Common Problems of Critical Care Patients

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Lewis: Medical-Surgical Nursing, 9th Edition

Chapter 66

Nursing Management: Critical Care


  • Critical care nurses care for patients with acute and unstable physiologic problems as well as their caregivers. This involves assessing life-threatening conditions, initiating appropriate interventions, and evaluating the outcomes of the interventions.

  • A critically ill patient is defined as one who is at high risk for actual or potential life-threatening health problems and who requires intense and vigilant nursing care.

Common Problems of Critical Care Patients

  • The patient admitted to the intensive care unit (ICU) is at risk for numerous complications and special problems.

  • Nutritional support is often necessary to prevent or correct nutritional deficiencies. This is usually accomplished by the early provision of enteral or parenteral nutrition.

  • Anxiety is a common problem for ICU patients, requiring careful assessment and management.

  • Controlling pain is paramount because inadequate pain control is often linked with agitation and anxiety. Continuous IV sedation and an analgesic agent may be used.

  • To reduce distress associated with impaired communication, use alternative methods of communication.

  • Since delirium is a common problem, identify predisposing factors and improve the patient’s mental clarity and cooperation with appropriate therapy.

  • Sleep disturbance is a significant stressor in the ICU, contributing to delirium and possibly affecting recovery. Structure the patient’s environment to promote sleep and use drug therapy as needed to induce and maintain sleep.

Issues Related to Caregivers

  • Caregivers play a valuable role in the patient’s recovery and should be considered members of the health care team as they can contribute to the patient’s well-being.

  • The major needs of caregivers of critically ill patients are categorized as informational needs, reassurance needs, and convenience needs.


  • Hemodynamic monitoring refers to the measurement of pressure, flow, and oxygenation within the cardiovascular system. Invasive and noninvasive hemodynamic measurements are made in the ICU.

  • Values commonly measured include systemic and pulmonary arterial pressures, central venous pressure (CVP), pulmonary artery wedge pressure (PAWP), cardiac output (CO), cardiac index (CI), stroke volume/index, stroke volume variation, and oxygen saturation of the hemoglobin of arterial blood (SaO2), mixed venous blood (SvO2), and central venous blood (ScvO2).

    • PAWP, a measurement of pulmonary capillary pressure, reflects left ventricular end-diastolic pressure under normal conditions.

    • CVP, measured in the right atrium or in the vena cava close to the heart, is the right ventricular preload or right ventricular end-diastolic pressure under normal conditions.

    • Systemic vascular resistance (SVR) is the resistance of the systemic vascular bed. Pulmonary vascular resistance (PVR) is the resistance of the pulmonary vascular bed. Both of these measures are adjusted for body size.

Principles of Invasive Pressure Monitoring

  • To accurately measure pressure, equipment must be referenced and zero balanced to the environment and dynamic response characteristics optimized.

  • Referencing means positioning the transducer so that the zero reference point is at the level of the atria of the heart or the phlebostatic axis.

  • Zeroing confirms that when pressure within the system is zero, the monitor reads zero.

  • Optimizing dynamic response characteristics involves checking that the equipment reproduces, without distortion, a signal that changes rapidly.

Types of Invasive Pressure Monitoring

  • Continuous arterial pressure monitoring is used to obtain systolic, diastolic, and mean blood pressures (BPs) in patients experiencing acute hypertension and hypotension, respiratory failure, shock, neurologic injury, coronary interventional procedures, continuous infusion of vasoactive drugs, and frequent arterial blood gas (ABG) sampling.

  • Pulmonary artery (PA) pressure monitoring is used to guide acute-phase management of patients with complicated cardiac, pulmonary, and intravascular volume problems by providing information regarding stroke volume, fluid volume, PA diastolic and wedge pressures, central venous pressure (CVP), core temperature, and oxygen saturation.

Noninvasive Hemodynamic Monitoring: Impedance Cardiography (ICG)

  • Impedance cardiography (ICG) is a continuous or intermittent, noninvasive method of obtaining cardiac output (CO) and assessing thoracic fluid status.

  • Major indications for ICG include early signs and symptoms of pulmonary or cardiac dysfunction, differentiation of cardiac versus pulmonary cause of shortness of breath, evaluation of etiology and management of hypotension, monitoring after discontinuing a pulmonary artery (PA) catheter or justification for insertion of a PA catheter, evaluation of drug therapy, and diagnosis of rejection following cardiac transplantation.

