Top tips for a critical care placement

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Visit the ward before you start

This gives you chance to meet your mentor and ask if there’s anything specific they would like you to read up on beforehand. You can have a look around the ward and see some of the machines you will come across on your time there. This was the one placement I didn’t manage to get to before starting and the first day nerves were ridiculous!

Do some reading before starting

I say this about every placement but I feel like a critical care placement really does need some pre-reading. Even if it’s just brushing up on your a&p knowledge! My placement had a student pack that contained common equipment and common medications used, as well as a list of reasons why a patient would be transferred to HDU/ITU which I found really useful as it gave me a little insight before starting. You can see my critical care series here.

It’s normal to be worried or terrified, I was!

Critical care was my first placement of second year, after spending the whole of first year in a community hospital on an elderly rehab ward. I hadn’t been on an acute ward before critical care. I loved it from day 1 and really thrived there, it developed my confidence so much! I walked in on day 1 terrified, feeling that I would never know what I was doing. This is normal I can promise you that. Trust your own skills and knowledge and know that the nurses there don’t expect you to know everything about the area, it’s too specialised for that. Just go in eager to learn and you cannot go wrong!

Develop knowledge of normal anatomy and what happens when it becomes abnormal

You may already have a good understanding of a&p, enhance this by reading up on pathophysiology. This is the explanations of how conditions develop and progress. It can really help your understanding of why patients are in HDU/ITU and what the treatment plan is.

Ask questions, utilise the knowledge that the nurses and doctors have in this area

The nurses and doctors in this area are so knowledgeable and in my experience, more than happy to share all this knowledge with students who are willing to learn. There are no silly questions and you will get to see some interesting things on a critical care placement! I watched intubations, extubations, trachestomy insertion, ecgs, sedation breaks and experienced my first arrest situation (which is very different in a critical care area because you can see it developing before it actually occurs). Remember to talk through things you see with your mentor and write reflections on any relevant experiences you have on critical care.

Learn the names of equipment used

When I was managing my own patient, in the afternoon I would take the time to fill the bed space trolley up with the essentials. If you know the names of the equipment used, it can really help your mentor and show your own initiative to fill the trolley up in quiet periods. Learn the bedside checks as well and how to carry these out, this is a job you can be doing for your mentor at the beginning of shifts whilst they carry out other tasks.

Brush up on your SBAR and A-E handovers

These are used every time you hand over on critical care (in my experience) and I soon learnt the quickest way to handover whilst still including all the information needed for the nurses taking over the care of your patient. It is a quick and concise way to hand over and means all hand overs include the relevant information.

Take a notebook, this is a must for any placement but especially for this one!

There is so much to learn on this placement, I filled two pocket notebooks in my 6 weeks in critical care! Make notes on everything, ask questions, use quiet time to research common medications using the ward BNF, read medical notes and make a note of any terminology you don’t understand so you can research it later on.

Learn the common medications used there and how they work

This really helped me to understand why patients were on medications and how the different doses worked. Ask your mentor for the common medications used and spend some time researching why they are used and how they help the patient. You can read the common medications I came across in critical care here.

If it is a short placement, use it to develop your medication knowledge and handover skills

If you have critical care for a spoke placement, you may not have time to fully develop your knowledge of the ward but you can use it to develop your handover skills and how to care for a critical patient. Enjoy every shift, take every opportunity and don’t be afraid to ask questions!

Love,

T x

Recommended reading for a critical care placement

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Acute and Critical Care in Adult Nursing

img_2524Part of the transforming nursing practice series, which I am a big fan of! This book contains everything you would need to know before and during a placement in a critical care area. Includes information on ABGs and  is separated into sections such as pain, respiratory distress etc making it easy to read in sections.

Oxford Handbook of Critical Care Nursing

img_2523This book is small enough to carry around in your bag and explains most procedures you are likely to encounter on a critical care placement. Includes sections on common medications used and sections on disorders affecting different systems within the body.

Critical Care Nursing Made Incredibly Easy!

img_2525This is another series of books that I am a fan of, they explain things in a way that is easy for everyone to understand – perfect for students who may not have had an acute placement before. This book includes explanations of over 100 disorders you may come across in a critical care environment. The cartoon pictures included provide a little bit of light-hearted humour as well!

