ICU Orientation Manual

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ICU/CCU Only

CompetenciesRead Johns Hopkins MHA Keystone ICU

Project module

Complete Hemodynamic Monitoring and ICPMonitoring self learning modules beforeattending agency nurse orientation class

Verbalization/Demonstration of arterialline/Swan Ganz and ICP set-up withverbalization of normal values duringagency nurse orientation class

General ICU exam covering all systems,including medication calculations

Attendance at 4-hour Pain Management Classfor GCH epidural certi fication must registerfor class

Review Post Cardiac Arrest TherapeuticHypothermia module


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Johns HopkinsMHA

ICU Keystone

Project

Compiled by:

Professional Nursing Development

SK/VA 03, Revised 1/10 FC


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Overview

In November 2003, Garden City Hospital became a participant in a two-three yearJohns Hopkins/ Michigan Hospital Association ICU Keystone Project along with 58

other Michigan hospitals, which is an ongoingculture change of practice in medicine and

nursing. The project is being conducted to improve patient safety and communicationamong caregivers in association with the US Department of Health and Human Services

Agency for Healthcare Research and Quality, Johns Hopkins University, and the Institute

of Healthcare Improvement (IHI).

The objective of the project is to implement evidence-based medicine and nursing andreduce the risk of medical errors:

Implementing the use of specialists who coordinate ICU care with a checklistapproach to daily rounds that encourages communication among multiple

caregivers.

Multidisciplinary rounds/patient goal setting form (see attached) is donedaily and left at the bedside.

Attempting to eliminate bloodstream infections.

Improving care of ventilator patients to reduce dependence on the breathingapparatus, which is a key factor in reducing length of stay and infections.

Accomplished through interventions called vent bundling.~ bundling refers to the interventions specified ~

Developing skills to sustain care of patients with severe infections

Early recognition: Emergency Department, Medical/Surgical units,Obstetrics, etc

Sepsis: Early goal directed therapy

Communication & Symptom Management

Family Centered Care

Developing a comprehensive patient safety program that includes a web-basederror reporting system (ICU only) Completed in 2005.

Please visit the web sites:

http://www.MHA.org

http://www.josieking.org/memories.html

http://www.mharchives.org/ICU/projectoverview.asp
http://www.mha.org/http://www.mha.org/http://www.josieking.org/memories.htmlhttp://www.josieking.org/memories.htmlhttp://www.mharchives.org/ICU/projectoverview.asphttp://www.mharchives.org/ICU/projectoverview.asphttp://www.mharchives.org/ICU/projectoverview.asphttp://www.josieking.org/memories.htmlhttp://www.mha.org/


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Johns Hopkins MHA ICU Keystone Project Interventions

Intervention 1: Cultural Unit Based Safety Program (CUSP):

Patient Safety Initiative

Advocates safety for healthcare providers and patients by participating in:

Cultural safety survey to identify staffs safety concerns

Daily walking rounds with all healthcare providers.

Briefing process

Report session at change of shift with Resident/Charge Nurses

Reporting errors and follow-up on quality reports

Investigate defect: Staff identify defects in frontline caregivers

Implementation of improvements

Disseminating results of the survey and reports

Medical rounds assigned

Executive walking rounds

CEO executive summary (ICU, Progressive and Acute Care)

Intervention 2: Daily Goals and Rounding(Goal: To be a permanent part of the chart)

Evaluates the effect of interventions & to improve communication by utilizing the Daily

Goals Sheet(see attached sheet) during multidisciplinary team rounding to determine:

Safety risks Discharge needs

Scheduled labs/tests Progression of interventions as setForth by JHH/MHA

Family/social issues Pain management and sedation

Cardiac status Consultations

Implemented on 1 East (oncology/medical) & 2C/N (acute/progressive care)


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Intervention 3:Ventilator Bundle

(ICU, Progressive and Acute Care)

For mechanically vented patients (refer to standing order sheet for adult mechanicalventilated patients):

HOB >30 degreesto reduce the frequency and risk for nosocomial pneumonia

Oral care protocol every 2 hours and PRN.

Thromboprophylaxisto prevent deep vein thrombosis (DVT)

Peptic ulcer disease prophylaxisto reduce the risk of UGI bleeding

Daily interruption of sedative drug infusionsto decrease the duration ofmechanical ventilation and length of stay

Intensive insulin therapy: Goal is to maintain blood glucose 100-139mg/dL toreduce morbidity and mortality among critically ill patients.Tight glycemic control protocol (see attached copy) may be instituted if

criteria are met:

Patient must be on a ventilator

Two consecutive blood glucose results of >139 mg/dL or one bloodglucose >200 mg/dL, would initiate an order for an insulin drip

Intensivist/ICU Resident order

Daily screening of respiratory functionfollowed by trials of spontaneous breathing toreduce the duration of mechanical ventilation, decrease complications and cost of care


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Intervention 4: Eliminate Catheter-Related Blood Stream Infections

(CR-BSI) Hospital wide intervention

Compliance with the following interventions will decrease the risk for CR-BSIs:

Appropriate hand washing: Proper hand washing is required before and afterpalpating catheter insertion sites, as well as before and after inserting,replacing, accessing, repairing, or dressing an intravascular catheter

Mandatory use of protective covering for all healthcare providers: Sterilegown, sterile gloves, face shield with mask. Stop procedure if indicateduntil sterility observed.

