Critical Care Application

8/22/2019 Critical Care Application

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Areas where patients require complex

assessment, high-intensity medication,

continuous therapy and interventions,and unrelenting nursing attention and

continuous watchfulness.


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CRITICAL CARE NURSING IS THE NURSINGSPECIALTYTHATDEALSWITHHUMANRESPONSESTO

LIFE-THREATENING PROBLEMS (LEWIS, 2004).

CRITICAL CARE IS THE MULTIDISCIPLINARY

HEALTHCARESPECIALTYTHATCARESFORPATIENTS

WITHACUTE, LIFE-THREATENINGILLNESSORINJURY.

A CRITICALLY ILLPATIENT ISPHYSICALLYUNSTABLE

WITH REAL OR POTENTIAL LIFE-THREATENING

HEALTH PROBLEMS REQUIRING CONTINUOUS

INTENSIVE ASSESSMENT AND INTERVENTIONS(AACN, 2003).


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The clinician in critical care integrates data fromhemodynamic devices, mechanical ventilators,

bedside testing devices, and observation from

direct patient assessments to form a

comprehensive picture of the patients status

and the effect of care. The data must be readily

accessible at the devices used with the point of

care.


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Historically, critically ill patients were cared

for in critical care units, but due to increasedpatient acuity and an aging population, criticalcare patients can be found in a variety of settings(Kidd, 2001). Implied in these definitions is atechnologically intense environment geared to themonitoring and support needs of the critically ill

patients (Bachman, 1995). Embedded in much ofthat technology are microprocessors, which permitgathering, processing, and storage of largevolumes of clinical and financial data. In 1986,

Saba and McCornick estimated that the volume ofdata collected by nurses in critical care settings ona daily basis was a high as 1,500 data points


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Resources storages, both staff and time, increasethe difficulty of data management. Informationtechnology offers resolutions to these difficultiesthrough manipulation of large volumes of data andpresenting them in the clinician in meaningful ways toguide quality and cost-effective decision-making.Effective and efficient integration of informationdrives improvement in the patient care and hence isincreasingly employed in critical care settings.Information technology is found in many patient careunits in the critical care settings. Themicroprocessors that are embedded in many of the

devices use with critical care patients facilitatedownloading of the data that resides in the devices toan information management system.


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Developers of automated approaches to information

management in the critical care settings have

incorporated complex formulas into physiology

monitors, rapidly analyzed small samples of gas or

fluids, maintained near normal physiologic range with

the life-supporting equipment, and stored large

volumes of data that would otherwise bedisorganized, lost, inaccurate, or illegible.


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INFORMATIONTECHNOLOGYINTHECRITICALCAREENVIRONMENTHASSEVERALMAJORCAPABILITIES:

Process, store and integrate physiologic and diagnostic information

from various sources

Present deviations from present ranges by an alarm or an alert

Accept and store patient care documentation in a lifetime clinical

repository

Trend data in a graphical presentation

Provide clinical decisions support through alerts, alarms, and

protocols

Provide access to vital patient information from any location, both

inside and outside of the critical care settings

Comparatively evaluate patients for outcomes analysis

Present clinical data based on concept-oriented views

(Organized data by patient problem or by system)


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* PHYSIOLOGICMONITORS, INCLUDING

ARRHYTHMIAANDHEMODYNAMICMONITORS

* MECHANICALVENTILATORS

* CCISS

There are several data-intense information systemsthat exit in the critical care environment from whichdata can be oriented and integrated in a meaningful

way. The CCIS (Critical Care Information Setting)must include data from multiple sources,encompassing current and historical information.Information technology applications and functionstypical in the critical care environments that will be

described in this chapter include the following:


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DEVICES CONNECTIVITY INFRASTRUCTURE

Bedside monitoring devices are capable ofsending information to software applications. Inconcepts, the term Medical Information Bus(MIB) is used to classify the backbone of

information exchange allowing data to bemoved from one point to another. Thisinfrastructure is used to send the workloadgenerated by the patient care devices (e.g.

monitors, ventilators, infusion pumps) in themodern critical care setting. Most medicaldevices have small communication portsavailable that have capability to transmitdigital data to clinical software applications.