Intensive Care Nursing: A Framework for Practice 

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This book is described as the ‘bible of intensive care nursing’. It may be useful to read this book when you have read one of the others or if you decide to progress into a career in critical care, however it is a fantastic book and one which I read bits of during my time on ICU.

Websites

ABGs – you will not be expected to fully understand these but if you can go into the placement with a basic understanding it will help you understand some of the results

ECGs – you will not be expected to fully understand these but here are a few sources if you would like to do some reading on them

Tracheostomy care

You can read my critical care blog series here

Love,

T x

Common equipment used in critical care

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Monitor – Every patient requires a monitor which allows for continuous monitoring of observations. These include blood pressure, heart rate, respiratory rate and oxygen saturations, CO² and temperature can also be added on to the monitor.

Ventilator – A ventilator can assist patients’ with their own breathing, or completely take over the control of a patients’ breathing. This allows their body to rest and recuperate. The patient will either have an endotracheal tube or a tracheostomy. A tracheostomy tube allows the patient to receive full support whilst awake. If the patient has an endotracheal tube, they will be sedated.

Arterial line – An arterial line is inserted into an artery and this enables constant monitoring of blood pressure, through being connected to the monitor. They also allow access for frequent blood samples and ABGs. The arterial line can be inserted into the radial, brachial, femoral or pedal artery. The most common ones I saw in critical care were radial ones. The arterial line is sutured to the skin to keep it in place.

Central line – A central line is an intravenous line, inserted into one of the larger veins in the body. They are mainly used for administering medications, IV fluids are also given through central lines. Central lines are usually inserted into the jugular vein, but they can also be inserted into the femoral or subclavian veins.

endotracheal-tube-500x500Endotracheal tube – This is a plastic tube that is used during mechanical ventilation. The tube is inserted into the patient’s trachea, often the tube will be cut to a size recommended by the Dr carrying out the intubation. A bougie may be used to guide the insertion of the tube. Once inserted, the tube will be attached to the ventilator via ventilator piping. There is a cuff on these tubes that will be inflated to prevent movement of the tube, cuff pressure is checked regularly to ensure there are no leaks.

Indwelling urinary catheter – All patients within critical care will have a urinary catheter in place. This is to ensure accurate monitoring of urine output for the patients fluid balance records. Urine output will usually be recorded every hour.

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Vas Cath – A vas cath is a specialised central line that is used only for dialysis. Placed in the jugular, femoral or subclavian veins. I only saw one of these in my time on critical care and it was placed in the femoral vein.

 

Product_PicWindow_Carefeed-AdultNasogastric tube – This is a flexible tube that is inserted through the nose and down into the stomach. The NG tube can be used to provide nutrition via a ng feed and to administer certain medications. The NG tube is aspirated regularly to check if the patient is absorbing the ng feed and to test the ph level of any aspirations collected. The position of the NG tube should be checked and recorded regularly by measuring the length of the tube visible. Before using the NG tube, the guide wire should always be removed.

tracoe-twist-ref-301-tracheostomy-tubeTracheostomy tube – A small tube placed into a hole made in the neck, allowing access to the trachea. A tracheostomy is used when a patient is being weaned from ventilator support. These are temporary and will be removed when the patient no longer needs them. The inner tubes are cleaned every 4 hours.

Intravenous infusion pumps – Used for any medication that is administered through a central line. The amount of medication infused every hour is recorded on the fluid balance chart. These are the ones used in my trust, others may vary.

 

Let me know if you’ve seen any other equipment on your critical care placements!

Love,

T x

 

 

Acidosis and Alkalosis

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You can read my post about ABGs here.

Respiratory Acidosis

Respiratory acidosis is caused by poor alveolar ventilation. This leads to the retention of CO². Causes can include asthma, respiratory depression and COPD.

An ABG would show:

ph level

CO²

Respiratory Alkalosis

Respiratory alkalosis is caused by excessive alveolar ventilation, also known as hyperventilation. This causes more CO² to be exhaled than usual. PaCO² is reduced, causing the ph level to increase. Causes can include anxiety (panic attack), pulmonary embolism and pneumophorax.

An ABG would show:

ph level

CO²

Metabolic Acidosis 

Metabolic acidosis can occur due to increased acid production or decreased acid excretion. Can be caused by things such as diabetic ketoacidosis and Addison’s disease.