Use of full-barrier precautions for patient: Full body drape head to foot.

Use of chlorhexidine for skin preparation:Located in all sterile dressing kitsand central line kits

Apply sterile dressing to site with all dressing changes

Subclavian vein placement is the preferred site:Attempt to avoid the femoralsite

Removing unnecessary central venous catheters

Intervention 5: Improvement in Sepsis Care:

Intervention ensures patients receive optimal care by improving sepsis care

(Refer to attached Severe Sepsisjournal article & Standing order sheet for Severe Sepsis)

Prevention:hospital acquired infections such as catheter related blood streaminfections, ventilator-associated pneumonia, surgical site infections, and

urinary tract infections.

Early goal directed therapy (EGDT):proactive approach in patients with aknown or suspected infection.

Appropriate intervention:antibiotics, steroids, activated protein c

Continuum of sepsis:

Systemic inflammatory response syndrome (SIRS)

Sepsis (known or suspected infection)

Severe Sepsis (Sepsis and one or more organ system dysfunction)

Septic shock (Severe sepsis plus hypotension)


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What is Early Goal Directed Therapy (EGDT)?

Early goal directed therapy to restore a balance between oxygen delivery and oxygen

demand are provided during the first 6 hours of suspected or known infection. Patients

may be given intravenous fluids (colloid or crystalloid), vasoactive agents, and bloodtransfusions to increase oxygen delivery. Early identification of severe sepsis is critical

to provide EGDT and improve patient outcomes.

Who is at risk for Severe Sepsis? All critically ill patients

Severe community acquired pneumonia

Urinary tract infection

Chronic Diseaseso Diabeteso Heart failure

o Chronic renal failureo Chronic obstructive pulmonary disease

Intra-abdominal surgery

Meningitis

Compromised immune statuso HIV/AIDSo Use of cytotoxic and immunosuppressive agentso Malignant neoplasmso Alcoholism

Cellulitis

Criteria for Early Goal Directed Therapy (EGDT) forSevere Sepsis and Septic Shock

1. Two or more signs of inflammation:

Temperature >100.4 F (38.0 C) or < 96.8 F (36 C)

Heart Rate >90 beats per minute

Respiratory Rate >20 breaths per minute or PaCO2 12,000 cells/mm3, 10% bands

2. Suspected or confirmed infection.

Positive cultures (blood, sputum, urine, etc.)

Antibiotic, antifungal, or other anti-infective therapy

Documentation of pneumonia (x-ray, ultrasound, etc.) Have WBCs been found in normally sterile fluid

Perforated organ (bowel)

3. Systolic blood pressure 4 mmol/L

Evidence of > 1 organ dysfunction (Severe sepsis)


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References

Ely, E.W. & Bernard, G.R. 2005. Contemporary Diagnosis and Management of Sepsis

Ahrens, T. & Tuggle, D. 2004. Surviving Severe Sepsis: Early Recognition and Treatment. Critical Care

Nurse Supplement October 2004.

Severesepsis overview. http://www.xigris.com/overview/at

Diagnostic Criteria for SepsisInfection, documented or suspected, and some of the following:

General variables

Fever (core temperature >38.3 C)

Hypothermia (core temperature < 36 C)**Heart rate >90 min 1 or >2 SD above the normal value for age

Tachypnea

Altered mental status

Significant edema or positive fluid balance (> 20mL/kg over 24 hours)Hyperglycemia (plasma glucose > 120 mg/dL) in the absence of diabetes

Inflammatory variables

Leukocytosis (WBC > 12,000 uL)

Leukopenia (WBC < 4000 uL)

Normal WBC count with > 10% immature forms**Plasma C-reactive protein > 2 SD above the normal value

**Plasma procalcitonin > 2 SD above the normal value

Hemodynamic variables

Arterial hypotension (SBP< 90 mm Hg, mean ABP < 70, or a SBP decrease > 40 mm Hg)Mixed venous oxygen saturation > 70%

Cardiac index > 3.5 L/min

Organ dysfunction variables

Arterial hypoxemia (PaO2/FIO2 1.5 or activated partial thromboplasm time>60)

Ileus

Thrombocytopenia (plt count < 100,000 uL)

Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 mmol/L)

Tissue perfusion variables

Hyperlactatemia (>1 mmol/L)

Decreased capillary refill or mottling

** SD: Standard Deviation:A parameter that indicates the way in which a probability function or a probability density function is centered

around its mean and that is equal to the square root of the moment in which the deviation from the mean is squared. (Standard Deviation (SD) is nreported on the lab report. To obtain SD lab personnel may be contacted)
http://www.xigris.com/overview/athttp://www.xigris.com/overview/at


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Intervention 6: Communication & Symptom Management

Intervention that encourages promoting a family-centered environment.

Provide family with information, reassurance/support, and opportunity to be nearthe patient.

Obtain clarification about how to meet the needs of the family by asking thefamily members.

