Fundamentals of Critical Care

Ian Peate OBE FRCN is Senior Lecturer, Roehampton University; Visiting Professor of Nursing, St George’s University of London and Kingston University London; Visiting Professor, Northumbria University; Visiting Senior Clinical Fellow, University of Hertfordshire, and Editor-in-Chief of the British Journal of Nursing.Barry Hill is the Director of Education (Employability) for Nursing, Midwifery and Health at Northumbria University. His academic practice includes teaching and learning as well as research which impacts on undergraduate, postgraduate and CPD programmes. He specialises in clinical education relating to acute and critical care, and advanced level practice.

• Contributors xixPreface xxvAcknowledgements xxviiHow to use your textbook xxixAbout the companion website xxxiChapter 1 The critical care unit 1Vikki ParkIntroduction 2Levels of care 2The critical care environment 2Critical care patients 3Level 1 care 4Level 2 care 4Level 3 care 4Critical care competence 5The interprofessional team 6Communication 7Ways of working 7Understanding philosophies of care 8Humanising critical care 8Surviving critical care 9Death in critical care 9Resilience 9Nursing considerations and recommendations for practice 11Future challenges 11Conclusion 11References 12Chapter 2 Organisational influences 14Vikki ParkIntroduction 15The four UK nations 15Legislation 15Professional Statutory Regulatory Bodies (PSRBs) 15Shared decision making 16Capacity for shared decision making 16Confidentiality 17Decisions relating to end-of-life care 17Risk management 18International influences 18National influences 18UK government organisations 18Networks 19National guidelines 20Quality assurance 20Local policies 21Nursing considerations and recommendations for practice 21Conclusion 21References 22Chapter 3 Legal and ethical issues 24Leonie Armstrong, Tracey Carrott, and Jacqueline NewbyIntroduction 25Confidentiality 25End-of-life care and best interest decisions 26Ethical themes 27Mental Capacity Act 27Organ donation 29Consent (authorisation in Scotland) for organ donation 30First person consent 31First person opt-in 31First person opt-out 31Appointed/nominated representative (not Scotland) 31Deemed consent 31The ethics of deemed consent 32Consent from a person in the highest-ranking relationship 32Cadaveric organ donation 33The organ donation process 33Post organ retrieval 34Organ allocation 34Conclusion 35References 35Chapter 4 Professional issues in critical care 37Aurora MedonicaIntroduction 38Opportunities for learning 38NMC Code in critical care units: journey to independent, safe practice 38The core principles 39UK National Competency Framework: critical care 41Development of critical thinking in healthcare 42The prioritising process 42Support systems: the student 44Conclusion 44References 45Chapter 5 Using an evidence-based approach 46Sadie Diamond-Fox and Alexandra Gatehouse Introduction 47What is evidence-based practice (EBP)? 47Step 1: formulating a clinical question – the PICO method 48Step 2: locating the evidence/research: performing a systematic literature review 48Step 3: critical appraisal and the hierarchy of evidence 49Step 4: extracting the most relevant and useful results 51Step 5: implementing research into practice 52Quality healthcare in critical care 53Clinical audit and quality improvement 53Research and development in critical care 55Conclusion 56References 56Chapter 6 Nursing care 58Sarah Crowe and Fiona McLeodIntroduction 59Standards of care 59Physical care 63Mobility 66Critical care bundles 67Conclusion 67References 68Chapter 7 Skin integrity 70Victoria ClemettIntroduction 71Anatomy and physiology of the skin 71Impact of ageing on skin and tissue integrity 71Pressure ulcers 71Nursing assessment 75Prevention of pressure ulcers 76Management of pressure ulcers 79Wound healing 79Patient factors that affect wound healing 79Nursing assessment 79Recognising wound infection 81Management of non-healing wounds 83Conclusion 83References 84Chapter 8 Shock 86Barry HillIntroduction 87Shock 87Hypovolaemic shock 87Blood analysis 88Multiple organ dysfunction syndrome 89Staging of hypovolaemic shock 