Metabolic Alkalosis

Metabolic alkalosis occurs due to a decreased hydrogen ion concentration. This leads to a rise in bicarbonate. Can also occur directly due to an increased bicarbonate concentration. Causes can include vomiting/diarrhoea (gi loss of H+ ions) and heart failure or cirrhosis (renal loss of H+ ions).

Below is what an ABG would show for metabolic acidosis and alkalosis:

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Love,

T x

 

 

 

A guide to ABGs

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ABG is an abbreviation for arterial blood gas. ABGs are performed by taking blood from an artery instead of from a vein. ABGs are performed to give an accurate measurement of ph, oxygen and carbon dioxide levels within the blood. They are used to check the function of the lungs and how well they are able to move oxygen and remove carbon dioxide.

To begin to understand ABGs and be able to interpret them, you need to know the normal ranges:

  • pH – 7.35 – 7.45
  • paO² – 10 – 14 kPa
  • paCO² (carbon dioxide) – 4.5 – 6.0 kPa
  • HCO3 (metabolic) – 22 – 26 mmol/L
  • Base excess – -2 to +2 mmol/L
  • O² sats – 94-100%

 

paO² – partial pressure of oxygen

This should be >10kPa (kilopascal) on room air in a healthy patient.

If patient is <10kPa on room air – patient is hypoxaemic (lack of oxygen within the blood)

If patient is <8kPa on room air – patient is severely hypoxaemic and in respiratory failure, CO² would be looked at to determine type 1 or type 2.

Ph level – acidity/alkalinity of the blood 

Acidotic – <7.35

Alkalotic – >7.45 

The smallest change in the ph level can have detrimental effects on the human body. The causes of a change in ph level can be respiratory or metabolic. Changes in ph are caused by a CO2 imbalance (respiratory) or a HCO3 imbalance (metabolic). Co2 and HCO3- act as buffers to keep the ph level within its normal range.

paCO² – partial pressure of carbon dioxide

paCO² is the respiratory element of an ABG.

The chemistry behind respiratory acidosis/alkalosis follows:

CO² binds with H2O and forms carbonic acid (H2CO3). This is acidic, causing the ph level to decrease below 7.35. If the patient is retaining CO², the blood will become more acidic. If the patients’ respiratory rate is raised, CO² will be ‘blown off’ meaning there is less CO² in the system than usual therefore the blood becomes more alkalotic.

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HCO3- (Bicarbinate)

HCO3- is produced by the kidneys and ‘collects’ acids (H+ ions). It is a byproduct of the body’s metabolism.

When HCO3- is raised, ph level is increased due to a decrease in H+ ions (alkalosis).

When HCO3- is low, ph level is decreased due to an increase in H+ ions (acidosis).

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Base Excess

Base excess is another marker of metabolic acidosis/alkalosis. It is the amount of acid that must be added to each litre of fully oxygenated blood to return the ph level to 7.40 and to gain a paCO² level of 5.3kPa.

If the base excess is high ( > +2mmol/L) = this indicates higher than normal HCO3- within the blood.

If the base excess is low (< -2mmol/L) = this indicates lower than normal HCO3- within the blood.

Compensation

Respiratory acidosis/alkalosis can be metaolically compensated. This is done by increasing or decreasing the levels of HCO3-.

Metabolic acidosis/alkalosis can be compensated by the respiratory system. This is done by retaining or ‘blowing off’ carbon dioxide.

You can read more about acidosis and alkalosis here.

Love,

T x

 

Information researched through critical care nurse, on Geeky Medics, Oxford Medical Education and from medical textbooks.

 

 

 

 

Common medications used in critical care

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I often see posts from students who have received placement allocations in critical care and are wondering what to read up on. Here are a list of the most common medications used in critical care that I hope others may find useful.

Sodium Chloride 0.9% (also known as normal saline) – every patient will usually have this on ITU, it is a source of water and electrolytes. Used for replenishing fluid and restoring/maintaining the concentrations of sodium and chloride ions.

Hartmanns fluid – used to replace body fluid and mineral salts. A mixture of sodium chloride, sodium lactate, potassium chloride and calcium chloride in water.

Propofol – sedation used in ITU for critically ill patients on ventilators. Propofol is given continuously via IV infusion.