Integrate family-centered values in the units standards and policies

Provide family with ICU patient brochure

Be consistent with patients familieso Visiting hourso Pain managemento Treatments

Make family-centered care a multidisciplinary group endeavoro Physicianso Nurseso Respiratory Therapisto Case Managerso Dietary

Discuss challenging cases/concerns at staff meetings and committees.

Documentation Reminders

Completion of daily rounds sheet

Daily interruption of sedative drug infusions (wake-up call)& assessments

Pain assessment/management q2h

Oral care q2h

Communication & Symptom Management
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References

http://www.MHA.org

http://www.josieking.org/memories.html

http://www.mhaarchives.org/ICUgrant/projectoverview.asp

Michigan Health & Hospital Association Members Join Johns Hopkins to Enhance ICU

Safety. Michigan Health & Hospital Association Newsletter. October 22, 2003

Pronovost, P., and Berenholtz, S. Inproving Sepsis Care in the Intensive Care Unit: An

Evidence-Based Approach. VHA Research Series 2004
http://www.mha.org/http://www.mha.org/http://www.josieking.org/memories.htmlhttp://www.josieking.org/memories.htmlhttp://www.mhaarchives.org/ICUgrant/projectoverview.asphttp://www.mhaarchives.org/ICUgrant/projectoverview.asphttp://www.mhaarchives.org/ICUgrant/projectoverview.asphttp://www.josieking.org/memories.htmlhttp://www.mha.org/


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Garden City Hospital

Critical Care Services

Tight Glycemic Control Protocol

PURPOSE:The goal is to maintain a blood glucose range between 100-139mg/dL Regular Human Insulin Concentration =l00units/l00mL 0.9%NaC1

SUPPORTIVE DATA:Hyperglycemia associated and insulin resistances arecommon in both diabetic and non-diabetic critically ill patients. Studieshave reported substantially reduced morbidity and mortality in patientsadmitted to the intensive care unit for mechanical ventilation who hadtight glycemic control (some literature presents 80-1 l0mg/dL).

Significantly fewer deaths due to multiple organ failure with sepsisoccurred with intensive insulin therapy and the length of stay for patientsrequiring more than five days of intensive care was substantially reduced.Bloodstream infections, critical illness, polyneuropathy and duration ofmechanical ventilation were all significantly lower in patients who hadtight glycemic control. Recent studies supporting these findings havefurther defined these benefits by demonstrating a definite relationshipbetween increasing morbidity and mortality and increasing blood sugarlevels.

AOA 29.00.01 Special care Units (SCU): Special care Units exist to provide the

focused use of intensive staff and technologic resources forpatients.

AOA 16.03.00 Standards of Practice and Care: Nursing care is based uponwritten

standards of practice and standards of care.

DOCUMENTATION: Document blood glucose levels and rate changes onNursing Insulin Flow Sheet. Documentation should include the amount ofthe rate change as well as the new drip rate.

SCOPE: RN ICU-CCU

PATIENT POPULATIONS:1. ICU patients with anticipated ICU stays of greater than 24-48 hours.2. The protocol does not apply automatically to patients with diabetic

ketoacidosis hyperosmolar-nonketoacidosis, but may be used for suchpatients at attending physicians discretion.

3. Adult patient receiving mechanical ventilation in a critical care bed.


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4. Diabetic and non-diabetic patients are eligible.5. Discontinue all previous insulin orders including insulin in total parenteral

nutrition.6. Discontinue all antidiabetic medications.

EXCLUSION:1. Hematocrit 55% (lab draw is required in these patients due tolimitations of bedside glucose meter).

INITIAL ASSESSMENT:1. On admission to the ICU and at a minimum once daily, all patients will have

baseline blood sugar ordered. If over 1 39mg!dL, repeat xl after two hours.2.Assess for:

History of DMObesityHow much glucose patient is getting from diet, 1Vs, IVPB, etc.

Medications (steroids, anti-diabetic medications)Nutrition Support

CRITERIA FOR INITIATION OF PROTOCOLREQUIRES PHYSICIAN ORDERand one of the following:1. Two blood glucose values greater than 139 mg/dL or;2. One blood glucose value greater than 210 mgIdL3. Unstable blood glucose values on sliding scale

TRIGGERS FOR DISCONTINUATION OF PROTOCOL/CONVERSION TOLONG OR INTERMEDIATE ACTING INSULIN PLUS SLIDING SCALE(REQUIRES PHYSICIAN ORDER).

1. Patients ability to eat and is eating, has received their 1 dose of subcutaneousinsulin or when patient is normoglycemic while receiving < 2 units per hour.

2. Glucose less than 8Omg/dL x 3 consecutive measurements.3. Glucose less than 140 mg/dL on stable insulin dose for more than 12 - 24

hours.4. Notify physician of any or all of the above. Ask physician to consider

discontinuation of insulin infusion and initiation of longer acting insulin andsliding scale coverage when infusion rate and blood glucose is stable for 12 -24 hours.

ADMINISTRATION1. Standard insulin drip = 100 units regular human insulin in l00ml 0.9% NaCL.2. Administer insulin via an infusion pump.3. Insulin drip must be changed at least every 24 hours.

INITIAL DOSE1. Bolus and infusion rate=Blood Glucose divided by 100.


