Critical Care Nursing Practice Guide

A Road Map for Students and New Graduates

Critical Care Nursing Practice Guide

A Road Map for Students and New Graduates Second Edition

Elizabeth Simon, PhD, RN, ANP-BC, Alumnus-CCRN Dean and Professor School of Nursing Nyack College Nyack, New York, USA

Formerly at Hunter College New York, USA

Forewords Usha Ukande, RNRM, PhD Bennett Schepens, PhD

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The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers. 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. Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book. This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought. Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. Inquiries for bulk sales may be solicited at: [email protected] Critical Care Nursing Practice Guide: A Road Map for Students and New Graduates First Edition: 2011 (Published by Jones & Bartlett Learning, LLC, an Ascend Learning Company) Second Edition: 2017 ISBN 978-93-86322-04-3

Printed at Repro India Limited

Dedicated to The nurses in India whose clinical knowledge, conscientiousness, competence, and the contributions to health care go unnoticed or unrecognized.

Contributors Anne Bove, RN, MS, ANP

Juby Joseph, RPh, PharmD

Critical Care Educator Bellevue Hospital Medical Center New York, USA

Clinical Pharmacist Nassau University Medical Center Long Island, New York, USA

Elizabeth John, RN, MS, ANP Nurse Practitioner, Neuro ICU Long Island Jewish Hosptial Long Island, New York, USA

Foreword Critical Care Nursing Practice Guide: A Road Map for Students and New Graduates by Elizabeth Simon is a concise yet full of thorough guidance for the new nursing entrants to Critical Care Nursing. It effortlessly walks the students through the procedures of how safe and competent care can be administered to adult critically ill patients. It orients the students toward efficiently managing critical care patients and also equips them with a better understanding of the basic procedures to be followed in the intensive care unit (ICU) and other sensitive and high-risk patient categories. Of the many chapters that are of immense help to the student nurses, are well written in lucid language, I would like to specially mention: zz Eyeballing Your Patient: This chapter explains to the nurse most important things to look before taking shift report. It helps nursing students to get familiarized with the patients and make them comfortable before beginning any nursing interventions as prescribed. zz Machines, Monitors, and Meters: This chapter helps the novice nurse students to become comfortable with ventilators, volumetric pumps, cardiac monitors, transducers, hypothermia machines, fluid warmers, defibrillators, pacemakers, Doppler, hemofiltration, pulse oximeters, capnographs and other equipment used routinely in ICUs. It discusses alarms and their meaning, and how to troubleshoot problems. zz Procedures in the ICU: This chapter covers commonly performed procedures such as chest tube insertion, thoracocentesis, paracentesis, central line catheters, etc. and are explained with an emphasis on the nurses’ role. zz Documentation: This chapter is the most important part of a nurses’ role and covers electronic medical records, nursing flow sheets and notes; documentation is time sensitive and it also warns the students against practices like ‘back charting’ which could invite legal consequences. In a nutshell, the book is an excellent guide thoroughly researched and written from the students’ point of view. It is a modest attempt to present the important content related to nursing and critical care in a lucid manner and includes most of the basic and essential concepts related to the subject of critical care. I further commend that this book caters to the needs of graduate nursing students and their faculty.

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In my opinion, the book may even be useful for postgraduate nursing students and other health care professionals as well as it can be kept in adult ICUs for quick reference. I have the pleasure to highly recommend it. Dr Usha Ukande, RNRM, PhD President, Nursing Research Society of India Principal, Choithram College of Nursing Indore, Madhya Pradesh, India

Foreword First you should know I do not write this foreword as an expert in nursing practice. But I am also not a novice when it comes to nursing and nurses. I am from a family with five nurses and as many various technicians and experts in the associated fields of care from pharmacy to laboratory to MRI technician. I have read, edited and submitted nursing curriculum for state approval. I have hired nurses to instruct, attended faculty meetings, and visited nurses in clinical area and lab. And I have been a patient in need of critical care with a heart assist pump (balloon pumb) and then recovery from cardiac surgery. I have also had both parents in critical care in the past five years. My life has intersected with nursing and health care on many levels, a family of medical experts, personal experience as a patient, and as a planner for nursing education. None of that makes me qualified to write a book like you have before you now but it gives me a number of perspectives to bring to the book. I have asked critical care nurses question after question. Sometimes I was given a reasonable answer but as a major in the sciences and science teacher for many years my nonsense meter is sensitive when it comes to answers to medical questions. This book provides the science behind the care with a careful review of the anatomy and the pathophysiology associated with critical care in each area. It would certainly make me feel better as a patient if my nurses would have read this Practice Guide. Critical Care Nursing Practice Guide is a book that will lead you into the world of critical care from the perspective of Dr Elizabeth Simon, an expert nurse and a compassionate caregiver. Dr Simon has years of experience as a nurse, staff development instructor, nursing professor, and college dean of nursing. Her years of work as a nurse and her dedication to good practice are evident in the pages that follow. Dr Simon knows from that experience and education that a good list is sometimes necessary when you return to a particular type of patient so she provides many helpful checklists. She also knows that detail in care provides the best and most compassionate care, as you will see in the specifics provided for each phase of care from assessment to her pearls of practice in the last chapter. Expertise is evident in the detail and attention Dr Simon gives to each facet of critical care nursing. The compassion and care of Dr Simon seeps through the pages in the insight