89Principles of managing hypovolaemic shock 90Fluid resuscitation 91Training and education for Registered Nurses 91Cardiogenic shock 91Obstructive shock 93Altered pathophysiology 93Tension pneumothorax 94Cardiac tamponade 94Pulmonary embolism (PE) 94Distributive shock 95Conclusion 96References 97Chapter 9 Communication 98Paul JebbIntroduction 99Communicating effectively with patients 100Communicating during a pandemic 100Communication with families 102Conclusion 103References 103Chapter 10 Electronic health records 105Timothy KuhnIntroduction 106Digitisation within healthcare 106Understand your responsibilities and the law in relation to record keeping 107Intensive Care Society Guidelines 107Understanding the different types of EHRs in critical care and how they are used 108Understanding what patient data is available within the critical care unit and how this is recorded in an electronic health record 109Understanding how EHRs are used in critical care audit and research 110Understanding the benefits and barriers to EHRs 112Conclusion 113References 113Chapter 11 Pharmacology 115Sadie Diamond-Fox and Alexandra GatehouseIntroduction 116Principles of pharmacology and pharmacotherapy 116The processes of drug therapy 116Medication safety in critical care 119Drugs and dialysis 120Core drugs utilised within critical care 120Respiratory drugs 120Cardiovascular drugs 122Haematological drugs 126Renal drugs 126Fluids and electrolytes 127Gastrointestinal drugs 128Insulin 129H2-histamine antagonists and proton pump inhibitors (PPIs) 129Anti-emetics 129Laxatives and anti-diarrhoeal drugs 130Neurological drugs 130Analgesics 130Opioids 130Non-opioid analgesics 130Epidural and regional anaesthesia 130Sedatives and anxiolytics 131Muscle relaxants 131Anticonvulsants 132Antideliriogenics 132Immunomodulatory drugs 132Antibacterial agents 132Antifungals 133Antiviral drugs 134Corticosteroids 134Immunoglobulins 134Toxicology 134Conclusion 135References 135Chapter 12 Anaesthesia and sedation 138Lorraine Mutrie and Iain CarstairsIntroduction 139Indications for sedation and anaesthesia 139Anaesthetic and sedative medications 142Sedative drugs 142Neuromuscular blocking agents and reversal agents 143Sedation management 145Conclusion 147References 148Chapter 13 Medicines management and drug calculations 150Jan GuerinIntroduction 151Purpose of pharmacological interventions in the critically ill adult patient 152Legal and professional issues 152Collaborative multidisciplinary team working 154Medication errors 154Overview of routes and methods of administering medications in CCU 155Rights of medication administration 158Managing and reporting a medication error 159Anaphylaxis 160Pathophysiology and clinical manifestations of DIA 160Management for DIA 160Medication calculation formulae 160Displacement 165Conclusion 165References 166Chapter 14 Neurological critical care 167Samantha O’DriscollIntroduction 168Neurological anatomy and physiology 168Central nervous system 169Neurological assessment 174Signs and symptoms of increasing ICP 179Primary and secondary brain injury 180Management of raised ICP 180Nursing care 181Transfer 182Conclusion 184References 184Chapter 15 Cognition 186Barry Hill and Sadie Diamond-FoxIntroduction 187Cognitive impairment 187Causes of cognitive impairment 187Signs of cognitive impairment 188Delirium 188Risk factors 190Management of delirium 191Sleep 193Assessment of sleep in ICU 193Conclusion 195References 195Chapter 16 Respiratory care: intubation and mechanical ventilation 197Barry Hill and Lorraine MutrieIntroduction 198Respiratory failure 198Hypoventilation 198Ventilation/perfusion (V/Q) mismatch 199Work of breathing 199Arterial blood gases (ABGs) 200Non-invasiveventilation (NIV) 201Continuous positive airway pressure (CPAP) 204High flow nasal oxygen 204Intubation 204Mechanical ventilation 206Artificial ventilation 207Minute ventilation (Vm) 207Fraction of inspired oxygen 207Positive end-expiratorypressure (PEEP) 207Volume control 207Pressure control 207Inspiratory:Expiratory (I:E) ratio 208Inverse ratio 208Synchronisation 208Humidification 208Benefits of mechanical ventilation 208Risks of mechanical ventilation 