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2. Round to nearest 0.5 unit (nearest half of a unit). For example: If a patient hasa blood glucose = 258, Initial bolus = 2.5 unitsInitial infusion rate = 2.5 units per hourInitial Blood Glucose (mg/dL)Initial Bolus

Initial Infusion Rate (100 units regular insulin/100 mL NaC1)

Initial Blood Glucose (mg/dL) Initial Bolus Initial Infusion Rate (100units regular insulin / 100mL NaCl)

140 - 175 1.5 units 1.5mL / hour

176 - 225 2 units 2 mL / hour

226 - 275 2.5 units 2.5 mL / hour

276 325 3 units 3 mL / hour

326 375 3.5 units 3.5 mL / hour

>376 4 units 4 mL / hour

KEY POINTS:1. If blood glucose falls 50 mg/dL between 2 consecutive readings and current

blood glucose is 200mg/dL:decrease insulin drip by 50% (round up to thenearest 0.5 units).

2. If blood glucose falls> 50 mg/dL between 2 consecutive readings and currentblood glucose is > 200 mg/dL:continue insulin drip at the current rate.

3. Notify ICU Resident/Intensivist if Blood Glucose> 400 mg/dL or if there is achange >100 mg/dL in one hour.

FREQUENCY OF TESTING:While insulin is infusing, either finger sticks (bedside glucose testing) or serumglucose measurements should be taken every hour X 4. Then glucose checkscan be reduced to every 2 hours until 4 consecutive values remain in the desiredrange with no change in infusion rate, then glucose checks can be reduced toevery 4 hours. Every 2-hour testing should be continued or resumed if any of thefollowing occur: changes in clinical condition, changes in nutrition, and changesin steroid or pressor therapy. STAT blood glucose should be checked if patientshows sign of hypoglycemia.

NUTRITION PROTOCOL:If tube feedings, TPN, or other forms of nutrition are held for >1 hour, hold insulininfusion; check blood glucose every 6 hours. When nutrition is restarted, resumeinsulin drip at the previous rate and resume blood glucose checks as listed insection entitled, Frequency of Testing.


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SPECIAL CIRCUMSTANCES:Stop insulin infusion if the patient is off the unit for more than 1 hour and bloodglucose monitoring cannot be continued. When nutrition is restarted, resumeinsulin drip at the previous rate and resume blood glucose checks atthe previous rate and resume BG checks as listed in section entitled, Frequency

of Testing.

HYPOGLYCEMIA PROTOCOLIn this protocol hypoglycemia is defined as blood glucose < 70mg/dLIf blood glucose


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REFERENCES:Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulintherapy in critically ill patients. N EnglJMed200l; 345:1359-67.Evidence Based Rating Scale :Level V

Finney SJ, Zekveld C, Elia A, et al. Glucose control and mortality incritically ill patients. JAMA. 2003;290:204l-2047.Evidence Based Rating Scale :Level V

MHA Website

ADA Website, 2008

ADA Nutrition Recommendation and Interventions for DiabetesPosition Statement, Diabetes Care, Volume 31, Supplement IJanuary, 2008.

Policy and Procedure collaboratively developed and approved by the CriticalCare and Pharmacy and Therapeutics Committees. May 2005

APPROVAL: Critical Care CommitteePharmacy Department

DISTRIBUTION: Critical Care Unit Based Clinical Policy and Procedure Manual

REVIEW :8/06, 10/08

REVISION: 1/09


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Arterial Line and Swan Ganz Set-up

Competency for Agency Nurse Staff

Name: ________________________________ Date: ________________________

Behavioral Objective: Demonstrate proper set-up of equipment for arterial lines and Swan Ganz.

Verbalize pressure of each chamber: RAP (CVP), PAP, PCWP.

Competency Method of

Verification

Reviewer

Title,

Initial

and DateArterial Lines

I. Verbalize and gather equipment.

II. Demonstrate set-up pressure lineIII. Verbalize zeroing line after demonstration

of leveling phlebostatic axis

IV. Verbalize maintaining pressure bag at ___at all times and flush q ___ hour and PRN

V. Verbalize method for obtaining bloodspecimen from arterial line

VI. Demonstration calculation of MAP

VII. Verbalize normal arterial SBP and DBPVIII. Verbalize nursing responsibilities and

troubleshooting

Verbalize andDemonstrate

Swan GanzI. Verbalize and gather equipmentII. Demonstrate set-up pressure lineIII. Verbalize preparation of room and patientIV. Verbalize assisting physician and remaining

at the bedside throughout the procedureV. Verbalize recording waveforms and

documenting strips in the chart

VI. Demonstrate interpreting waveformsVII. Verbalize pressure of each chamber:

RAP (CVP):

PAP:PCWP:VIII. Verbalize and demonstrate identifying

placement of catheter

IX. Verbalize procedure for removal of PA lineafter physician order obtained.

X. Verbalize Nursing Responsibilities andtroubleshooting



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XI. Verbalize use of catheter ports:Distal Lumen - Yellow:

Proximal Port - Blue:

Distal Port - White:Red:

Temperature probeXII. Verbalize procedure for performing CardiacOutput:

*Preparation

*Procedure

Verifying Signature: _________________________________ Date: ____________

Comments:

SK/07, revised FC/10


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GARDEN CITY HOSPITAL

CRITICAL CARE SERVICES PROTOCOL

CARE OF PATIENT WITH INTRACRANIAL PRESSURE MONITOR

PURPOSE: To direct the caregiver in the care and management of the patientwith Intracranial Pressure (ICP) Monitor.

