perfusion to the end organs

– May result in multiple organ dysfunction

SHOCK

TYPES OF SHOCK

– Hypovolemic Shock

– Cardiogenic Shock

– Distributive Shock

– Obstructive Shock

SHOCK

SIGNS & SYMPTOMSThe body attempts to compensate for shock:

1. Tachycardia Attempts to deliver more blood to the tissues

2. Vasoconstriction Attempts to maintain adequate BP in order to

adequately perfuse the body tissues3. Increased ADH Secretion

ADH makes the body hold onto water in an effort to maintain volume and thus enough blood pressure to perfuse the body tissues

SHOCK

SIGNS & SYMPTOMS– Hypovolemic Shock:

Low BP , tachycardia, orthostatic hypotension,

restlessness, confusion, agitation (or listless),

thirst, pallor, cool, clammy skin, resp. rate,

UOP, CO, PAWP, CVP, SVR,

lactate levels

SHOCK

SIGNS & SYMPTOMS– Cardiogenic Shock:

Low BP , tachycardia, restlessness, confusion,

agitation (or listless), thirst, pallor, cool,

clammy skin, resp. rate, UOP, CO,

PAWP (low with RVF), CVP, SVR,

JVD, peripheral edema, ventricular gallop,

dyspnea, pulmonary crackles, lactate levels

SHOCK

SIGNS & SYMPTOMS– Anaphylactic Shock:

Low BP , tachycardia, orthostatic hypotension,

restlessness, confusion, agitation (or listless),

thirst, pallor, warm feeling, pruritus, hives,

angioedema, bronchoconstriction, wheezing,

laryngoedema, dyspnea, cool, clammy skin,

UOP, CO, PAWP, CVP, SVR, lactate levels

SHOCK

SIGNS & SYMPTOMS– Obstructive Shock:

Low BP, tachycardia, restlessness,

confusion, agitation (or listless), pallor,

cool, clammy skin, UOP, CO,

symptoms related to cause

SHOCK

SIGNS & SYMPTOMS– Septic Shock:

Early Stage (Hyper-dynamic, Warm Phase)

Normal BP, tachycardia, confusion, agitation (or listless), resp. rate, temp, normal color, normal or UOP, CO, normal PAWP, CO, SVR,

SHOCK

SIGNS & SYMPTOMS– Septic Shock:

Late Stage (Hypo-dynamic, Cold Phase)

Low BP, tachycardia, orthostatic hypotension, restlessness, confusion, agitation (or listless), thirst, pallor, cool, clammy skin, UOP, CO, PAWP, CVP, SVR, lactate levels

SHOCK

TREATMENTS– Hypovolemic Shock:

Volume (IVF, Blood)

– Cardiogenic Shock: CO Preload & Afterload Myocardial Demand

SHOCK

TREATMENTS– Anaphylactic Shock:

Epinephrine IVF Vasoconstrictors Support/Maintain Airway

– Obstructive Shock: Treat the Cause

SHOCK

TREATMENTS– Septic Shock:

IVF (150cc/hr or wide open)

Treat Cause (pan culture, antibiotics)

Vasoconstrictors in warm phase

Treat temp if needed

SHOCK

DEFINITION– SIRS

Systemic Inflammatory ResponseManifested by two or more of the following:

– Temp > 38C or < 36C, HR > 90/min, RR > 20/min, CO2 < 32 mmHg, WBC > 12,000 or < 4,000 or > 10% (immature) bands

– Sepsis Inadequate perfusion to the body tissues due

to bacteremia.

SEPSIS

DEFINITION– Severe Sepsis

Sepsis associated with organ dysfunction, hypo-perfusion or hypotension.

– Septic ShockSystemic response to infection.

SEPSIS

SIGNS & SYMPTOMS– Early Stage (Hyper-dynamic, Warm Phase)

Normal BP, tachycardia, confusion, agitation (or listless), resp. rate, temp, normal color, normal or UOP, CO, normal PAWP, CO, SVR,

SEPSIS

SIGNS & SYMPTOMS– Late Stage (Hypo-dynamic, Cold Phase)

Low BP, tachycardia, orthostatic hypotension, restlessness, confusion, agitation (or listless), thirst, pallor, cool, clammy skin, UOP, CO, PAWP, CVP, SVR, lactate levels

SEPSIS

COMPLICATIONS

– Acute Renal Failure

– Multiple Organ Failure

– Disseminated Intravascular Coagulation

– Death

SEPSIS

TREATMENT

1. Give IVF (150cc/hr or wide open)

2. Treat the Cause (Pan culture, antibiotics,)

3. Give Vasoconstrictors in warm phase (vasoconstrictors are contraindicated in cold phase).

4. Treat Temperature as needed

5. Consider Protein Activated C (Xigris)

SEPSIS

THE END

CRITICAL CONDITIONS

THANK YOU

CRITICAL CONDITIONS

REFERENCES

1.Johanson WG and Peters JI. "Respiratory Failure." IN: Textbook of Respiratory Medicine, Murray and Nadel, eds.; 1988. 2.Morris AH. "Acute Respiratory Failure." IN: Therapeutic Strategies in Current Therapy in Critical Care Medicine, JE Parrillo, ed.; 1987. 3.Pontoppidan H, Geffin B and Lowenstein E. Acute respiratory failure in the adult, Parts I-III. N Engl J Med 287:690-698, 743-752, 799-806, 1972. 4.Pingleton SK. Complications of acute respiratory failure. Am Rev Respir Dis 137:1463-1493, 1988. 5.Heffner JE. Tracheal intubation in mechanically ventilated patients. Clin Chest Med 9:23-35, 1988. 6.Stauffer JL. Medical Management of the Airway. Clin Chest Med 12:449-482. 7.Bone RC. Symposium on Respiratory Failure. Med Clinics of N Amer 67:551-750, 1983.