208Ventilator care bundles 209Prone positioning 209Prone positioning in COVID-19 209Weaning from mechanical ventilation 210Conclusion 210References 211Chapter 17 Lung function in critical care 213Rana Din and Joyce SmithIntroduction 214Anatomy and physiology 214Composition of air 215Alveolar gas 215Expired air 216Lung volumes 216Pulmonary ventilation 216External respiration 217Ventilation/Perfusion 217Transport of gases 217Internal respiration 218Assessment of lung function 220Normal breath sounds (vesicular) 221Absent Sounds 221Wheeze 222Crackles 222The work of breathing 222Compliance 222Resistance 222Emphysema 222Asthma 223Obstructive sleep apnoea 224Prone positioning 224Conclusion 225References 226Chapter 18 Cardiac physiology 227Paul SinnottIntroduction 228Functions of the cardiovascular system 228Anatomy of the heart and great vessels 228Pericardium 229Layers of the heart 229Chambers of the heart 230Valves of the heart 230Coronary circulation 232Cardiac conduction system 235The cardiac cycle 236Cardiac output and blood pressure 237Regulation of heart rate 238Stroke volume 239The regulation of blood pressure 240The microcirculation 242Capillary exchange 243Effects of ventilation on the cardiovascular system 245Conclusion 245References 246Chapter 19 Cardiovascular critical care 247Alice Shaw and Paul SinnottIntroduction 248Cardiovascular assessment 248Heart rate and rhythm 248Atrial ectopic beats 249Ventricular ectopic beats 253Blood pressure 254Invasive blood pressure monitoring 255Central venous catheters (CVCs) and central venous pressure (CVP) 256Markers of organ and tissue perfusion 258Neurological status 258Urine output 258Blood results 259Advanced haemodynamic monitoring 260Cardiac pacing 262Nursing considerations and recommendations for practice 263Conclusion 263References 263Chapter 20 Fluids and electrolytes in critically ill patients 265Barry HillIntroduction 266The role of the critical care nurse 266Intravenous fluids 266Crystalloids versus colloids critical care 267Fluid management 268Third spacing 269Assessment and monitoring 269Training and education 271Electrolyte replacement therapy 271Management of hyperkalaemia 272Oral sodium and water 272Oral rehydration therapy (ORT) 272Oral bicarbonate 273Parenteral preparations for fluid and electrolyte imbalance 273Plasma and plasma substitutes 276Plasma substitutes 276Fluid overload 276The four Ds of fluid management 276Hyponatraemia 277Hypernatraemia 277Hypokalaemia 277Hyperkalaemia 277Hypophosphataemia 278Hypocalcaemia 278Hypomagnesaemia 278Conclusion 279References 279Chapter 21 Critical care emergencies 280Alexandra Gatehouse and Sadie Diamond-FoxIntroduction 281A – Airway 282B – Breathing 290C – Circulation/Cardiovascular 291D – Disability 298E – Everything else (exposure, endocrine, electrolytes and environmental) 301Care of the patient post return of spontaneous circulation (ROSC) 307Critical care emergencies and human factors 307Debriefing 309Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) 309Conclusion 310References 310Chapter 22 Gastrointestinal critical care 313Anna Riley, Joe Box, and Aileen AherneIntroduction 314Anatomy and physiology 314GI monitoring and investigation in the critically ill 317Imaging and endoscopy 318Bowel charts and abnormal GI motility 320The acute abdomen in critical care 322Common surgical procedures cared for in critical care 325Post-operative monitoring 325Abdominal surgical drains 326Anaesthetics 326Post-operative complications 326Wound dehiscence 327GI pharmacology 327Conclusion 328References 328Chapter 23 Nutrition in critical care 330Barry Hill and Lorraine MutrieIntroduction 331Pathophysiology 331Fight or flight 332Resistance 332Exhaustion 332Nutritional screening and assessment 333Indirect calorimetry (IC) 333Routes of administration 334Nursing considerations and recommendations for practice 336Care of people with feeding tubes 336Glycaemic control 337Refeeding syndrome 338Discontinuing feed 339Nutritional guidance 339Conclusion 340References 341Chapter 24 Renal critical care 343Alexandra Gatehouse and Sadie Diamond-FoxIntroduction 344Anatomy and physiology of the renal tract 344Vascular supply 