SUPPORTIVE DATA: Continuous measurement of intracranial pressure (ICPprovides useful information in patients with intracranialhypertension and in patients at risk for developing intracranialhypertension ICP recording is achieved by operative (burr-hole)placement of an epidural pressure transducer or alternatively byinsertion of an intraventricular catheter.

AOA 16.03.04 Standards of Care; Standards of care describes the applicationnursing technique / intervention to specific patient problems,needs, and nursing diagnoses.

AOA 29.00.01 Special Care Uni ts (SCU); Special Care Units (SCU) exist toprovide the focused use of intensive staff and technologicresources for patients.

CONTENT STEPS:1. Position patient to prevent flexion of the neck or hips. Neck, head

and extreme head flexion increase ICP. Head rotation of 90degrees to either side may also result in increased ICP. Head ofbed should be elevated 30-45 degrees (unless otherwise ordered)to improve venous drainage from the head. Normal levels ICP 4-15mm hg.

2. Initially record ICP, MAP, CPP every 15 minutes to establish atrend.

A. MAP mean arterial pressure by A-line or by non-invasiveblood pressure monitoring with the following formula:

MAP = diastolic BP x 2 + systolic BP 3

B. CPP cerebral perfusion pressure may be altered byhypertension or hypotension. It may also be affected byincreased ICP. Normal range CPP= 60-90 mmHg. Inpatients being monitored with ICP, CPP is not allowed tofall below 50mmHg. CPP is calculated with the followingformula:

CPP = MAP ICP mmHg


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3. Subsequently record ICP, MAP, CPP every 1 hour.4. Inform physician if:

MAP < 60ICP > 20CPP < 50

5. Utilize neurological assessment sheet to record level ofconsciousness, GCS, MAP, ICP, CPP.

6. Concentrate nursing care activities into schedule blocks of timeto avoid over stimulation of the patient.

7. Avoid frequent inducement of cough reflex. Hyperventilateprior to suctioning patient.

8. Monitor for HA, nausea, vomiting, seizure activity, changes inventilator patterns, hyperthermia, posturing, decerebrate or

decorticate, increased diuresis, papilledema and Cushingstriad (irregular respiratory pattern, widening pulse pressure andbradycardia.

9. Avoid hypothermia and hyperthermia.10. Avoid excessive fluid intake.11. Avoid stimulating valsalva movements.12. The site must be kept clean and dry and should be covered

with an occlusive dressings at all times.

CROSS REFERENCE: Intracranial Pressure MonitoringCamino, Becker, Goeltec

REFERENCE: AACN Procedure manual for critical care 4thedition Lynn-McHale, Carlson; WB Saunders Zool, 2001 pp 561-569

Nursing Assessment and Management of Patients with HeadInjuries, LeJeune, Gerard M., Howard-Fain, Tamara. Dimensionsof Critical Care Nursing, Nov 2002 Vol 21.

Caring for patient swith increased intracrancial pressure. LeJeune, M.RN, Howard-Fain, Tamara, RN, Nursing 2002Evidence Based Rating Scale: Level II

Nursing Procedures and ProtocolsLippincott, Williams, and Wilkins 2003 pp 393-398Evidence Based Rating Scale: Level II

Critical Care Nursing Reference, Fourth Edition, Mosby, 2006Pp 463-468Evidence Based Rating Scale: Level II


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APPROVAL: Critical Care CommitteeNeurology Department


REVIEW:6/99, 5/2000, 7/03, 1/05, 11/06, 10/08

REVISION:6/99, 1/05


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GARDEN CITY HOSPITAL

CRITICAL CARE SERVICES PROCEDURE

BECKER INTRACRANIAL PRESSURE MONITORING SYSTEM INSERTION

PROCEDURE

PURPOSE:To direct the caregiver in preparing the patient and the equipment fortheinsertion of the Becker Intracranial Pressure Monitoring System.

SUPPORTIVE DATA:A physician order is required. Intracranial pressure monitoring isutilized to monitor intracranial pressure and evaluate for trends inpressures and therapeutic interventions. Danger signals of

increased intracranial pressure (ICP)1. Level of consciousness (LOC) changes2. Increased blood pressure3. Decreased apical rate4. Onset hemiparesis5. Pupillary changes6. Sudden headache or worsening headache7. Vomiting

AOA 16.03.04 Standards of Care: Standards of care describe the application ofnursing technique / intervention o specific patient problems,

needs, andnursing diagnoses.

AOA 29.00.01 Special Care Uni ts (SCU): Special Care Units exist to providethe focused use of intensive staff and technologic resources for patients.

SCOPE: RN CCU/ICU

EQUIPMENT LIST:1. Becker External Drainage and Monitoring System2. Mounting bracket3. IV pole4. Transducer pressure monitoring system (no flush system:

Baxter Tru-Wave Disposable Pressure Transducer withStopcock.)