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Software developers design hardware andsoftware interfaces to allow the devices to

communicate and supply information to the clinicalinformation system. Examples of messaging standardsthat are used to intercede informational workflowswithin the healthcare enterprise are Health Language

Seven (HL7) standards and the Institute of Electricaland Electronics Engineers (IEEE) Medical Data DeviceLanguage (MDDL).


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In the NASA programs of the 1960s, physiologic

monitors were developed to oversee the vitalsigns of the astronauts. By the 1970s, thesemonitors had found their way into the hospitalsettings, where they replaced manual methodsof gathering patient vital signs. These early

monitors were large and cumbersome and hadlimited capabilities (Wiggett, 1996). In the 1990s,the focus of the development has shifted tointegration if monitoring data into information

systems.


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MOSTPHYSIOLOGICMONITORSCONSISTOFFIVE

BASICPARTS:

Sensors Signal conditioners to amplify or filter the display

device

File to rank and order information

Computer processor to analyzed data and directreports

Evaluation or controlling component to regulate the

equipment or alert the


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Advanced hemodynamic monitoring system allow for calculation of

hemodynamic indices and limited data storage. Hemodynamic monitoring can

be used to:

Measure hemodynamic parameters

Closely examine cardiovascular function

Evaluate cardiac pump output and volume status

Recognize patterns (arrhythmia analysis) and extract features

Assess vascular system integrity

Evaluate the patients physiologic response to stimuli

Continuously evaluate blood gases and electrolytes

Estimate cellular oxygenation

Continuously evaluate glucose levels

Store waveforms

Automatically transmit selected data to a computerized patient database


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Hemodynamic monitoring can be invasive or

noninvasive. Invasive catheters are typically usedto measure and monitor various pressures and

cardiac output. Noninvasive monitoring methods

are increasingly common and include pressure

measurement using oscillometric techniques,oxygenation measurement using pulse oximetry

technology, and measurement of cardiac output via

Doppler.


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Invasive hemodynamic monitoring techniqueshave traditionally involved use of thepulmonary artery catheter (PAC), which wasoriginally designed for measurement of

pulmonary artery and wedge pressures.

With growing popularity of use, the PAC has comeunder recent and persistent criticism concerning itssafety and appropriate use. This criticism promptedformation of the Pulmonary Artery ConsensusConference Organization (PACCO) with broadrepresentation from professional nursing and medicalsocieties. The PACCO determined that it is appropriateto use the PAC when either conventionalhemodynamic therapies have not produced desirableresults or hemodynamic therapies require themonitoring provided by the PAC.


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Intermittent measurement using thermodilution techniqueshas become that standard methodology for assessmentof cardiac output; however, the accuracy of thistechnique is highly user-dependent for the followingreasons:

The bolus must be injected within 4 seconds

The amount of the solution must be accurate

The temperature of the injectate must be precisely

measured and accurately maintained The catheter must be properly placed within the heart

and pulmonary artery

The computer must have the appropriate computationconstant entered

The bolus must be injected at the appropriate time in therespiratory cycle


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Computerized monitoring and analysis of cardiac rhythm haveproved reliable and effective in detecting potentially lethal

heart rhythm (Widman, 1992). Standards for testing and

reporting the performance of arrhythmia analysis system have

been developed by the American Heart Association. A key

functional element is the systems ability to detect ventricularfibrillation and respond with an alarm. However, no standards

currently specify the minimal accuracy to computerized

detection system.


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Sensor

Signal conditioner

Cardiograph

Pattern recognition

Rhythm analysis

Diagnosis Written report

Detection surveillance

Diagnostic or

interpretive

Basic Components of

Arrhythmia MonitorsSystem Types


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INADETECTIONSYSTEM, THECRITERIAFORANORMAL ECG AREPROGRAMMEDINTO THE COMPUTER. THE COMPUTER MIGHT SURVEY THE ECG FOR WAVEAMPLITUDE AND DURATION AND FOR THE INTERVALS BETWEEN WAVES. THE

PROGRAMMAYEVENINCLUDEANALARMRESPONSEIFTHE R-R INTERVAL.

