Acute and Critical Care Nursing at a Glance E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Wiley Series on Cognitive Dynamic Systems
• Sprache: Englisch

Seitenzahl: 407

Veröffentlichungsjahr: 2018

Beschreibung

From the publishers of the market-leading at a Glance series comes a comprehensive yet accessible overview of all the fundamental elements of acute and critical care nursing.

Acute and Critical Care Nursing at a Glance provides an introduction to the key knowledge and skills for patient assessment and problem identification, as well as how to plan, implement and evaluate care management strategies.  It also explores clinical decision-making processes and their impact on care delivery, as well as key psychosocial issues, pain management, and safe transfer.  All information is presented in a clear, double-page spread with key information accompanied by tables, illustrations, photographs and diagrams.

Key features:

• Superbly illustrated, with full colour illustrations throughout
• An accessible, evidence-based, introduction to a complex topic
• Presents information structured according to the Resuscitation Council’s systematic ABCDE framework for ease of understanding
• Accompanied by patient case studies to help apply theory to practice

Acute and Critical Care Nursing at a Glance is ideal for nursing students, healthcare assistants, and registered nurses working within the acute and critical care setting.

Leseprobe

This title is also available as an e-book.

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Acute and Critical Care Nursing at a Glance

Edited by

Helen Dutton

MSc, BA, RNT, RGN Senior Fellow, Higher Education Academy Course Leader, BSc (Hons) Professional Practice Senior Lecturer, Critical Care College of Nursing, Midwifery and Healthcare University of West London, London, UK

Jacqui Finch

MSc, BSc (Hons), RGN, RNT, FHEA Senior Lecturer/Course Leader, Intensive Care College of Nursing, Midwifery and Healthcare University of West London and The London Northwest Healthcare NHS Trust, London, UK

Series Editor: Ian Peate OBE, FRCN

This edition first published 2018 © 2018 John Wiley & Sons Ltd.

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Library of Congress Cataloging-in-Publication Data

Names: Finch, Jacqui, 1961- editor. | Dutton, Helen, editor.

Title: Acute and critical care nursing at a glance / edited by Jacqui Finch, Helen Dutton.

Description: Hoboken, NJ : Wiley, 2017. | Series: At a glance series |

 Includes bibliographical references and index. |

Identifiers: LCCN 2017012986 (print) | LCCN 2017014342 (ebook) | ISBN

 9781118815151 (pdf) | ISBN 9781118815168 (epub) | ISBN 9781118815175 (pbk.)

Subjects: | MESH: Emergency Nursing—methods | Critical Care Nursing—methods

 | Handbooks

Classification: LCC RC86.8 (ebook) | LCC RC86.8 (print) | NLM WY 49 | DDC

 616.02/5–dc23

LC record available at https://lccn.loc.gov/2017012986

John Wiley & Sons Limited is a private limited company registered in England with registered number 641132. Registered office address: The Atrium, Southern Gate, Chichester, West Sussex, United Kingdom. PO19 8SQ.

Cover image: © simonkr/Gettyimages Cover design by Wiley

CONTENTS

Contributors

Acknowledgements

Preface

Abbreviations

About the companion website

Part 1: Nursing in acute and critical care

1: Critical care without walls

Changing patterns in acute care

Reconfiguration of critical care services

Safe staffing levels

Resuscitation to medical emergency

Critical care outreach

Monitoring the acutely unwell patient

2: Recognising risk of deterioration: ABCDE assessment

The acutely unwell patient

ABCDE

3: Early warning tools and care escalation

Recognising the deteriorating patient

National Early Warning Score (NEWS)

Care escalation using SBAR

4: Hospital-acquired infection: infection prevention and control

Infection prevention and control

Evidence-based guidelines

High Impact Intervention Care Bundles

5: Pain management

Types of pain

Assessment of pain

Management of pain

6: Psychosocial issues

Anxiety

Transfer or relocation anxiety

Sleep deprivation

Ethical concerns

7: Safe transfer of the acutely unwell patient

Types of patient transfer

Decision making and professional accountability

Assessment, medical and nursing management

Part 2: Airway: maintaining airway patency

8: Upper airway: assessment and management

Upper airway structure and function

Airway assessment

Maintaining the airway

9: Advanced airway management

Ensuring a clear airway

Maintaining the airway with adjuncts

Artificial airways

10: Airway management: tracheostomy

Tracheostomies

Types of tracheostomy tubes

Tracheostomy tube: care issues

Part 3: Breathing: patients with breathing problems

11: Respiratory physiology: oxygenation

Transport of oxygen

Transport of carbon dioxide

Ventilation and perfusion

12: Respiratory physiology: ventilation

Inspiration and expiration

Alveolar ventilation (

V

A

)

Work of breathing

Lung volumes

Functional residual capacity

13: Assessment of breathing

Breathing assessment: look

Breathing assessment: listen

Breathing assessment: feel

Breathing assessment: measure

Breathing assessment: investigate

14: Respiratory investigations

Chest X-ray

Peak expiratory flow rate

Blood tests

Arterial blood gas analysis

15: Oxygen therapy

Oxygen therapy

Caring for the patient on oxygen therapy

16: Respiratory failure

Lung failure

Ventilatory failure

Mixed respiratory failure

Supporting respiratory function

17: Breathing problems: obstructive disorders

Asthma

Chronic obstructive pulmonary disease

18: Breathing problems: lung (parenchymal) disorders

Community-acquired pneumonia

Hospital-acquired pneumonia

Nursing considerations to reduce risk of pneumonia

Care and management

19: Breathing problems: pleural disorders

The pleura

Pleural effusion

Pleurisy

Pneumothorax

Chest tube drainage

20: Respiratory support: non-invasive ventilation

High flow oxygen therapy

Continuous positive airway pressure

Bi-level positive airways pressure

21: Principles of thoracic surgery

Types of thoracic surgery

Nursing management

Psychological and emotional support

Part 4: Circulation: patients with circulatory problems

22: Circulatory physiology 1: circulation

The heart

Blood flow through the heart (Figure 22.1)