5. Preservative free 0.9% NS Solution 250 ml6. Surgical mask, gown, sterile gloves, towels7. Standard Monitoring set8. Cranial Access (separate package) in Pyxis


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CONTENT STEPS:Refer to figure 1.0 1.3 for the following content steps

A. Equipment Set-Up1. Obtain all equipment2. Remove Becker system wearing a surgical face mask and

sterile gloves.3. Check to ensure that all components are assembled and all

connections are tight and leak free.4. Remove air from saline bag by inserting a 23 gauge 1-inch

needle into additive port and squeezing bag.5. Connect standard monitoring set to main stopcock, flush

tubing from main stopcock through patient line, then from mainstopcock through Becker tubing system.

6. Discard standard monitoring tubing and IV bag and attach thenon- flush tru-wave valve to the main stopcock. Keep clampopen to drainage bag while flushing (this is done by removingred dead end plug and tightening transducer to stopcock.

7. Attach Becker system to pole clamp. The zero reference mark;main pole clamp and main system stopcock will all line up atthe Foramen of Monroe (zero mark). Do not change zeroreference.

8. Check system for any residual air bubbles. Air can beremoved by combined injection of saline and aspiration of airvia 25 gauge needle at injection sites on patient line stopcockor patient line.

9. Ensure no fluid comes through filter at top of collectionchamber. (If filter becomes wet a new system must beobtained).

B. Equipment Connection to Patient To be completed byPhysician.

1. Before attaching system to patient; zero, drainage/monitoringsystem to Foramen of Monroe.

2. Connect catheter to pre-filled system; *Remember to turn patientline stopcock to off position. Remove patient line dead end capand connect.

3. Care should be taken to ensure that the catheter and completesystem is devoid of any air bubbles.


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C. System Calibration1. Level transducer with Foramen of Monroe. (Between top of ear

and end of eyebrow).

2. Turn stopcock off to patient and open to air3. Drop flow chamber to zero; monitor will read zero (0), when zeroon monitor pressed. Then raise chamber to 20-22 mmHg toverify accuracy monitor should read 22+ or one.

4. Use cm H20 and set scale (verify physician order formeasurement units)

5. If catheter changed, system is changed.

D. Sampling needed:

1. Open sample port stopcock.2. Use a syringe with barrel pulled back 1cc before needle placed inport.

a. Place needle in port and let drain; then pull cut needleand send specimen.

b. DO NOT pull on barrel of syringe.c. Document color of specimen and amount taken.

E.Trouble Shooting for system malfunction1. Turn stopcock near patient off to patient.2. Mount on IV pull set up.3. Flush collection chamber if not done. See step 1 of original setup4. Take needle and syringe and pull back for fluid fill and air bubble

removal or flush forward to where stopcock is. Can use 20ccsyringe with normal syringe and flush up to chamber with bagopen at bottom.

5. All injection sites should be cleaned with alcohol and thenalcohol allowed to dry before a needle is inserted into them.

6. Sterile technique should be observed in setting up the system.7. The main stopcock must be correctly aligned with the patient for

accurate pressure monitoring.8. Mounting panel must be securely mounted. If the panel is

allowed to drop, reduction in system pressure will result and over-drainage of CSF may occur.

9. Always ensure stopcocks are in the proper position for themaneuver being carried out.

10. Be aware waveform if it dampens, check entire system.


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F. To Replace Drain Bag1. Close flow chamber slide clamp.2. Remove the bag from the system mounting panel using sterile

technique.

3. Disconnect the drainage bag connection line. Discard the bag.

DOCUMENTATION:1. Document date and time of initial insertion and set up of the

Becker ICP system.2. Tag the line for start date and change date.3. Document in nurses notes initial readings and readings at least 2

hours or at intervals as ordered. Document any proceduresperformed that may increase or decrease ICP.

SEE ATTACHMENTS.

REFERENCES:Becker EDMSII Booklet

AACN Procedure Manual for Critical Care 4thedition.Lynn-McHale, Carlson; WB Saunders Zool, pp 561-569.

Evidence Base:Level II

Sole, Klein, Moseley, Introduction to Critical Care Nursing,5thEdition; Chapter 13, Nervous System Alterations, p. 393Evidence Based Rating Scale: Level II

APPROVAL: Critical Care Committee


REVIEW:3/91, 1/05, 11/06, 10/08

REVISION:11/95, 1/97, 1/98, 8/00, 7/03, 1/05, 8/06


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Name: ________________________ Date: ____________

Intracranial Pressure Monitoring Post-Test

1. Name two functions of a Becker ICP monitor/drainage system:

_____________________________________________

_____________________________________________

2. List the three components within the skull that determine ICP:

_____________________________________________

3. Calculate the CPP based on the values below: ___________

MAP=82 ICP=12

4. When would you expect an increase in P1 amplitude?a. Development of a mass

b. Increased CSF volume

c. Hypertension

d. Increased Venous Volume

5. An elevation in which wave would indicate poor compliance within the

skull?

a. P1

b. P2

c. P3

6. List three symptoms associated with increased ICP:

_______________________________________________

7. What three components make up Cushings Triad? (circle all that apply)

a. Irregular respiratory pattern

b. Narrowing pulse pressure

c. Widening pulse pressure

d. Bradycardiae. Tachycardia

8. True or False: Maintenance of any ICP monitor should be done

sterilely.