344Renin-angiotensin-aldosterone system (RASS) 344The nephrons 345Control of plasma osmolality 346Electrolyte balance 346Acid-base balance 352Renal failure 352Acute kidney injury 353Classification of AKI 353Pathophysiology 353Organ cross-talk 354Risk factors for AKI 355Clinical features and examination 355Investigations 355Specific disorders associated with AKI 357Drug-induced renal damage 357Management of AKI 359Clinical features and examination 361Management 361Chronic kidney disease 362Management 362Diabetic nephropathy 362Continuous renal replacement therapy (CRRT) 364Dosing of CRRT 364Anticoagulation 364Drug dosing and RRT 367Kidney transplantation – critical care considerations 367Conclusion 368References 368Chapter 25 Endocrine critical care 370Geraldine Fitzgerald O’Connor and Emma LongIntroduction 371Thyroid and parathyroid glands 371Disorders of the thyroid gland 371Thyroid crisis 372Parathyroid glands 372Disorders of the parathyroid glands 372Hypocalcaemia 373Pituitary gland 373Disorders of the pituitary gland 373Diabetes insipidus 374Pathophysiology 375Hyperglycaemia in the critically ill 376Diabetic emergencies 376Pathophysiology 380Conclusion 383References 384Chapter 26 Haematological and immunological critical care 385Barry Hill, Gerri Mortimore, and Pamela ArasenIntroduction 386Normal physiology 386Blood components 386Haematopoiesis 387Disorders of erythrocytes 387B12 vitamin deficiency 387Sickle cell anaemia 388Genetic haemochromatosis 389Haemostasis 390Lymphoma 390Disseminated intravascular coagulation 393Thrombocytopenia 394Neutropenia and sepsis 394Vasculitis 396Blood transfusions in adults 397Blood sample collections 398Blood groups 398Compatibility 399Indications for blood transfusions 399Platelets 400Fresh frozen plasma (FFP) 400Cryoprecipitate 400Granulocytes 400Procedural safety 400Pre-procedure and sampling 400Administration of the blood product 400Post-procedural care 401Traceability 401Patient information 402Alternatives to blood transfusions 403Summary of SaBTO recommendations on consent 403Conclusion 408References 408Chapter 27 Musculoskeletal considerations in critical care 411Clare L. Wade and Helen SangerIntroduction 412Trauma 412Management of traumatic injury 413Intensive care unit-acquired weakness 415Assessment of musculoskeletal impairment or injury 418Management of musculoskeletal injury and impairment 419Conclusion 424References 424Chapter 28 Burn care within a critical care setting 426Nicole LeeIntroduction 427Classification of burn wound depths 427Pathological considerations 429Burn size estimation 430An ABCDE approach to burn care 432Breathing 433Cardiovascular 433Disability (neurological assessment) 434Exposure (and everything else) 434Psychological support 434Acknowledgement 436References 436Chapter 29 Maternal critical care 438Wendy PollockIntroduction 439Epidemiology 439Adapted physiology 439Recognising clinical deterioration 441Nursing considerations and recommendations for practice 442Conclusion 448References 449Chapter 30 Critical care transfers 451Kirstin Geer, Mark Cannan, and Stuart CoxInter-hospital and intra-hospital patient transfers 452Transfer of the critically ill adult 452Critical care bed and repatriation 456The risks of critical care transfer 457Preparation for transfer 458ABCDE process during critical care transfer 458Conclusion 469References 469Chapter 31 Rehabilitation after critical illness 470Helen Sanger and Clare L. WadeIntroduction 471The impact of critical illness – what do we mean by morbidity? 471Describing physical functioning and morbidity 472Models of post-critical care morbidity 473Assessment 473Goals 475Key timepoints in RaCI 477Treatment 478National guidelines and standards 480Conclusion 481References 481Chapter 32 Dying and death 484Helen Merlane and Leonie ArmstrongIntroduction 485End-of-life care 485Palliative care 486Dying 486Recognising Dying 486Advance care planning 488Involve and support 489Nursing the dying patient 489The critical care environment 489Symptom management 490End-of-life care discharges from a critical care setting 491Care after death 494Conclusion 495References 495Index 497

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