Venous Oxygen Saturation

  • Both CVP and PA catheters can include sensors to measure oxygen saturation of hemoglobin in venous blood termed central venous oxygen saturation (ScvO2) and mixed venous oxygen saturation (SvO2).

  • SvO2/ScvO2 reflects the dynamic balance between oxygenation of the arterial blood, tissue perfusion, and tissue oxygen consumption (VO2). Sustained decreases may indicate decreased arterial oxygenation, low CO, low hemoglobin level, or increased oxygen consumption or extraction.

Complications with PA Catheters

  • Infection and sepsis are serious problems associated with PA catheters.

  • Other complications include air embolus, pulmonary infarction or PA rupture, and ventricular dysrhythmias.

  • If a PA catheter cannot be wedged, it may need to be repositioned by the physician or a qualified health care provider.

Noninvasive Arterial Oxygenation Monitoring

  • Pulse oximetry is a noninvasive and continuous method of determining arterial oxygenation (SpO2). Monitoring SpO2 may reduce the frequency of ABG sampling.

  • Accurate SpO2 measurements may be difficult to obtain on patients who are hypothermic, receiving IV vasopressor therapy, or experiencing hypoperfusion.

Nursing Management: Hemodynamic Monitoring

  • Obtain baseline data regarding the patient’s general appearance, level of consciousness, skin color and temperature, capillary refill, vital signs, peripheral pulses, and urine output to correlate with the data from biotechnology.

  • Single hemodynamic values are rarely significant. Monitor trends in these values and evaluate the whole clinical picture with the goals of recognizing early clues and intervening before problems escalate.


  • Circulatory assist devices (CADs) decrease cardiac work and improve organ perfusion when conventional drug therapy is no longer adequate.

  • CADs provide interim support in three types of situations: (1) the left, right, or both ventricles require support while recovering from acute injury, (2) the heart requires surgical repair but the patient must be stabilized, and (3) the heart has failed and the patient is awaiting cardiac transplantation.

Intraaortic Balloon Pump

  • The intraaortic balloon pump (IABP) provides temporary circulatory assistance to the compromised heart by reducing afterload (via reduction in systolic pressure) and augmenting the aortic diastolic pressure, resulting in improved coronary blood flow and perfusion of vital organs.

  • IABP therapy is referred to as counterpulsation because the timing of balloon inflation is opposite to ventricular contraction.

  • The IAPB assist ratio is 1:1 in the acute phase of treatment. That is, one IABP cycle of inflation and deflation for every heartbeat.

  • Complications of IABP therapy may include vascular injuries such as dislodging of plaque, aortic dissection, thrombus and embolus formation, and compromised distal circulation.

Ventricular Assist Devices

  • Ventricular assist devices (VADs) provide left, right, or biventricular support for failing hearts for a longer term (usually months) while allowing more mobility than the IABP.

  • VADs are inserted into the path of flowing blood to augment or replace the action of the ventricle. Some VADs are implanted (e.g., peritoneum), and others are positioned externally.

Nursing Management: Circulatory Assist Devices

  • Nursing care of the patient with a VAD is similar to that of the patient with an IABP.

    • Patients are observed for bleeding, cardiac tamponade, ventricular failure, infection, dysrhythmias, renal failure, hemolysis, and thromboembolism.

    • A patient with a VAD may be mobile and require an activity plan.

  • Ideally, patients with CADs will recover. However, many patients die, or the decision to terminate the device is made and death follows. Both the patient and caregiver require psychologic support.


  • Endotracheal (ET) intubation involves the placement of a tube into the trachea via the mouth or nose past the larynx.

  • Indications for ET intubation include (1) upper airway obstruction (e.g., resulting from burns, tumor, bleeding), (2) apnea, (3) high risk of aspiration, (4) ineffective clearance of secretions, and (5) respiratory distress.

  • A tracheotomy is a surgical procedure that is performed when the need for an artificial airway is expected to be long term.

  • Oral ET intubation is the procedure of choice for most emergencies.

  • Nasal ET intubation is indicated when head and neck manipulation is risky.

Endotracheal Intubation Procedure

  • All patients undergoing intubation need to have a self-inflating bag-valve-mask (BVM) available and attached to oxygen, with suctioning equipment ready and IV access.

