Icu Orientation Manual 3o2653

ICU/CCU Only Competencies

 Read Johns Hopkin’s MHA Keystone ICU Project module  Complete Hemodynamic Monitoring and I Monitoring self learning modules before attending agency nurse orientation class  Verbalization/Demonstration of arterial line/Swan Ganz and I set-up with verbalization of normal values – during agency nurse orientation class  General ICU exam covering all systems, including medication calculations  Attendance at 4-hour Pain Management Class for GCH epidural certification – must for class  Review Post Cardiac Arrest Therapeutic Hypothermia module

Johns Hopkins MHA ICU Keystone Project Compiled by: Professional Nursing Development

SK/VA 03, Revised 1/10 FC

Overview In November 2003, Garden City Hospital became a participant in a two-three year Johns Hopkins/ Michigan Hospital Association ICU Keystone Project along with 58 other Michigan hospitals, which is an ongoing culture change of practice in medicine and nursing. The project is being conducted to improve patient safety and communication among caregivers in association with the US Department of Health and Human Services Agency for Healthcare Research and Quality, Johns Hopkins University, and the Institute of Healthcare Improvement (IHI). The objective of the project is to implement evidence-based medicine and nursing and reduce the risk of medical errors: 

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Implementing the use of specialists who coordinate ICU care with a checklist approach to daily rounds that encourages communication among multiple caregivers.  Multidisciplinary rounds/patient goal setting form (see attached) is done daily and left at the bedside. Attempting to eliminate bloodstream infections. Improving care of ventilator patients to reduce dependence on the breathing apparatus, which is a key factor in reducing length of stay and infections.  Accomplished through interventions called vent bundling. ~ bundling refers to the interventions specified ~ Developing skills to sustain care of patients with severe infections  Early recognition: Emergency Department, Medical/Surgical units, Obstetrics, etc  Sepsis: Early goal directed therapy Communication & Symptom Management  Family Centered Care Developing a comprehensive patient safety program that includes a web-based error reporting system (ICU only) – Completed in 2005.

Please visit the web sites:   

http://www.MHA.org http://www.josieking.org/memories.html http://www.mharchives.org/ICU/projectoverview.asp

Johns Hopkins MHA ICU Keystone Project Interventions Intervention 1: Cultural Unit Based Safety Program (CUSP): Patient Safety Initiative Advocates safety for healthcare providers and patients by participating in: 

Cultural safety survey to identify staff’s safety concerns

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Daily walking rounds with all healthcare providers.

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Briefing process

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Report session at change of shift with Resident/Charge Nurses

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Reporting errors and follow-up on quality reports

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Investigate defect: Staff identify defects in frontline caregivers

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Implementation of improvements

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Disseminating results of the survey and reports

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Medical rounds assigned

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Executive walking rounds

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CEO executive summary (ICU, Progressive and Acute Care)

Intervention 2: Daily Goals and Rounding (Goal: To be a permanent part of the chart) Evaluates the effect of interventions & to improve communication by utilizing the Daily Goals Sheet (see attached sheet) during multidisciplinary team rounding to determine:  Safety risks

 Discharge needs

 Scheduled labs/tests

 Progression of interventions as set Forth by JHH/MHA

 Family/social issues

 Pain management and sedation

 Cardiac status

 Consultations

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

Intervention 3: Ventilator Bundle (ICU, Progressive and Acute Care) For mechanically vented patients (refer to standing order sheet for adult mechanical ventilated patients):

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HOB >30 degrees to reduce the frequency and risk for nosocomial pneumonia

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Oral care protocol every 2 hours and PRN.

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Thromboprophylaxis to prevent deep vein thrombosis (DVT)

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Peptic ulcer disease prophylaxis to reduce the risk of UGI bleeding

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Daily interruption of sedative drug infusions to decrease the duration of mechanical ventilation and length of stay

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Intensive insulin therapy: Goal is to maintain blood glucose 100-139mg/dL to reduce morbidity and mortality among critically ill patients. Tight glycemic control protocol (see attached copy) may be instituted if criteria are met:  Patient must be on a ventilator  Two consecutive blood glucose results of >139 mg/dL or one blood glucose >200 mg/dL, would initiate an order for an insulin drip  Intensivist/ICU Resident order

Daily screening of respiratory function followed by trials of spontaneous breathing to reduce the duration of mechanical ventilation, decrease complications and cost of care

Intervention 4: Eliminate Catheter-Related Blood Stream Infections (CR-BSI) – Hospital wide intervention Compliance with the following interventions will decrease the risk for CR-BSIs: 

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

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Mandatory use of protective covering for all healthcare providers: Sterile gown, sterile gloves, face shield with mask. “Stop” procedure if indicated until sterility observed.