Alfentanil – used as an opioid analgesia. Suppresses respiratory activity in patients receiving invasive ventilation. Acts within 1-2 minutes and has a short duration of action. Often used alongside sedation such as Propofol.

Noradrenaline – a vasoconstrictor used to treat hypotension. Norad is administered continuously via IV infusion into a central line.

Atracurium – a muscle relaxant used to paralyse. Dose is calculated on patients’ ideal body weight, not actual body weight. Able to be used in patients’ with hepatic or renal impairment due to the way it metabolises. Atracurium relaxes the vocal cords to allow intubation.

Vasopressin – often used as support for other vasoconstrictors, such as norad.

Ranitidine – reduces gastric acid output. Ranitidine is mainly used to stop stomach acid coming up from the stomach while the patient is under anaesthetic or sedation. It can also help to clear up infections within the stomach, when taken with antibiotics.

Remifentanil – used for sedation. Has a shorter onset duration than Alfentanil. Remi is often used overnight for patients who are not quite ready for extubation.

Digoxin – is a cardiac glycoside which increases the force of myocardial contraction and reduces conductivity within AV node. Digoxin helps make the heart beat with a more regular rhythm. Digoxin is used to treat atrial fibrillation.

Quetiapine – antipsychotic. Used for the treatment of ‘mania’ episodes.

Haloperidol – antipsychotic. Mainly used to ease agitation or restlessness in elderly patients.

Furosemide – diuretic. Used in critical care to offload a large positive fluid balance or if the patient is not passing an adequate amount of urine per hour.

Aminophylline – used to treat reversible airway obstructions.  Aminophylline is usually given via IV infusion and is used to treat the acute symptoms of asthma, bronchitis, emphysema, and other lung diseases. Will often be given to patients who become ‘wheezy’ if nebulisers do not appear to be helping. Aminophylline belongs to a group of medicines known as bronchodilators.

Clonidine – used as a sedative agent when weaning patients off stronger sedation.

Tinzaparin –  an anticoagulant used to prevent blood clots in patients with reduced mobility. As the patients in critical care are often sedated and bed bound, all patients will be administered tinzaparin or a variant of this.

Antibiotics – The common ones used are Co-Amoxiclav, Tazocin, Meropenum and Clindamycin.

Love,

T x

 

Information was collated through talking to consultants, critical care nurses and further research through the BNF.

 

 

A day on ITU

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The shift pattern on ITU is the same as the shift pattern on HDU (You can read my day on HDU post here) :

Long day: 07:15 – 19:45

Nights – 19:15 – 07:45

Just like on HDU, there is no ‘typical’ day on ITU as every day can be different from the next. Below is one day that I experienced on ITU.

07:15 – 07:45 – During this time, we received a handover from the nurse in charge. We then went onto the ward and received a more detailed handover for the patients we would be looking after that day. This included details about why the patient was admitted and followed the A-E approach with a few extra sections. This handover also included any planned interventions for that day, such as x-rays or planned transfers. On ITU, the staff nurses’ have 1 patient each for the whole day (1:1).

07:45 – 10:00 – The nurse in charge checked the resus trolley and ventilation trolley to ensure all the correct equipment is present, working and within the expiry date. The staff nurses completed bedside equipment checks such as ensuring the equipment alarms are operating, checking the oxygen and suction points were working and checking the infusions to ensure there is enough left to last a couple of hours. In ITU, there are also ventilator settings and alarms that need to be checked to ensure they are working correctly. After all these checks, the patient was assisted with personal hygiene needs and repositioned. Pressure areas are checked and patients on ITU are repositioned 4 hourly, with pressure areas checked on each reposition. Everything is documented on the daily observations chart, an A3 sheet with information on both sides. All observations, fluid input/output and re-positioning is documented on there. The patients have a drink and breakfast if they are able to eat.

10:00 – 12:00 – Usually between this time, the consultants and nurse in charge will do a ward round. They discuss each patient and what the next step of their medical plan should be. Sometimes this will be a new medication or a change in ventilator settings, depending on how the patient is responding to their current treatment plan. Sedation holds may begin around this time to allow the patient to have time to respond, sometimes the patient is not ready to fully break from sedation so the sedation may be restarted and a sedation hold attempted the next day.