The vascular system

23: Circulatory physiology 2: the heart and cardiac cycle

The coronary arteries

The conduction system

The cardiac cycle

Cardiac output and blood pressure

24: Circulatory physiology 3: control of circulation

Neurohormonal mechanisms of blood pressure control

Common medications

25: Assessment of circulation

Cardiovascular assessment: look

Cardiovascular assessment: listen

Cardiovascular assessment: feel

Cardiovascular assessment: measure

Cardiovascular assessment: investigate

26: Cardiac investigations

The 12-lead ECG

Exercise tolerance testing

Chest X-ray

Blood tests to investigate cardiac status

Echocardiography

Doppler ultrasound

Coronary angiogram

27: Fluid, electrolytes and intravenous fluids

Fluid and electrolyte balance

Fluid and electrolyte imbalance

Intravenous therapy

Fluid and electrolyte replacement

28: Haemodynamic monitoring

Haemodynamic monitoring

Arterial blood pressure monitoring

Central venous pressure monitoring

Hazards: arterial and central lines

29: Acute chest pain

The patient presenting with chest pain

Acute coronary syndromes

Management of acute coronary syndrome

Other life-threatening causes

30: The 12-lead electrocardiogram

Electrocardiogram waveform

Electrocardiogram leads

Electrocardiogram interpretation

31: Altered heart rhythm

Tachyarrhythmias

Bradyarrythmias

Nursing management

32: Physiology of the immune system

Non-specific or innate immune response

Components of the immune system

Specific ‘adaptive’ immune response

33: Acute circulatory failure 1: distributive (sepsis)

Mechanisms and consequences of sepsis

Recognising the patient at risk from sepsis

Management of the patient with sepsis

34: Acute circulatory failure 2: distributive (anaphylaxis and neurogenic)

The immune response, allergy and anaphylaxis

Clinical presentation and management of anaphylaxis

Neurogenic shock: definition and clinical presentation

Clinical management

35: Acute circulatory failure 3: hypovolaemia

Fluid distribution within the body

Hypovolaemia: causes and pathophysiology

Clinical presentation and patient assessment

Nursing management: key priorities

36: Acute circulatory failure 4: obstructive

Pulmonary embolism

Tension pneumothorax

Cardiac tamponade

37: Acute circulatory failure 5: heart failure

Heart failure: how does it happen?

Heart failure management

Acute decompensated heart failure

38: Principles of cardiac surgery

Coronary artery bypass grafting

Heart valve surgery

Nursing management postsurgery

39: Physiology of the gastrointestinal system

The gastrointestinal tract

Anatomy and physiology of key gastroinestinal organs

Anatomy and physiology of the accessory organs of the gastrointestinal tract

40: Acute medical and surgical gastrointestinal problems

Main organs of the gastrointestinal tract: acute disorders

Accessory organs of the gastrointestinal tract: acute disorders

41: Physiology of the renal system

Urinary tract

Functional unit: the nephron

Applied physiology

42: Acute kidney injury

Risk factors for acute kidney injury

Definition of acute kidney injury

Pathophysiology and clinical presentation

Principles of nursing management

43: Burns: immediate care

Introduction

First aid

Airway

Breathing

Circulation

Burn wound assessment

Burns referral

44: Major trauma

Communication

Catastrophic haemorrhage

Assessment and management

Fractures

Ongoing care

45: Resuscitation

Preventing cardiopulmonary arrest

Resuscitation guidelines

Presence of relatives

Part 5: Disability: patients with neurological impairment

46: Physiology of the brain

Gross structure

Functional units

47: Neurological assessment

Assessment of impaired consciousness

Assessing pupillary response

Assessment of the vital signs

Assessment of fluid balance

Assessing blood glucose

48: Neurological impairment

Cerebrovascular accident

Infection

Seizures

Trauma

Raised intracranial pressure

49: Drug overdose and poisoning

Drugs commonly taken in overdose

Other types of overdose and poisoning

History taking and patient assessment

50: Acute endocrine problems

Hormonal influence and acute organ dysfunction

Diabetic emergencies: a common endocrine problem

Part 6: Exposure

51: Skin integrity

Skin: function and structure

Factors impairing skin integrity in acute illness

Nursing assessment

52: Nutritional assessment and support

Daily nutritional requirements in health

Malnutrition and the body’s response to illness

Nutritional assessment

Providing nutritional support

Nutritional support and rehabilitation

Part 7: Decision making in acute and critical care

53: Summary of decision making

Clinical reasoning and decision making

Assessment

Minimising risk

Evidence-based practice

Ethical and legal issues

54: Professional, legal and ethical considerations

Legal considerations

Ethical considerations

Professional considerations

55: Mental health concerns

Recognising and assessing needs

Liaison psychiatry services

56: Last days of life

Clinical decision making in the last days of life

Advance care planning

Care of the dying patient in critical care

Appendix

References and Further Reading

Glossary

Index

EULA

Guide

Cover

Table of Contents

Preface

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Contributors

Sharon Elliot Chapters 8, 9, 37 Head of Pre-registration University of West London, London, UK

Adrian Jugdoyal Chapter 55 Hepatology Advanced Nurse Practitioner Northwick Park and St Mark’s Hospital; Associate Lecturer University of West London, London, UK