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

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

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Apply sterile dressing to site with all dressing changes

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

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Removing unnecessary central venous catheters

Intervention 5: Improvement in Sepsis Care: Intervention ensures patients receive optimal care by improving sepsis care (Refer to attached Severe Sepsis journal article & Standing order sheet for Severe Sepsis)   

Prevention: hospital acquired infections such as catheter related blood stream infections, ventilator-associated pneumonia, surgical site infections, and urinary tract infections. Early goal directed therapy (EGDT): proactive approach in patients with a known or suspected infection. Appropriate intervention: antibiotics, steroids, activated protein c

Continuum of sepsis:   

Systemic inflammatory response syndrome (SIRS) Sepsis (known or suspected infection) Severe Sepsis (Sepsis and one or more organ system dysfunction)  Septic shock (Severe sepsis plus hypotension)

What is Early Goal Directed Therapy (EGDT)? Early goal directed therapy to restore a balance between oxygen delivery and oxygen demand are provided during the first 6 hours of suspected or known infection. Patients may be given intravenous fluids (colloid or crystalloid), vasoactive agents, and blood transfusions to increase oxygen delivery. Early identification of severe sepsis is critical to provide EGDT and improve patient outcomes.    

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Who is at risk for Severe Sepsis? All critically ill patients Severe community acquired pneumonia Urinary tract infection Chronic Diseases o Diabetes o Heart failure o Chronic renal failure o Chronic obstructive pulmonary disease Intra-abdominal surgery Meningitis Compromised immune status o HIV/AIDS o Use of cytotoxic and immunosuppressive agents o Malignant neoplasms o Alcoholism Cellulitis

Criteria for Early Goal Directed Therapy (EGDT) for Severe Sepsis and Septic Shock 1. Two or more signs of inflammation:  Temperature >100.4 F (38.0 C) or < 96.8 F (36 C)  Heart Rate >90 beats per minute  Respiratory Rate >20 breaths per minute or PaCO2 <32 mmHg  WBC >12,000 cells/mm3, <4000 cells/mm3, or >10% bands 2. Suspected or confirmed infection.  Positive cultures (blood, sputum, urine, etc.)  Antibiotic, antifungal, or other anti-infective therapy  Documentation of pneumonia (x-ray, ultrasound, etc.)  Have WBCs been found in normally sterile fluid  Perforated organ (bowel) 3. Systolic blood pressure <90mm Hg after fluid bolus (Septic shock) Lactate > 4 mmol/L Evidence of > 1 organ dysfunction (Severe sepsis)

References Ely, E.W. & Bernard, G.R. 2005. Contemporary Diagnosis and Management of Sepsis Ahrens, T. & Tuggle, D. 2004. Surviving Severe Sepsis: Early Recognition and Treatment. Critical Care Nurse Supplement October 2004. Severe sepsis overview. http://www.xigris.com/overview/at

Diagnostic Criteria for Sepsis Infection, documented or suspected, and some of the following: General variables Fever (core temperature >38.3 C) Hypothermia (core temperature < 36 C) **Heart rate >90 min –1 or >2 SD above the normal value for age Tachypnea Altered mental status Significant edema or positive fluid balance (> 20mL/kg over 24 hours) Hyperglycemia (plasma glucose > 120 mg/dL) in the absence of diabetes Inflammatory variables Leukocytosis (WBC > 12,000 uL) Leukopenia (WBC < 4000 uL) Normal WBC count with > 10% immature forms **Plasma C-reactive protein > 2 SD above the normal value **Plasma procalcitonin > 2 SD above the normal value Hemodynamic variables Arterial hypotension (SBP< 90 mm Hg, mean ABP < 70, or a SBP decrease > 40 mm Hg) Mixed venous oxygen saturation > 70% Cardiac index > 3.5 L/min Organ dysfunction variables Arterial hypoxemia (PaO2/FIO2 <300) Acute oliguria (urine output <0.5 mL/kg/hr or 45 mmol/L for at least 2 hrs Creatinine increase >0.5 mg/dl Coagulation abnormalities(international normalized ratio >1.5 or activated partial thromboplasm time>60) Ileus Thrombocytopenia (plt count < 100,000 uL) Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 mmol/L) Tissue perfusion variables Hyperlactatemia (>1 mmol/L) Decreased capillary refill or mottling ** SD: Standard Deviation: A parameter that indicates the way in which a probability function or a probability density function is centered around its mean and that is equal to the square root of the moment in which the deviation from the mean is squared. (Standard Deviation (SD) is not reported on the lab report. To obtain SD lab personnel may be ed)