FC/10


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Becker ICP Set Up

Competency for Agency Nurse Staff

Name: ________________________________ Date: ________________________

Behavioral Objective:

Demonstrate proper set-up of equipment for Becker ICP.

Verbalize normal values ICP and CPP.

Competency Method of

Verification

Reviewer

Title, Initial

and Date

Becker ICP

VI. Verbalize and gather equipment.VII. Demonstrate set-up pressure lineVIII. Verbalize zeroing after demonstration of

leveling at Foramen of Monro

IX. Verbalize maintaining pressure bag at ___at all times

X. Verbalize method for obtaining CSFspecimen

VI. Demonstration calculation of CPP

IX. Verbalize normal ICPX. Verbalize nursing responsibilities and

Troubleshooting

XI. Verbalize signs and symptoms of increasedICP


Verifying Signature: _________________________________ Date: ____________

Comments:

FC/10


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Post Cardiac Arrest

Therapeutic

Hypothermia

Self Learning Module

For ICU RNs


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Why Use Therapeutic Hypothermia?

Brain temperature during the first 24 hours after resuscitation from cardiac

arrest may have a significant effect on survival and neurological recovery.

Cooling to 32-34 degrees Celsius for 24 hours may decrease chance of deathand increase the chance of neurological recovery. Hypothermia activates the

sympathetic nervous system causing vasoconstriction and shivering. Shivering

increases oxygen (O2) consumption by 40-100%. Sedatives, opiates, and

neuromuscular blockers can counteract these responses and enhance the

effectiveness of active cooling.

How Does Therapeutic Hypothermia Work?

Hypothermia shifts the oxyhemoglobin curve to the left and may result indecreased O2 delivery. However, the metabolic rate is also lowered, decreasing

O2 consumption/carbon dioxide (CO2) production. Ventilator settings may

need to be adjusted due to decreased CO2 production, using temperature

corrected blood gases. Hypothermia initially causes sinus tachycardia, then

bradycardia. It is extremely important to keep the patients temperature >30

degrees Celsius as temperatures


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Who Is Eligible For Therapeutic Hypothermia at Garden City Hospital?

Adults over the age of 18 (Women must have a negative UCG)

Witnessed cardiac arrest with a ROSC (return of spontaneous

circulation) to a systolic blood pressure >90, with or without the use ofvasoactive medications

Unresponsive at enrollment with a GCS (Glasgow coma scale) 12 hours since ROSC

Glasgow Coma Scale >8

Minimal pre-morbid cognitive status

Other reason for coma (i.e. drug overdose as etiology for arrest) and/or

intracranial pathology (i.e. intracranial hemorrhage, ischemic stroke),

subarachnoid hemorrhage (SAH), sedation

Sepsis as etiology for arrest

Uncontrollable bleeding/Pre-existing coagulopathy or bleeding if

known: INR > 3.0, Platelets < 30,000

Significant trauma, especially intra-abdominal such as splenic or liver

laceration (due to increased risk of bleeding)

What Supplies Do I Need To Prepare?

Two one liter bags of 4 degrees Celsius 0.9% NS (stored in the

ED/ICU refrigerators)


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pack the patient in ice (groin, sides of chest, axilla and neck). DO NOT

STOP COOLING DURING TRANSPORT OF PATIENT.

Gaymar Cooling Device Settings

Initially set the machine to rapidcooling automatic mode with target

temperature of 34 degrees Celsius. Once the patient reaches 34 degrees

Celsius, set gradualcooling automatic mode to 33 degrees Celsius. Assess the

cooling blanket settings and patients temperature in degrees Celsius. Cooling

is maintained for 24 hours from the time the target temperature, between 32-

34 degrees Celsius is reached. KEEP THE GAYMAR UNIT PLUGGED IN

AT ALL TIMES.

Monitoring The PatientTemperature

Our goal is to maintain the patients core temperature between 32-34 degrees

Celsius for 24 hours. Maintain the patient blanket temperature at 33 degrees

Celsius in gradual automatic mode, assess and document the patient temp

hourly. If ice packs are being used, add or remove ice packs to maintain the

core temperature of 32-34 degrees Celsius. If the patients temperature drops

to < 31 degrees Celsius, consider infusing 250 ml boluses of warm 40 degree

Celsius 0.9 Normal Saline or LR until temperature >32 degrees Celsius.

Monitor closely for arrhythmias if patient temperature < 32 degrees Celsius.

Skin assessments should be completed and documented every 6 hours.

Hemodynamics

Vital signs are to be documented every 15 minutes for the first hour, then

hourly. Maintain a MAP 65-120 mmHg with IV fluids, vasopressors or

nitrates if needed. Levophed is included in the standing orders to start at

1mcg/min, titrate to keep MAP 80-100mmHg (Max dose 30mcg/min, RN to

call pharmacy when needed).

Laboratory

Request temperature correction when blood gas values are being calculated.