Catherine Lynch Chapter 54 Senior Lecturer University of West London, London, UK

Carl Margereson Chapters 11, 12, 53 Senior Lecturer University of West London, London, UK

Caroline Smales Chapters 4, 32 Senior Lecturer University of West London, London, UK

Sharon Smith Chapters 14, 26 Senior Lecturer University of West London, London, UK

Renata Szczecinska Chapters 21, 30, 31, 38 Cardiac Practice Development Nurse King’s College Hospital NHS Foundation Trust Associate Lecturer University of West London, London, UK

Dean Whiting Chapter 44 Advanced Nurse Practitioner in Trauma and Orthopaedics Buckinghamshire Healthcare NHS Trust; Honorary Senior Lecturer in Trauma Science Barts and the London School of Medicine and Dentistry Queen Mary University of London, London, UK

Suzanne Whiting Chapter 43 Burn Care Advisor for the London and South East Burns Network Buckinghamshire Healthcare NHS Trust, UK

Acknowledgements

With grateful thanks to our academic and clinical colleagues who willingly shared their ideas, knowledge and experience to help in shaping many of the chapters in Acute and Critical Care Nursing at a Glance

Victoria Allen Chapter 35

Senior Lecturer, University of West London, London, UK

Kate Bradley Chapters 10, 20

Lecturer, University of West London, London, UK

Barry Hill Chapters 46, 47, 48

Lecturer, University of West London, London, UK

John Mears Chapters 5, 51

Senior Lecturer, University of West London, London, UK

Lyndsey Mears Chapter 56

Senior Lecturer, University of West London, London, UK

Trisha Mukherjee Chapters 28, 35

Modern Matron: Intensive Care

The London Northwest Healthcare NHS Trust, London, UK

Madhini Sivasubramanian Chapter 37

Lecturer, University of West London, London, UK

Liz Staveacre Chapters 1, 18

Senior Sister: Critical Care Outreach

The London Northwest Healthcare NHS Trust, London, UK

Preface

In 2000, the UK Department of Health’s publication the Comprehensive Critical Care – A Review of Adult Critical Care Services classified patients according to the severity of their illness. This led to the concept of ‘critical care without walls’, identifying the presence of acutely unwell patients outside the Intensive Care Unit and acknowledging that specialist nurse education and training in recognition and preliminary management of acute deterioration, was now required in all areas of clinical practice. Since that time, society’s growing, diverse and ageing population has augmented this need and an ever increasing use of technology in care settings has meant that practitioners are frequently required to plan, implement and evaluate care for patients with complex, multiple problems in a variety of clinical settings. Certainly, the expansion of community services has meant that many patients are successfully managed outside the hospital. However, the centralisation of acute services in healthcare, especially for emergency medicine, has seen a huge demand for in-hospital bed capacity in some areas. This has led to the increasing development of a wide range of assessment units designed to manage large numbers of patients presenting to hospital with acute problems. Over recent years the development of critical care outreach teams and the birth of track and trigger systems all assist with this, but there still remains a great need for nurses to further develop their assessment skills and their ability to promptly and appropriately respond to worsening clinical scenarios and life-threatening events. The 2015 Nursing and Midwifery Council Code of Conduct clearly states that registered nurses and midwives must, at all times, ‘preserve safety’. Whilst acknowledging the limits of their competence, they have to be able to assess accurately the patients in their care, taking account of current evidence and knowledge and demonstrate the ability to make timely referral. Failure to achieve this standard is failure to act in the patients’ best interests.

It has been suggested that nurses may possess differing perspectives on what clinical deterioration actually is. This may be irrespective of the scoring systems that exist to assist them and, of course, the tools themselves are sometimes subject to misinterpretation and misuse. One way to address this is to revisit the basic principles of normality and abnormality when considering how a patient might present, systematically collecting subjective and objective data in order to recognise when problems are occurring. Development of sound clinical reasoning like this, strongly founded in evidence-based knowledge, will vastly contribute to the provision of quality care, ensuring patient safety both now and in the future.

The chapters in the book are structured according to the systematic ABCDE framework.1 This emphasises the priorities of care when faced with an acutely unwell patient and use of the ‘at a glance’ approach greatly facilitates this with its focus on immediacy. To complement this, in each chapter the text and accompanying diagrams present key information in a concise format, using current evidence gathered from local, national and international policies, protocols and guidelines. In addition, the inclusion of patient case studies and multiple choice questions covering a range of specialist content also serve to highlight significant issues in practice, enabling consolidation of learning by way of self-assessment. In summary, we hope this book will be a good reference source for our readers (be they registered or student practitioners), fostering their critical thinking. We also hope, in the interests of evidence-based quality care, that it creates a desire in our readers to learn more about critical care and that this knowledge is used to teach and support others who are providing care to the acutely ill.