  • Premedication for ET intubation varies, depending on the patient’s level of consciousness (e.g., awake, obtunded) and the nature of the procedure (e.g., emergent, nonemergent).

  • Rapid sequence intubation (RSI) is the rapid, concurrent administration of a combination of both a paralytic agent and a sedative agent during emergency airway management to decrease the risks of aspiration, combativeness, and injury to the patient.

  • Before intubation is attempted, the patient is preoxygenated using a self-inflating BVM with 100% O2 for 3 to 5 minutes.

  • Following intubation, the cuff is inflated, and the placement of the ET tube is confirmed while manually ventilating the patient with a BVM and 100% O2.

  • ABGs should be obtained within 25 minutes after intubation to determine oxygenation and ventilation status.

Nursing Management: Artificial Airway

  • Nursing responsibilities for the patient with an artificial airway may include some or all of the following: (1) maintaining correct tube placement, (2) maintaining proper cuff inflation, (3) monitoring oxygenation and ventilation, (4) maintaining tube patency, (5) assessing for complications, (6) providing oral care and maintaining skin integrity, and (7) fostering comfort and communication.

  • Two major complications of ET intubation are unplanned (inadvertent) extubation and aspiration.


  • Mechanical ventilation is the process by which the fraction of inspired oxygen (FIO2) at 21% (room air) or greater is moved into and out of the lungs by a mechanical ventilator.

  • Indications for mechanical ventilation include (1) apnea or impending inability to breathe, (2) acute respiratory failure, (3) severe hypoxia, and (4) respiratory muscle fatigue.

Types of Mechanical Ventilation

  • Negative pressure ventilation involves the use of chambers that encase the chest or body and surround it with intermittent subatmospheric or negative pressure.

  • Positive pressure ventilation (PPV), used primarily with acutely ill patients, pushes air into the lungs under positive pressure during inspiration. Expiration occurs passively as in normal expiration. Modes of PPV are categorized into two groups: volume and pressure ventilation.

Settings of Mechanical Ventilators

  • Mechanical ventilator settings regulate the rate, depth, and other characteristics of ventilation and are based on the patient’s status (e.g., ABGs, body weight, level of consciousness, muscle strength). The ventilator is tuned as finely as possible to match the patient’s ventilatory pattern.

  • Ventilator mode is based on how much work of breathing (WOB) the patient ought to or can perform and is determined by the patient’s ventilatory status, respiratory drive, and ABGs.

  • Ventilator modes are controlled or assisted. With controlled ventilatory support, the ventilator does all of the WOB. With assisted ventilatory support, the ventilator and the patient share the WOB.

Modes of Pressure Ventilation

  • With pressure support ventilation (PSV), positive pressure is applied to the airway only during a patient-initiated inspiration.

  • Pressure-control inverse ratio ventilation (PC-IRV) combines pressure-limited ventilation with an inverse ratio of inspiration (I) to expiration (E). Because IRV imposes a nonphysiologic breathing pattern, the patient requires sedation with or without paralysis.

  • Airway pressure release ventilation (APRV) permits spontaneous breathing at any point during the respiratory cycle with a preset continuous positive airway pressure (CPAP) with short-timed pressure releases.

Other Ventilatory Maneuvers

  • Positive end-expiratory pressure (PEEP) is a ventilatory maneuver in which positive pressure is applied to the airway during exhalation.

    • With PEEP, exhalation remains passive, but pressure falls to a preset level greater than zero, often 3 to 20 cm H2O.

    • The major purpose of PEEP is to maintain or improve oxygenation while limiting risk of oxygen toxicity.

  • CPAP is similar to PEEP.

    • The pressure in CPAP is delivered continuously during spontaneous breathing, thus preventing the patient’s airway pressure from falling to zero.

    • CPAP is commonly used in the treatment of obstructive sleep apnea and can be administered noninvasively by a tight-fitting mask or an ET or tracheal tube.

  • Automatic tube compensation is an adjunct designed to overcome WOB through an artificial airway.

  • Bilevel positive airway pressure (BiPAP) provides two levels of positive pressure support: a higher inspiratory positive airway pressure and a lower expiratory positive airway pressure along with oxygen.

    • It is a noninvasive modality and is delivered through a tight-fitting face mask, nasal mask, or nasal pillows.