Patients may require intensive glucose control. If the blood glucose is

>150mg/dl X 1, initiate the Tight Glycemic Control Protocol. Urine output

should be documented at least every two hours. Hypothermia induced

diuresis is common, aggressive fluid replacement may be required. If an acute

decreased in urine output is detected, confirm bladder contents with bladder


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scanner. The patient will have serial labs drawn throughout the procedure

contact physician if:

Potassium < 3.4

Magnesium < 2

Calcium < 8

Uncontrolled shivering

Heart rate < 50 or > 110 beats per minute

Systolic blood pressure < 80mmHg or > 180 mmHg

Any change in Troponin value

Shivering

Shivering is a bodily response to early hypothermia. When the core body

temperature drops, the shivering reflex is triggered. Muscle groups around thevital organs begin to shake in small movements in an attempt to create

warmth by expending energy. The approach towards shiver control involves

the combined us of pharmacological and non-pharmacological interventions.

The goal of these therapies is to achieve a Bedside Shivering Assessment Scale

score of 0.

BSAS Score Treatment

0 = none None reassess in 30 minutes

1 = Mild (localized to neck

and/or thorax only

2 = Moderate (gross movement

of the upper extremities)

3 = Severe (gross movement of

the trunk & upper & lower

extremities

Meperidine (Demerol) 25mg IVP,

may repeat q15 minutes prn x 3doses, if ineffective, in any 6 hour

period (Maximum 75mg). PLUS

Buspirone 30mg down OGT

(synergistic with Meperidine) Q 12

hours PRN X 24 hours.

If Meperidine ineffective,

administer: Roccuronium

(Zemuron) 50 mg every 30 mins

PRN and reassess in 30 minutes(RN to call pharmacy when

needed).

Magnesium Sulfate 1-3

grams/hour gtt for persistent

shivering (RN to call pharmacy

when needed).


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Medications For Sedation/Analgesia

Administer sedatives using the Richmond Agitation Sedation Scale (RASS).

Our goal is (-4) deep sedation, these scores should be documented hourly.Begin sedation with Propofol at 5mcg/kg/min, increase every 5 minutes by

5mcg/kg/min, with a maximum dose of 50mcg/kg/min. Add Fentanyl drip

in addition when Propofol is maximized. Begin Fentanyl at 1mcg/kg slow IVP

then start drip at 50mcg/hr. Increase infusion by 25mcg/hr every 30 minutes,

if needed, with a maximum dose of 150mcg/hr (RN to call pharmacy when

needed). Add Lorazepam in addition to Propofol and Fentanyl when they are

maximized. Give Lorazepam 2mg IVP every 30 minutes until sedation goal

achieved then start drip at 1mg/hr. Increase infusion by 1mg/hr every 30

minutes, if needed with a maximum dose of 10mg/hr (RN to call pharmacywhen needed).

RASS Scale

Re-Warming

Begin re-warming 24 hours after target temperature reached. Re-warm

gradually in a controlled manner to avoid vasodilatation and hypotension.

Our goal is to re-warm the patient over 6-8 hours. Re-warming too rapidly can

cause vasodilatation, hypotension, and rapid electrolyte shifts. Our goal is to

maintain a MAP of 80-100mmHg. Anticipate a reduction in cardiac output

and BP (decreased CVP) as the cooler blood shifts from the core to the


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extremities. Follow the CVP closely; aggressive IV fluids may be necessary to

maintain adequate volume status during re-warming.

Gaymar: Increase the blanket temperature setting by 0.5 degrees

Celsius every 1-2 hours.

Passive Re-warming: Remove all cooling devices and cover patientwith a sheet.

Assess and document vital signs with CVP every 1 hour until temperature

reaches 36 degrees Celsius. Monitor K+ every 4 hours and prn. Monitor

serum glucose levels every 1 hour until temperature reaches 36 degrees

Celsius. As insulin resistance resolves, the patient is at risk for hyperglycemia.

Follow ABGs as needed with temperature corrected values. Adjust ventilator

settings according to the physician orders. Maintain paralysis until patient

temperature > 36 degrees Celsius, then discontinue. Titrate sedation to

comfort and ventilator synchrony as per physician orders.

Celsius Fahrenheit

30.0 86.0

30.5 86.9

31.0 87.8

31.5 88.7

32.0 89.6

32.5 90.5

33.0 91.4

33.5 92.3

34.0 93.2

34.5 94.1

35.0 95.0

35.5 95.9

36.0 96.8

36.5 97.7

37.0 98.6

37.5 99.5

38.0 100.4

Reference:Hypothermia after Cardiac Arrest Study Group. (2002). Mild

Therapeutic Hypothermia to Improve the Neurologic Outcome After Cardiac

Arrest. New England Journal of Medicine, 346(8):549-556.


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Bernard SA, Gray TW, Buist MD, et al. (2002). Treatment of Comatose

Survivors of Out-of-Hospital Cardiac Arrest With Induced Hypothermia. New

England Journal of Medicine, 346(8): 557-563.

Zeiner A, Holzer M, Sterz F, et al. (2001). Hyperthermia After Cardiac Arrestis Associated with an Unfavorable Neurologic Outcome.Arch Intern Med,

161(16): 2007-2012.

Documents

ICU Orientation Manual