Helen DuttonJacqui Finch

Note

1

Resuscitation Council UK (2015) The ABCDE approach.

https://www.resus.org.uk/resuscitation-guidelines/abcde-approach/

Abbreviations

A

Aorta

ABCDE

Airway, breathing, circulation, disability circulation

ABG

Arterial blood gas

ACEI

Angiotensin converting enzyme inhibitors

ACP

Advance care plan

ACS

Acute coronary syndrome

ACTH

Adrenocorticotrophic hormone

ADH

Antidiuretic hormone

AECOPD

Acute exacerbations of COPD

AF

Atrial fibrillation

AKI

Acute kidney injury

ALS

Adult advanced life support

AMI

Acute myocardial infarction

AMPLE

Allergies, Medications, Past medical history, Last ate and drank, Events leading (to injury)

AMTS

Abbreviated Mental Test Score

ANNT

Aseptic non-touch technique

ANS

Autonomic nervous system

ARB

Angiotensin receptor blockers

ARDS

Acute respiratory distress syndrome

ATOMFC

Airway, tension pneumothorax, open pneumothorax, massive haemothorax, flail chest, cardiac tamponade

ATP

Adenosine triphosphate

AV

Atrioventricular

AVN

Atrioventricular node

AVPU

Alert, voice, pain, unresponsive

BBB

Blood–brain barrier

BiPAP

Bi-level positive airways pressure

BMI

Body mass index

BMR

Basal metabolic rate

BNP

B-type natriuretic peptide

BP

Blood pressure

CA

Cardiac arrest

Ca+

Calcium ion

CABG

Coronary artery bypass grafting

CAM ICU

Confusion assessment method: Intensive care unit

CAP

Community-acquired pneumonia

CCF

Congestive cardiac failure

CCOT

Critical care outreach team

CHF

Chronic heart failure

CO

Cardiac output

COPD

Chronic obstructive pulmonary disease

CPAP

Continuous positive airways pressure

CPB

Cardiopulmonary bypass

CPR

Cardiopulmonary resuscitation

CQC

Care Quality Commission

CRBSI

Catheter-related blood stream infection

CRF

Chronic respiratory failure

CRP

C-reactive protein

CRT

Capillary refill time

CSF

Cerebrospinal fluid

CT

Computed tomography

CTPA

Computerised tomographic pulmonary angiography

CURB 65

Confusion, urea, respiratory rate, systolic blood pressure (age ≥65)

CVA

Cerebrovascular accident

CVC

Central venous catheter/cardiovascular centre

CVP

Central venous pressure

CXR

Chest X-ray

DDAVP

1- deamino-8-D-arginine vasopressin

DI

Diabetes insipidus

DINAMAP

Direct non-invasive automated mean arterial blood pressure measurement

DKA

Diabetic ketoacidosis

DNAR

Do not attempt to resuscitate

DVT

Deep vein thrombosis

ECG

Electrocardiogram

EPAP

End positive airways pressure

ERCP

Endoscopic retrograde cholangio-pancreatogram

ERV

Expiratory reserve volume

ETT

Endotracheal tube

EWS

Early warning systems

FBAO

Foreign body airway obstruction

FEV

1

Forced expiratory volume in one second

FRC

Functional residual capacity

FVC

Forced vital capacity

GABA

Gabba amino butyric acid

GAD-7

Generalised anxiety disorder assessment

GCS

Glasgow Coma Scale

GFR

Glomerular filtration rate

GI

Gastrointestinal

GTN

Glyceryl trinitrate

H+

Hydrogen ions

HADS

Hospital anxiety and depression scale

HAP

Hospital-acquired pneumonia

HCO

3

-

Bicarbonate ion

HCAI

Healthcare-associated infection

HDU

High dependency unit

HF

Heart failure

HFNC

High flow nasal cannula

HFPEF

Heart failure with preserved ejection fraction

HHS

Hyperglycaemic hyperosmolar syndrome

HME

Heat and moisture exchanger

HR

Heart rate

I:E ratio

The ratio of inspiration to expiration

ICD

Implantable cardioverter

ICP

Intracranial pressure

ICU

Intensive care unit

IPAP

Inspiratory positive airways pressure

IV

Intravenous

JVD

Jugular venous distension

JVP

Jugular venous pressure

K+

Potassium ion

LMA

Laryngeal mask airway

LMWH

Low molecular weight heparin

LOC

Level of consciousness

LPA

Lasting power of attorney

LV

Left ventricle

LVF

Left ventricular failure

LVSD

Left ventricular systolic dysfunction

mAChR

Muscarinic receptors

MAP

Mean arterial pressure

Mg++

Magnesium ion

MgSO

4

Magnesium sulphate

MI

Myocardial infarction

MILS

Manual in-line stabilisation

MODS

Multiple organ dysfunction syndrome

MRI

Magnetic resonance imaging

MUST

Malnutrition universal screening tool

Na

+

Sodium ion

NATMIST

Name, age, time of injury, mechanism of injury, injuries sustained, signs and symptoms, treatments given

NC

Nasal cannula

NEWS

National Early Warning Score

NICE

The National Institute for Health and Care Excellence

NIV

Non-invasive ventilation

NSTEMI

Non-ST-segment elevated myocardial infarction

NPA

Nasopharyngeal airway

NSAID

Non-steroidal anti-inflammatory drugs

OPA

Oropharyngeal airway

PA

Pulmonary artery

P

AO

2

The partial pressure of oxygen in the alveoli

PAINAD

Pain Assessment in Advanced Dementia

P

aO

2

The partial pressure of oxygen in arterial blood

PCA

Patient-controlled analgesia

PCI

Percutaneous coronary intervention

PCT

Proximal convoluted tubule

PE

Pulmonary embolism

PEEP

Positive end expired pressure

PEF

Peak expiratory flow

PEFR

Peak expiratory flow rate

PNS

Parasympathetic nervous system

PPCI

Primary percutaneous coronary intervention

PPE

Personal protective equipment

PS

Pressure support

PSP

Primary spontaneous pneumothorax

qSOFA

Quick Sequential (Sepsis Related) Organ Failure Assessment

RA

Right atrium

RAAS

Renin-angiotensin-aldosterone system

REM

Rapid eye movement

ROSC

Return of spontaneous circulation

RR

Respiratory rate

RV

Residual volume/Right ventricle

SAN

Sinoatrial node

SAH

Subarachnoid haemorrhage

SBAR

Situation, background, assessment, recommendation

SBP

Systolic blood pressure

SIADH

Syndrome of inappropriate ADH

SNS

Sympathetic nervous system

SOCRATES

Site, onset, character, radiation, associated symptoms, time course, exacerbating and relieving factors, severity