Intervention 6: Communication & Symptom Management Intervention that encourages promoting a family-centered environment.  Provide family with information, reassurance/, and opportunity to be near the patient.  Obtain clarification about how to meet the needs of the family by asking the family .  Integrate family-centered values in the units standards and policies  Provide family with ICU patient brochure  Be consistent with patients families o Visiting hours o Pain management o Treatments  Make family-centered care a multidisciplinary group endeavor o Physicians o Nurses o Respiratory Therapist o Case Managers o Dietary  Discuss challenging cases/concerns at staff meetings and committees.

Documentation Reminders  Completion of daily rounds sheet  Daily interruption of sedative drug infusions (wake-up call) & assessments  Pain assessment/management q2h  Oral care q2h  Communication & Symptom Management

References http://www.MHA.org http://www.josieking.org/memories.html http://www.mhaarchives.org/ICUgrant/projectoverview.asp “Michigan Health & Hospital Association Johns Hopkins to Enhance ICU Safety”. Michigan Health & Hospital Association Newsletter. October 22, 2003 Pronovost, P., and Berenholtz, S. Inproving Sepsis Care in the Intensive Care Unit: An Evidence-Based Approach. VHA Research Series 2004

Garden City Hospital Critical Care Services Tight Glycemic Control Protocol PURPOSE: The goal is to maintain a blood glucose range between 100-1 39mg/dL Regular Human Insulin Concentration =l00units/l00mL 0.9% NaC1 IVE DATA: Hyperglycemia associated and insulin resistances are common in both diabetic and non-diabetic critically ill patients. Studies have reported substantially reduced morbidity and mortality in patients itted to the intensive care unit for mechanical ventilation who had tight glycemic control (some literature presents 80-1 l0mg/dL). Significantly fewer deaths due to multiple organ failure with sepsis occurred with intensive insulin therapy and the length of stay for patients requiring more than five days of intensive care was substantially reduced. Bloodstream infections, critical illness, polyneuropathy and duration of mechanical ventilation were all significantly lower in patients who had tight glycemic control. Recent studies ing these findings have further defined these benefits by demonstrating a definite relationship between increasing morbidity and mortality and increasing blood sugar levels. AOA 29.00.01 Special care Units (SCU): Special care Units exist to provide the focused use of intensive staff and technologic resources for patients. AOA 16.03.00 Standards of Practice and Care: Nursing care is based upon written standards of practice and standards of care. DOCUMENTATION: Document blood glucose levels and rate changes on Nursing Insulin Flow Sheet. Documentation should include the amount of the rate change as well as the new drip rate. SCOPE: RN ICU-CCU PATIENT POPULATIONS: 1. ICU patients with anticipated ICU stays of greater than 24-48 hours. 2. The protocol does not apply automatically to patients with diabetic ketoacidosis hyperosmolar-nonketoacidosis, but may be used for such patients at attending physician’s discretion. 3. Adult patient receiving mechanical ventilation in a critical care bed.