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for practice and attention to detail. Dr Simon has written the type of book a novice and experienced nurse alike will value and take with them to the critical care units. When I teach something a few times I know it very well. It seems as if I am very smart but in reality repetition of content and practice at skills has taught me all the detail most people do not remember. It is the same for nursing. When a nurse first walks into a new situation a resource like Dr Simon’s book can be invaluable so the detail is remembered. Each time the type of patient changes those details and change the review. This book provides the difference between good care and excellent care. As a practicing nurse you will remember what you do most often but when new types of patients come your way it is comforting to have a resource like Dr Simon’s Critical Care Nursing Practice Guide. Patients depend on the nurse’s expert knowledge and practice at a time when life and death are equal outcomes. Each procedure, detail, action, check, record kept, observation and even knowledge of the anatomical detail become factors that which can tip the scale towards life. So, the next time I land in the ICU, in bed or beside it, and ask a question or need a procedure, I hope you have had the practice needed to remember everything required. If not, I hope you took the time to read the key chapter in Dr Simons book to refresh your memory of the knowledge and keys to good practice needed in my room. If you are new to the ICU I hope you have memorized this Practice Guide and have it closed by for reference. Because you know I am going to ask a question or challenge a procedure if my loved one looks uncomfortable. I will not mind if you check your facts or procedures on your break (if you get one). This book provides foundational knowledge base for each type of situation the ICU nurse may face. Hide it in your locker at the ICU and pull it out when you need it. It is a book you will value and keep. Bennett Schepens, PhD Assistant Provost for Institutional Research and Professional Programs Nyack College, New York, USA

Preface This book is a step-by-step practice guide that helps new nursing graduates, critical care nurses and other clinicians to get competent in providing care to the patient in the intensive care units.   This book takes the reader through topics such as how to begin, organize, prioritize, analyze, reason, and make decisions during the daily routines and emergencies that arise in any unit along the continuum of critical care. Unlike other books in the same genre, this is written in the perspective of an experienced preceptor teaching a novice at the bedside. Most of the books adopt a body system approach while this book embraces to provide a simple reading in style as well as in practical application. The original book was first published in the US in 2011 which was expensive in Indian standards. I was a Fulbright scholar at Choithram College of Nursing, Indore, Madhya Pradesh, India and during my stay in India, I perceived the demand for this book among the nursing and medical community. I am thankful to Dr Rattan Sahajpal, ICU in-charge, Choithram Hospital, and Ms Shweta Patnaik, Assistant Professor, College of Nursing and other nursing faculty members who encouraged me to get this book published in India. I revised the entire book and added two additional chapters. My ultimate goal is to make the book available to Indian nurses and other clinicians at a reasonable cost. I am pleased to accomplish my goal. Elizabeth Simon

Acknowledgments I would like to express a deep sense of gratitude to Almighty Lord Jesus, Who is continuously giving the strength and direction in all walks of my life. I would like to pen my gratitude to my loving husband, Babu Simon, who gave continuous cooperation, guidance, encouragement and support in bringing out this book. I would like to thank all my teachers of Christian Medical College of Nursing, Ludhiana, Punjab, India, who provided me the strong foundation in nursing. I am indebted to Columbia University School of Nursing, Teachers College and Hunter College, New York for opening doors of nursing excellence. My deep heartfelt thanks to my students at Nyack College, New York, whose radiant faces and poses in chapter opener pictures gave life to this book. I am thankful to Ms Grace Mathew, our Nursing Skills Lab Manager, who made these lively shots possible. I express gratefulness to the Nyack College Administration for granting me a sabbatical leave to enhance faculty productivity. My genuine gratitude for Jones & Bartlett Learning, Boston, MA for giving permission and needed support for publishing this revised version in India. I convey my sincere thanks to Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India for their efforts and suggestions, especially Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President), Ms Chetna Malhotra Vohra (Associate Director—Content Strategy), and Ms Ruby Sharma (Project Manager) for helping me through my idea.

Contents 1. Eyeballing Your Patient ••Purpose  2 ••Technology and Your Patient  2 ••Focus on the Patient  2 ••Have a Mental Picture of Your Patient  3 ••Important Points to Remember  4

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2. Taking and Giving Shift Report ••Shift Report: What Is It?  6 ••Shift Report: Why Is It Important?  7 ••Does Location Matter?  8 ••Taped versus Bedside  8 ••What Should be in It? (Content)  10 ••What Should not be in It?  10 ••Professional Behaviors  10 ••Documentation Tool  11 ••Important Points to Remember  12

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3. Assessing Your Patient ••Head: Nervous System Assessment  15 ••Chest: Respiratory Assessment  15 ••Circulation/Chest: Cardiovascular Assessment  18 ••Blood Pressure Reading  20 ••Mean Arterial Pressure (MAP)  21 ••Abdominal Assessment (GI System)  21 ••Renal System Assessment (Elimination)  26 ••Skin Assessment (Protection)  27

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4. Machines, Monitors, and Meters ••Machines  30 ••Understanding Mechanical Ventilation  30 ••Troubleshooting Alarms  37 ••Weaning (Liberation from the ventilators) from the Ventilators  40 ••Pain management, Sedation and Neuromuscular blockade   42 ••Hypothermia Machine  47

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