SP

Secondary pneumothorax

S

pO

2

Oxygen saturation of peripheral capillary blood

SSP

Secondary spontaneous pneumothorax

SSRI

Selective Serotonin re-uptake inhibitor

STEMI

ST elevation myocardial infarction

Sup.VC

Superior vena cava

SV

Stroke volume

SVR

Systemic vascular resistance

SVT

Supraventricular tachycardia

TBSA

Total body surface area

TIA

Transient ischaemic attack

TIMI

Thrombolysis in myocardial infarction

TIPS

Trans intrahepatic portosystemic shunt

TSH

Thyroid-stimulating hormone

V/Q

Ventilation/perfusion

VATS

Video-assisted thoracoscopic surgery

VBG

Venous blood gas

V

E

Minute ventilation

VF

Ventricular fibrillation

VIP

Visual infusion phlebitis

V

T

Tidal volume

VT

Ventricular tachycardia

VTE

Venous thromboembolism

WBC

White blood cells

WCC

White cell count

WHO

World Health Organization

WOB

Work of breathing

About the companion website

Don't forget to visit the companion website for this book:

www.ataglanceseries.com/nursing/acutecare

There you will find valuable material designed to enhance your learning, including:

•

Interactive multiple choice questions       

•

Nine patient case studies with questions and answers

Part 1Nursing in acute and critical care

Chapters

1

Critical care without walls

2

Recognising risk of deterioration: ABCDE assessment

3

Early warning tools and care escalation

4

Hospital-acquired infection: infection prevention and control

5

Pain management

6

Psychosocial issues

7

Safe transfer of the acutely unwell patient

1Critical care without walls

The last decade has seen a change in the environment in which care of the acutely unwell patient is delivered. Nurses working in acute care areas are increasingly exposed to patients who require more detailed assessment and monitoring. Nurses need to be competent in the skills required to care effectively for critically ill patients.

Changing patterns in acute care

The general population is ageing, with those requiring hospital admission older, sicker and generally more dependent. In 2010 the over-65 age group accounted for 10 million of the population in the UK, and by 2030 the number will be closer to 15.5 million. Emergency admissions for patients who have increasingly complex comorbidities requiring multidisciplinary and cross-speciality input are increasing. Meanwhile, greater emphasis has been placed on managing patients in their home environment for longer periods, meaning those who are admitted to hospital are sicker and require greater use of resources. Technological developments in healthcare means that treatments once thought too high a risk are now commonplace in hospitals.

With the increase in patient acuity it became evident that wards were not always able to cope effectively with the extra demands placed on them. Studies in the late 1990s identified that the deteriorating patient was not always recognised, and/or sufficient action was not taken prior to admission into the intensive care unit (ICU), adversely affecting patient outcome.

Reconfiguration of critical care services

In 2000 the Department of Health1 published its report, Comprehensive Critical Care, recommending a systems approach was taken to deliver care for patients during acute and critical illness, and in the recovery period. Critical care emerged as a new speciality, addressing the severity of patient illness, regardless of their physical location within the hospital. The Department of Health introduced the concept of ‘critical care without walls’, to ensure acutely unwell patients nursed in a variety of environments, from ward-based care through to intensive care, come under the ‘critical care umbrella’ (Figure 1.1). A spectrum of dependency levels from levels 0 to 3, were outlined to encompass all those requiring critical care:1

Level 0

: Patients whose needs can be met through normal care in an acute hospital.

Level 1

: Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care whose needs can be met on an acute ward with advice and support.

Level 2

: Patients requiring more detailed observation or interventions, including support for single organ failure, postoperative care, and those stepping down from a higher level of care.

Level 3

: Patients requiring advanced respiratory support or support of at least two organs, including all complex patients requiring support for multiorgan failure.

Workforce development, to ensure that staff caring for potentially critically ill patients receive education and training, is essential.2 Key clinical competencies to be achieved have been identified.3 Registered nurses are accountable for all aspects of care, even those tasks often delegated to others, such as the taking and recording of observations.4

Safe staffing levels

The Intensive Care Society (2013) and others published core standards for organisation of intensive care units (levels 2 and 3) and recommended safe staffing levels.5 As acutely unwell patients are nursed across a range of environments, there are challenges for the provision of safe staffing levels on acute wards, which have been highlighted by the Francis Report (2013).6NICE (2014) issued guidance for safe staffing for nurses in acute hospitals supporting ‘The Safer Nursing Care Tool’ (Table 1.1).2 This tool is based on the Department of Health classification, but adds an additional level, 1b, acknowledging the differing demands on nursing care activities, such as supporting the patient at risk of self-harm. It is designed to inform nursing establishments to be planned, linked to patient acuity both in ward-based care and critical care units.

Resuscitation to medical emergency

Cardiac arrests are predictable and preventable. Survival to discharge post cardiac arrest is as low as 15%.7 Early recognition of deterioration is the first step in the chain of survival. Almost half of patients who die without a ‘do not attempt resuscitation’ (DNAR) order have serious, potentially reversible abnormalities in their vital signs in the 24 h preceding death. In fact, slow, progressive physiological deterioration with unrecognised and inadequately treated hypoxaemia and hypotension, can often be seen prior to admission to ICU and leads to poor survival. Delays in time to treatment have a profound effect on patient outcome. Specific intervention and timely instigation of organ support, via a medical emergency team or critical care outreach team (CCOT), is more important than getting the patient to the ICU.