    • BiPAP is used for COPD patients with heart failure and acute respiratory failure and for patients with sleep apnea.

  • High-frequency oscillatory ventilation (HFOV) involves delivery of a small tidal volume (usually 1 to 5 mL per kg of body weight) at rapid respiratory rates (100 to 300 breaths/minute) in an effort to recruit and maintain lung volume and reduce intrapulmonary shunting.

  • Prone positioning is the repositioning of a patient from a supine or lateral position to a prone (on the stomach with face down) position.

  • Extracorporeal membrane oxygenation (ECMO) is a modification of cardiac bypass used for supporting the patient with severe respiratory failure.


Cardiovascular System

  • PPV can affect circulation because of the transmission of increased mean airway pressure to the thoracic cavity.

  • PPV’s effect on circulation results in decreased venous return, decreased left ventricular end-diastolic volume (preload), decreased CO, and hypotension.

Pulmonary System

  • As lung inflation pressures increase, the risk of barotraumas, including pneumomediastinum and pneumothorax, also increases.

  • Volutrauma results in alveolar fractures and movement of fluids and proteins into the alveolar spaces. This can occur when large tidal volumes are used to ventilate noncompliant lungs (e.g., ARDS).

  • Alveolar hypoventilation can be caused by inappropriate ventilator settings, leakage of air from the ventilator tubing or around the ET tube or tracheostomy cuff, lung secretions or obstruction, and low ventilation/perfusion ratio.

  • Respiratory alkalosis can occur if the respiratory rate or tidal volume (VT) is set too high (mechanical overventilation) or if the patient receiving assisted ventilation is hyperventilating.

  • Ventilator-associated pneumonia (VAP), a pneumonia occurring 48 hours or more after endotracheal intubation, occurs in 9% to 27% of all intubated patients.

  • Progressive fluid retention often occurs after 48 to 72 hours of PPV, particularly PPV with PEEP.

Gastrointestinal System

  • Ventilated patients are at risk for developing stress ulcers and GI bleeding.

  • Reduction of CO caused by PPV may contribute to ischemia of the gastric and intestinal mucosa and possibly increase the risk of translocation of GI bacteria.

  • Gastric and bowel dilation may occur as a result of gas accumulation in the GI tract from swallowed air.

  • Immobility, sedation, circulatory impairment, decreased oral intake, use of opioid pain medications, and stress contribute to decreased peristalsis.

Psychosocial Needs

  • The patient receiving mechanical ventilation experiences physical and emotional stress resulting from a variety of stressors.

  • Patients have identified four needs: need to know (information), need to regain control, need to hope, and need to trust. When these needs were met, they feel safe.

  • Patients receiving PPV usually require some type of sedation and/or analgesia to facilitate optimal ventilation.

  • At times the decision is made to paralyze the patient with a neuromuscular blocking agent to provide more effective synchrony with the ventilator and increased oxygenation.

Machine Disconnection or Malfunction

  • Most deaths from accidental ventilator disconnection occur while the alarm is turned off. Most accidental disconnections in critical care settings are discovered by low-pressure alarm activation.

  • Ventilator malfunction may also occur and may be related to several factors (e.g., power failure, failure of oxygen supply).

  • If machine failure/malfunction is determined, patients should be disconnected from the machine and manually ventilated with a BVM and 100% O2.

Nutritional Therapy: Patient Receiving Positive Pressure Ventilation

  • PPV and the hypermetabolism associated with critical illness can contribute to inadequate nutrition.

  • Patients likely to be without food for 3 to 5 days should have a nutritional program initiated within 12 to 24 hours. Enteral feeding via a small-bore feeding tube is the preferred method to meet caloric needs of ventilated patients.

  • Inadequate nutrition and the disuse of respiratory muscles contribute to decreased respiratory muscle strength, delay weaning, decrease resistance to infection, and decrease the speed of recovery.

  • A concern regarding the nutritional support of patients receiving PPV is the carbohydrate content of the diet.


  • Weaning is the process of reducing ventilator support and resuming spontaneous ventilation.

  • The weaning process differs for patients requiring short-term ventilation (up to 3 days) versus long-term ventilation (more than 3 days).

  • Weaning can be viewed as consisting of three phases: preweaning, the weaning process, and the outcome phase.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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