The next programmed search may be for thepresence of a compensatory pause (i.e., a prolonged R-Rinterval after premature ventricular contraction [PVC]). The

computer may then be programmed to store the number ofPVCs per minute and sound an alarm or alert the nursevisually (e.g., a flashing red light) and audibly (a loud sound)when more than five PVCs occur within a minute. Detectionsystem can even store in the memory the type of arrhythmia

and time of occurrence, so that patients arrhythmia historycan be plotted and compared to medication administration(Sorkin and Bloomfelf, 19820.


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Arrhythmia system can also be diagnostic;after the analog signal are digitized for processing,the program analyzed and diagnoses the ECG. The

computer, after processing the ECG, generates ananalysis report that is confirmed by a cardiologist,usually from another site. The computer that supportthese types of ECGs are usually dedicated system

(i.e., main memory is used only for ECG acquisition,analysis, and report generation). Diagnostic systemsare usually capable of retrieving a patients previousECGs for comparison. Bedside monitoringcapabilities are beginning to emerge thatincorporate 12 lead ECG capabilities, thecornerstone of the diagnostic system.


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INTERPRETIVESYSTEMSSEARCHTHE ECG

COMPLEXFORFIVEPARAMETERS:

Location of QRS complex

Time from the beginning to the end of the QRS

Comparison of amplitude, duration, and rate ofQRS complex with all limb leads

P and T waves

Comparison of P and T waves with all limb leads


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A CCIS is a designed to collect, store, organize,retrieve, and manipulate all data related to care of the

critically ill patient. It is focused on individual patients and theinformation directly related to the patients care. The primarypurpose of a CCIS is the organization of a patients currentand historical data to use by all care providers in patientcare (Milholland and Cardona, 1983). The power of a

modern CCIS is its ability to integrate information from avariety of sources and to manipulate that information inmeaningful ways. The CCIS should include data andinformation from bedside devices; results from ancillarydepartments, medication, orders, physical assessmentfindings gathered from the clinical team; andcomprehensive plans of care to guide patient care.


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Each patients data can be accessed

from any terminal or workstation. Thiscapability can extend across units and

departments or be restricted to a single

unit. In some instances, an alarm on one

patient can be forwarded to another

patient location, as determined by theclinician.

CCISS OFFER MANY FUNCTIONS TO FACILITATE THE WORK OF CRITICAL


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CCISSOFFERMANYFUNCTIONSTOFACILITATETHEWORKOFCRITICALCARENURSES (BUTLERAND BENDER, 1999). THECOMPONENTSOFACCIS INCLUDE:

Patient Management

Vital Sign Monitoring

Diagnostic Testing Results

Clinical Documentation to Support the Processof Physical Assessment Findings.

Decision Support

Medication Management

Interdisciplinary Plans of Care

Provider Order Entry


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FUTURE DEVELOPMENTS

As clinician information systems mature,their use in the patient care environmentwill become more pervasive. Adoption ofa standard interface language will furtherpromote the development of the clinicalinformation systems. As the patient movesthrough the ambulatory, critical care

medical/surgical areas, patient caregiverswill need easy access to secureinformation (Gartner, 2004)


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The development of clinical pathways andoutcomes management are important inimproving critical care performance. Outcomesare measurements made to determine the course

of an illness and the effects of treatment on thiscourse. CCISs can assist outcomes managementby facilitating the identification and analysis of therelationships between clinical intervention andoutcomes as well as between outcomes and cost.

Three types of data are useful in supporting outcomes analysis:

Input variables which stratify

patients into comparable groups

intervention

outcomes


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CRITICAL CARE NURSE

Is responsible to ensure that critically ill patients are seriouslyconditioned individuals.

Ensure that families of the medically ill patients shouldreceive optimal care.

Rely upon dedicated knowledge, skills and experience andof course automated system of support and intelligent systemto provide care to patient and families and createenvironments that are healing, compassionate and caring.


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CRITICAL CARE INFORMATION SYSTEM

Provide real-time resource utilization data and management

of information and access critical care areas through the

integration of the medical facilities in the critical care of

intensive care unit to an intelligent computer system which is

capable of processing all data.

Enables the electronic collection of hospital and patient-

specific critical care data of the entire patient in the critical

care areas which can be processed to create patient profile

which generate real rime and historical report on indicators

including bed occupancy, delayed discharges, readmission

rates, and outcomes.Automated collection and management of medical

information will become the important task of the critical care

information system.


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Critical Care Application

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