Critical care outreach

Critical care outreach teams have evolved to provide expert input outside the environment of intensive and high dependency units. They aim to avert or ensure timely admissions to critical/intensive care and share critical care skills across the multidisciplinary team. Implementation of early therapies, for example, high flow oxygen, fluid resuscitation, or care bundles such as the ‘Sepsis Six’ (Box 1.1) can improve mortality and reduce rates of cardiac arrest. The CCOT’s role in sharing critical care skills, improving early recognition of deterioration, has empowered nurses to escalate care appropriately and is now a widely adopted approach to maintaining patient safety.

Monitoring the acutely unwell patient

Recommendations to improve the recording of six key physiological observations (Figure 1.2), include the use of multiparameter Early Warning Scores to help identify patients at risk and escalate care appropriately.8 The National Early Warning Score (NEWS)9 (see Chapter 3) is a well-validated tool in the recognition and prevention of deterioration, and is now used widely in acute care trusts throughout the UK. Acutely unwell patients require competent and confident nurses to interpret clinical signs, recognise risk of deterioration and escalate care to the appropriate healthcare professional, ensuring senior medical input occurs in a timely manner to optimise patient outcome.

2Recognising risk of deterioration: ABCDE assessment

The acutely unwell patient

Most people in hospital are unlikely to become seriously unwell. If they should deteriorate, early detection through a detailed clinical assessment is essential so that nurses are able to identify the problem and ensure that appropriate care and treatments are given in a timely manner. When caring for an acutely unwell patient, the use of the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach helps keep the focus on those aspects of deterioration that are most likely to be life threatening, thereby improving patient outcome. This chapter gives an overview of each area, but these are also considered in more detail in later chapters.

ABCDE

The ABCDE approach (Figure 2.1) is an excellent clinical tool for the assessment and treatment of patients who are acutely unwell.1 This approach dictates that each element is assessed, then treated as necessary, before moving on to the next element. Early recognition and treatment of abnormal physiology in this progressive fashion initiates effective treatment, preventing further deterioration, whilst help can be sought from clinicians with specialist expertise. The process is used to reassess progress as treatments are instigated. Whilst nurses are familiar with taking and recording vital signs, assessment of the acutely unwell patient requires more detail, taking note and interpreting a range of clinical signs that assist in clinical decision making.

Assessment approach

A general impression when first approaching the patient is often the trigger for a more detailed assessment. The patient who does not respond to questions, has collapsed, or is perhaps severely distressed and sweating profusely, has clear markers of serious illness.

Airway (Figure 2.1A)

The airway is assessed for patency as a priority as airway obstruction is a medical emergency. If untreated it will rapidly lead to cardiac arrest, and so help is required immediately. An alert and chatty patient has a patent airway. A reduced level of consciousness is a common cause of both partial and complete airway obstruction, requiring the healthcare professional to perform the ‘head tilt chin lift’ manoeuvre, to keep the airway open. Partial airway obstruction is noisy, and requires immediate management (see also Chapters 8 and 9). Once the nurse is confident that the patient’s airway is patent, they can move on to assessment of breathing.

Breathing assessment (Figure 2.1B)

Adequate oxygenation is essential. SpO2 monitoring, available in all acute care environments, is measured promptly if deterioration is suspected. SpO2 values outside the patient’s target range (94–98% or 88–92% as prescribed) requires oxygen therapy to restore it to normal or near normal levels (also Chapter 15).2

Indicators of respiratory distress included:

Use of accessory muscles.

Central cyanosis.

Paradoxical breathing.

Leaning forward in tripod position.

Inability to complete sentences in one breath.

Audible wheeze (acute severe asthma/chronic obstructive pulmonary disease [COPD]).

Rapid shallow breathing.

Mouth breathing, purse-lipped breathing.

Respiratory rate has been shown to be a significant predictor of risk of deterioration.3 This important observation should be counted for 1 min to ensure accuracy and will normally be between 12 and 20 breaths/min. The chest should be inspected for bilateral equal expansion. Failure of both sides of the chest to move equally on inspiration could suggest a collection of pleural fluid, or a chest infection. If the trachea is displaced from the midline, with unilateral chest expansion and respiratory distress, a medical emergency such as tension pneumothorax, may be present. Urgent medical help is required. A patient who has breathing difficulties should be repositioned in the upright position, given appropriate prescribed therapy promptly (such as oxygen or bronchodilators), and help should be summoned if necessary, before moving on to circulatory assessment.

Circulation (Figure 2.1C)

The circulatory system transports oxygenated blood to the tissues. Patient pallor as a result of vasoconstriction also causes hands and feet to cool if circulation is inadequate. Profuse sweating and changes in level of consciousness are also associated with decreased perfusion. A peripheral pulse should be palpated manually and assessed for rate, rhythm and strength. Any abnormalities should prompt an ECG recording. A fall in systolic blood pressure is a late sign and can be due to problems such as: hypovolaemia, cardiac failure, pulmonary embolism, sepsis or anaphylaxis. Most patients who are hypotensive require fluid therapy (after excluding cardiac causes), so intravenous access should be obtained as necessary. Blood and fluid losses should be noted, considering urine output (which should be greater than 0.5 mL/k/h) and overall fluid balance (see also Chapter 25).

Disability (Figure 2.1D)

Level of consciousness can be quickly assessed using an AVPU assessment to assesses neurological status (also Chapter 46):

A: Alert: spontaneously talking and responding to questions.

V: Unconscious but roused by voice.

P:  Unconscious but responds to painful stimuli, such as trapezius squeeze (see Figure 2.1D).