4. Diabetic and non-diabetic patients are eligible. 5. Discontinue all previous insulin orders including insulin in total parenteral nutrition. 6. Discontinue all antidiabetic medications. EXCLUSION: 1. Hematocrit <20% or >55% (lab draw is required in these patients due to limitations of bedside glucose meter). INITIAL ASSESSMENT: 1. On ission to the ICU and at a minimum once daily, all patients will have baseline blood sugar ordered. If over 1 39mg!dL, repeat xl after two hours. 2.Assess for: History of DM Obesity How much glucose patient is getting from diet, 1V’s, IVPB, etc. Medications (steroids, anti-diabetic medications) Nutrition CRITERIA FOR INITIATION OF PROTOCOL REQUIRES PHYSICIAN ORDER and one of the following: 1. Two blood glucose values greater than 139 mg/dL or; 2. One blood glucose value greater than 210 mgIdL 3. Unstable blood glucose values on sliding scale TRIGGERS FOR DISCONTINUATION OF PROTOCOL/CONVERSION TO LONG OR INTERMEDIATE ACTING INSULIN PLUS SLIDING SCALE (REQUIRES PHYSICIAN ORDER). 1. Patients ability to eat and is eating, has received their 1 dose of subcutaneous insulin or when patient is normoglycemic while receiving < 2 units per hour. 2. Glucose less than 8Omg/dL x 3 consecutive measurements. 3. Glucose less than 140 mg/dL on stable insulin dose for more than 12 - 24 hours. 4. Notify physician of any or all of the above. Ask physician to consider discontinuation of insulin infusion and initiation of longer acting insulin and sliding scale coverage when infusion rate and blood glucose is stable for 12 24 hours. ISTRATION 1. Standard insulin drip = 100 units regular human insulin in l00ml 0.9% NaCL. 2. ister insulin via an infusion pump. 3. Insulin drip must be changed at least every 24 hours. INITIAL DOSE 1. Bolus and infusion rate=Blood Glucose divided by 100.

2. Round to nearest 0.5 unit (nearest half of a unit). For example: If a patient has a blood glucose = 258, Initial bolus = 2.5 units Initial infusion rate = 2.5 units per hour Initial Blood Glucose (mg/dL) Initial Bolus Initial Infusion Rate (100 units regular insulin/100 mL NaC1)

Initial Blood Glucose (mg/dL)

Initial Bolus

140 - 175 176 - 225 226 - 275 276 – 325 326 – 375 > 376

1.5 units 2 units 2.5 units 3 units 3.5 units 4 units

Initial Infusion Rate (100 units regular insulin / 100 mL NaCl) 1.5mL / hour 2 mL / hour 2.5 mL / hour 3 mL / hour 3.5 mL / hour 4 mL / hour

KEY POINTS: 1. If blood glucose falls 50 mg/dL between 2 consecutive readings and current blood glucose is 200mg/dL: decrease insulin drip by 50% (round up to the nearest 0.5 units). 2. If blood glucose falls> 50 mg/dL between 2 consecutive readings and current blood glucose is > 200 mg/dL: continue insulin drip at the current rate. 3. Notify ICU Resident/Intensivist if Blood Glucose> 400 mg/dL or if there is a change >100 mg/dL in one hour. FREQUENCY OF TESTING: ‘While insulin is infusing, either “finger sticks” (bedside glucose testing) or serum glucose measurements should be taken every hour X 4. Then glucose checks can be reduced to every 2 hours until 4 consecutive values remain in the desired range with no change in infusion rate, then glucose checks can be reduced to every 4 hours. Every 2-hour testing should be continued or resumed if any of the following occur: changes in clinical condition, changes in nutrition, and changes in steroid or pressor therapy. STAT blood glucose should be checked if patient shows sign of hypoglycemia. NUTRITION PROTOCOL: If tube feedings, TPN, or other forms of nutrition are held for >1 hour, hold insulin infusion; check blood glucose every 6 hours. When nutrition is restarted, resume insulin drip at the previous rate and resume blood glucose checks as listed in section entitled, “Frequency of Testing”.