12:00 – 18:00 – Again it’s hard to fully describe what happens in the afternoon as every day is different. Obs are usually completed hourly on ITU, they may be 2 hourly if the patient is self ventilating and being transferred to a ward. Obs on ITU include fluid input and output. Fluid input includes any medications given by IV or through a NG tube. Fluid output includes blood taken and NG tube aspirations as well as urine output. Every hour the balance is recorded so we can see if the patient is in negative or positive fluid balance. Equipment checks are carried out once again throughout the afternoon to ensure alarms are still functioning correctly.

Patient observations are monitored closely and medications/oxygen can be adjusted accordingly. If a patient is responding well to ventilation, the ASB rate, PEEP or oxygen % may be adjusted to see how the patient manages. Extubation may occur if the patient is responding well to treatment but this will be planned in advance and discussed in the days leading up to the decision. ABG’s will be taken and the results recorded on the daily observation chart, as well as the patients medical notes.

New patients can be admitted from surgery, A&E, HDU or other wards.

18:00 – 19:15 – Daily notes are completed for the patients we have been looking after. The daily handover sheet is updated ready for the handover to the night shift team.

19:15 – 19:45 – Night shift arrive and the nurse in charge gives a handover covering the whole ward. The night shift team then come onto the ward and receive detailed handovers for their patients.

Love,

T x

A day on HDU

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My first placement of year 2 is 6 weeks on ITU/HDU. At Derby university in second year, we have two hub placements. One is for 6 weeks and the other is for 12 weeks. We also have a spoke placement where we spend 4 weeks.

The shift pattern at my placement is:

Long day: 07:15 – 19:45

Nights – 19:15 – 07:45

There are 1/2 days but I won’t be doing any of these during my placement block.

There is no ‘typical’ day on HDU as every day can be different from the next. Below is one day that I experienced on HDU. Other areas/trusts will vary and I would love to hear about your typical days on placement!

07:15 – 07:45 – During this time, we received a handover from the nurse in charge. We then went onto the ward and received a more detailed handover for the patients we would be looking after that day. This included details about why the patient was admitted and followed the A-E approach with a few extra sections. This handover also included any planned interventions for that day, such as x-rays or planned transfers. On HDU, the staff nurses’ usually have 2 patients each for the whole day (2:1).

07:45 – 10:00 – The nurse in charge checks the resus trolley and ventilation trolley to ensure all the correct equipment is present, working and within the expiry date. The staff nurses also complete bedside equipment checks such as ensuring the equipment alarms are operating, checking the oxygen and suction points are working and checking the infusions to ensure there is enough left to last a couple of hours. After all these checks, the patient is asked if they would like to have a wash and a fresh gown. If the patient declines, they are re-positioned and a skin check completed. Everything is documented on the daily observations chart, an A3 sheet with information on both sides. All observations, fluid input/output and re-positioning is documented on there. The patients have a drink and breakfast if they are able to eat.

10:00 – 12:00 – Usually between this time, the consultants and nurse in charge will do a ward round. They discuss each patient and what the next step of their medical plan should be. Sometimes this will be a new medication or transfer to a ward such as respiratory or stroke wards, depending on the patient.

12:00 – 18:00 – It’s hard to fully describe what happens in the afternoon as every day is different. Obs are done hourly or 2 hourly, depending on the patient. Obs on HDU include fluid input and output. Fluid input includes any medications given. Fluid output includes blood taken as well as urine output. NG tube aspirations are included in the fluid output also. Every hour/2 hours the balance is recorded so we can see if the patient is in negative or positive fluid balance. Equipment checks are carried out once again throughout the afternoon to ensure alarms are still functioning correctly.

Personal care needs are met as needed and re-positioning is carried out regularly if the patient is unable to do so themselves. Patients observations are monitored closely and medications/oxygen can be adjusted accordingly. Equipment may also be changed if needed, such as changing a patient from a nasal cannula to an oxygen face mask. ABG’s may be taken in this time and the results recorded on the daily observation chart, as well as the patients medical notes.

New patients can be admitted from surgery, A&E or other wards.

18:00 – 19:15 – Daily notes are completed for the patients we have been looking after. The daily handover sheet is updated ready for the handover to the night shift team.

19:15 – 19:45 – Night shift arrive and the nurse in charge gives a handover covering the whole ward. The night shift team then come onto the ward and receive detailed handovers for their patients.

Look out for further blog posts in my HDU/ITU series!

Love,

T x