U: Unresponsive.

If changes in AVPU are noted then a more detailed assessment using tools such as the Glasgow Coma Score is required. Changes in level of consciousness caused by either hypo- or hyperglycaemia should be treated promptly. Changes in face symmetry, unequal arm movement or speech alterations could indicate brain injury due to a stroke. Patients with deteriorating consciousness need their airway protected by appropriately skilled healthcare personnel.

Exposure (Figure 2.1E)

It is important to maintain patient dignity whilst performing a full body check. Looking ‘under the sheets’ ensures no essential clues are missed. Temperature is an important indicator for infection and may be assessed here, or under circulation. If the patient is pyrexial, look for the source of infection, checking all invasive lines/devices and inspecting wounds and lesions for signs of bleeding, oozing, inflammation or tenderness.

3Early warning tools and care escalation

Recognising the deteriorating patient

Patients who are admitted into hospital with acute care needs have a right to receive reliable harm-free care. The recognition of clinical deterioration relies largely on nurses taking and recording vital signs, identifying where these are abnormal, communicating findings to skilled clinical personnel and ensuring appropriate interventions are given in a timely manner. Lack of recognition of physiological changes may lead to a delay in care, an extended hospital stay, ICU admission or even a premature death. Failure to rescue occurs when a patient’s deterioration is not recognised and they suffer harm from a potentially treatable condition. Nurses are accountable for ensuring accurate clinical observations are recorded and acted upon (Figure 3.1), even if delegated to a non-registered healthcare professional.1 Training, education and support for the healthcare team is essential in the delivery of harm-free care.

National Early Warning Score (NEWS)

In 2007 NICE recommended the use of ‘aggregated weighted track and trigger systems’.2 These are early warning systems (EWS) that consider a number of different clinical observations, generating an overall score to help evaluate risk of deterioration. The score gained is used to identify low, medium and high scoring groups, thereby determining frequency of observations and the need for review by the medical team and/or outreach. A number of EWS have been used across the UK, leading to a significant variation in trigger levels, and therefore a potential lack of understanding by clinical staff moving across the country to work in different clinical environments. A standardised National Early Warning Score (NEWS) developed by The Royal College of Physicians,3 has been embraced by acute care trusts across the UK. A unified approach helps all clinical staff to understand the level of the risk of deterioration of patients. Using NEWS consists of a number of straightforward steps:

Take each observation and record on NEWS chart (Figure 3.2).

Use the chart(Figure 3.3), to identify the score for each measurement, add together to get the NEWS (Figure 3.4).

Look at the

trigger thresholds

to determine whether the patient is at

low

,

medium

or

high

risk (Figure 3.5). Note that a score of 3 in any single parameter requires the doctor to be informed, even if they do not meet the medium trigger score of 5–6.

Follow hospital/NEWS protocol as to frequency of observations and appropriate clinical personnel to call (Figure 3.6).

Check for

clinical red flags

;

4

these may not score on NEWS but require urgent review (see red flags box).

Use a communication tool such as SBAR to escalate care.

Recording clinical observations

The NEWS chart requires the recording and scoring of the six physiological parameters identified by NICE (2007) namely:2

Respiratory rate.

Oxygen saturations.

Temperature.

Systolic blood pressure.

Heart rate.

Level of consciousness.

Trust protocols vary as to whether numbers or dots are used to record observations, but it is recommended that respiratory rate and oxygen saturations are recorded as a number.5 This enables changes in respiratory rate to be more clearly documented, especially when in the red zone at >25 breaths/min. The percentage of oxygen is recorded as either air, oxygen percentage, or in L/min (nasal specs), so response to oxygen therapy can be recorded.

NEWS and trigger thresholds

Figure 3.3 identifies scores for each physiological parameter, so there is no confusion between borderline values. For example, a heart rate of 110 beats/min scores 1; using the observation chart alone may not make this clear. The NEWS chart and the threshold and trigger chart have been made into pocket cards by some trusts, aiding accurate and consistent scoring.

An automatic addition of 2 is made to the NEWS if the patient is receiving oxygen therapy, correctly highlighting that the hypoxaemic patient receiving supplemental oxygen is unwell, and is at increased risk of deterioration and death. An alternative trigger range of oxygen saturations for patients who have adapted to chronic disordered physiology such as COPD and are at risk of hypercapnia (target range SpO2 of 88–92%), can be appropriate, but must be clearly marked and signed for by the doctor on the observation chart.

Trigger thresholds will define action to be taken at trust level. NEWS >7 requires urgent action (within 15 min) at senior medical level, support from outreach, continuous observations, with the possibility of transfer to a higher level of care. This is an opportunity to ask the medical team to consider the ‘ceiling of care’ as not all patients benefit from receiving advanced levels of support, such as intubation and mechanical ventilation in an ICU environment.3

Care escalation using SBAR

Doctors and outreach nurses looking after a large number of patients have competing priorities for their time. Clear, precise and accurate information is needed to enable them to focus on those who are most unwell. NEWS conveys severity of illness. A communication tool such as SBAR (Situation, Background, Assessment, Recommendation) (Figure 3.7) supports structured communication and good clinical decision making to improve patient outcomes:

Situation

: state who you are, which ward you are on, patient’s name, age, consultant and NEWS.

Background

: give a brief overview of the reason for admission, recent medical history, relevant past results, allergies, medication.

Assessment

: use the

ABCDE

mnemonic to outline current clinical assessment. State actions taken and any clinical response. For example, ‘I have given 2 L oxygen via nasal specs and the

S

pO

2

has now risen from 91 to 94%’.

Recommendation

: explain what is worrying you, what you need from the doctor/outreach and in what time frame. Make sure you understand any actions required of you by repeating the instructions to ensure accuracy.

The accurate, consistent use of an early warning tool and escalation strategy such as NEWS, and a communication tool such as SBAR, contributes to ensuring care is focused on those patients who are at the greatest risk of deterioration.

4Hospital-acquired infection: infection prevention and control

Infection prevention and control

Patients who are acutely unwell have increased susceptibility to infection due to accidental or surgical injuries, multiple invasive devices, decreased immunity, complex health problems and increased contact with healthcare staff. Therefore, healthcare-associated infection (HCAI), prevention and control in critical care is of paramount importance. Whilst twenty-first century healthcare can bring even the sickest and most traumatised patient back from the brink of death, a single infectious agent can enter the body and bring about death in a matter of hours. The National Point Prevalence Study (2011) on healthcare-associated infection,1 gives a ‘snapshot’ of the overall HCAI prevalence rate (the number of people suffering from a HCAI during the time of the study); it shows a prevalence rate of 6.4, a reduction from 8.2. Figure 4.1 highlights the six most common types of HCAI which account for more than 80% of all HCAIs.

Standard and transmission-based precautions

Every single act or intervention has the potential to spread infection, as microorganisms invisible to the naked eye can be moved from place to place, and person to person, resulting in entry to a susceptible host (patients or staff) through any orifice or break in the skin. Standard precautions rely on staff assessing the risk of the ‘task’ they are carrying out and deciding on the appropriate precautions that should be taken and where these are considered insufficient, implement additional ‘transmission-based precautions’ (Figure 4.2).2 Following these recommended guidelines will not only prevent patients from becoming infected but also staff from occupationally acquired infections.

Evidence-based guidelines

Healthcare professionals have a professional, legal and ethical responsibility to follow recommended standard infection prevention and control guidelines and minimise any risk of infection. The Department of Health (2014) National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (Epic 3)3 consolidate the ‘best available evidence currently available’ informing current practice. These address the following areas and should be integrated into healthcare policies that are easily accessible for all staff:

Guidelines for standard precautions for preventing HCAIs in hospitals and other acute care settings:

Hospital hygiene.

Hand hygiene.

Use of Personal Protective Equipment (PPE).

Safe use and disposal of sharps.

Asepsis.

Guidelines for preventing infections associated with the use of short-term indwelling urethral catheters.

Guidelines for preventing infections associated with the use of intravascular devices.

Hand hygiene

Hand hygiene, either hand washing or hand rubbing (Figure 4.3), is considered the single most important infection prevention activity4, 5 and it is important that staff know: how to decontaminate their hands, what product to decontaminate with and when to decontaminate:6

What

: hand washing with liquid soap and running water are to be used routinely to cleanse hands, especially when hands are visibly soiled, and/or when specific microorganisms such as

Clostridium difficile

or

Norovirus

are suspected or confirmed. If a higher level of hand hygiene is required, such as prior to an aseptic technique, antiseptic soap should be used. Hand rubbing with an alcohol hand rub gel can be quicker and easier to use in place of hand washing on visibly clean hands and when

Clostridium difficile

and

Norovirus

are not suspected.

How:

the technique used is most important and in order for microorganisms to be removed from hands (Figure 4.3) the product being used, either soap or alcohol solution

must

cover all surfaces of the hands. Using a methodical, vigorous rubbing action which will lift up microorganisms from the skin surface to be washed away, or ensure the hand rub fluid has contact with all parts of the skin will enable it to assert its killing action on the microorganisms. Common areas missed are shown in Figure 4.4.

When

: staff must decontaminate their hands at the most crucial times:

(i) Immediately before patient contact including aseptic procedures.

(ii) Immediately after patient contact or care.

(iii) Immediately after any exposure to body fluids.

(iv) After contact with the patients surroundings.

(v) After glove removal.

However, this is not exhaustive; additional hand hygiene opportunities include before and after starting a shift, after using the toilet, or before eating or preparing food.

A ‘bare below the elbow’ policy when providing direct patient care ensures sleeves do not impede access for regular hand washing and requires removal of wrist and hand jewellery. Any breaks in the skin need to be covered with a waterproof dressing and nails kept short and varnish free. Hand hygiene education and monitoring is important, in order to keep motivation high and ensure full compliance at all times.

High Impact Intervention Care Bundles

The Department of Health High Impact Intervention Care Bundles7 integrate ‘evidence’ generated from sources such as Epic 3 and are regularly reviewed to enable best available evidence to be integrated into clinical practice. Care bundles ‘bundle’ together small, straightforward sets of evidence-based practices, usually about three to five. When performed consistently as a group or bundle, improved patient outcomes have been demonstrated. Care bundles can be used to inform staff, audit clinical practice, provide positive feedback and highlight areas for improvement (Box 4.1).

An integral part of High Impact Intervention Care Bundles is ensuring ‘asepsis’ by utilising the framework of ANTT (aseptic non-touch technique)8 (Figure 4.5) which ensures ‘key parts’ and ‘key sites’ are protected from contamination, minimising the risk of infection.

HCAIs can result in significant morbidity and mortality, particularly in clinical areas that provide acute and critical care. Failure to prevent infection can be very costly in terms of lives affected and result in the closure of clinical services, delaying hospital admissions. Instigating all the measures mentioned above have contributed to a reduction in the prevalence of HCAIs. However, the challenge is ensuring ongoing improvement can be sustained.

5Pain management

Effectively managing pain remains a challenge for acute care nurses, with about 40% of hospital patients and 50% of surgical patients reporting pain, described as moderate or severe.1