SPECIAL CIRCUMSTANCES: Stop insulin infusion if the patient is off the unit for more than 1 hour and blood glucose monitoring cannot be continued. When nutrition is restarted, resume insulin drip at the previous rate and resume blood glucose checks at the previous rate and resume BG checks as listed in section entitled, “Frequency of Testing”. HYPOGLYCEMIA PROTOCOL In this protocol hypoglycemia is defined as blood glucose < 70mg/dL If blood glucose <50 mg/dL • Hold insulin infusion For Patient who is responsive and able to swallow: 1. Give 15gms. carbohydrate po: 1 cup skim milk or ½ cup orange or apple juice. Do not use OJ for renally impaired patients. Do not add sugar. 2. For patients with blood glucose <50mg/dL., obtain lab draw to confirm glucose results, but do not delay treatment. 3. Recheck blood glucose Q 15 minutes X 2. 4. Feed small snacks with protein and carbohydrate ( ie. cheese and crackers ) 5. Investigate cause and call physician. 6. Repeat treatment in 15-30 minutes if glucose remains under 70 mg/dL. 7. Establish IV access if not already available. For patient who is unresponsive, OR symptomatic, OR on an insulin drip, OR unable to swallow. 1. Dextrose 50% - 50ml. ( 25gm ) IV. 2. For patients with blood glucose <50mg/dL., obtain lab. draw to confirm glucose results, but do not delay treatment. 3. Recheck blood glucose in 15 minutes X 2, if <70mg/dL, repeat step 1 and recheck. 4. a. If patient is receiving a long acting product ( e.g. Lantus (glargine ) or 70/30, run D5W at 100mL/hr X 4 hours. b. If a patient on a Tight Glycemic Protocol, check blood glucose Q 15 minutes When >100mg/d., wait 1 hour then restart insulin infusion at 50% of original rate. 5. Investigate cause and call physician.

REFERENCES: Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N EnglJMed200l; 345:1359-67. Evidence Based Rating Scale : Level V Finney SJ, Zekveld C, Elia A, et al. Glucose control and mortality in critically ill patients. JAMA. 2003;290:204l-2047. Evidence Based Rating Scale : Level V MHA Website ADA Website, 2008 ADA Nutrition Recommendation and Interventions for Diabetes Position Statement, Diabetes Care, Volume 31, Supplement I January, 2008. Policy and Procedure collaboratively developed and approved by the Critical Care and Pharmacy and Therapeutics Committees. May 2005 APPROVAL: Critical Care Committee Pharmacy Department DISTRIBUTION: Critical Care Unit Based Clinical Policy and Procedure Manual REVIEW : 8/06, 10/08 REVISION: 1/09

Arterial Line and Swan Ganz Set-up Competency for Agency Nurse Staff Name: ________________________________

Date: ________________________

Behavioral Objective:  Demonstrate proper set-up of equipment for arterial lines and Swan Ganz.  Verbalize pressure of each chamber: RAP (CVP), PAP, PCWP.

Competency

Arterial Lines I. Verbalize and gather equipment. II. Demonstrate set-up pressure line III. Verbalize zeroing line after demonstration of leveling phlebostatic axis IV. Verbalize maintaining pressure bag at ___ at all times and flush q ___ hour and PRN V. Verbalize method for obtaining blood specimen from arterial line VI. Demonstration calculation of MAP VII. Verbalize normal arterial SBP and DBP VIII. Verbalize nursing responsibilities and troubleshooting Swan Ganz I. Verbalize and gather equipment II. Demonstrate set-up pressure line III. Verbalize preparation of room and patient IV. Verbalize assisting physician and remaining at the bedside throughout the procedure V. Verbalize recording waveforms and documenting strips in the chart VI. Demonstrate interpreting waveforms VII. Verbalize pressure of each chamber: RAP (CVP): PAP: PCWP: VIII. Verbalize and demonstrate identifying placement of catheter IX. Verbalize procedure for removal of PA line after physician order obtained. X. Verbalize Nursing Responsibilities and troubleshooting

Method of Verification

Verbalize and Demonstrate

Verbalize and Demonstrate

Reviewer Title, Initial and Date

XI.

XII.

Verbalize use of catheter ports: Distal Lumen - Yellow: Proximal Port - Blue: Distal Port - White: Red: Temperature probe Verbalize procedure for performing Cardiac Output: *Preparation *Procedure

ing Signature: _________________________________

Date: ____________

Comments:

SK/07, revised FC/10

GARDEN CITY HOSPITAL CRITICAL CARE SERVICES PROTOCOL CARE OF PATIENT WITH INTRACRANIAL PRESSURE MONITOR PURPOSE: To direct the caregiver in the care and management of the patient with Intracranial Pressure (I) Monitor. IVE DATA: Continuous measurement of intracranial pressure (I provides useful information in patients with intracranial hypertension and in patients at risk for developing intracranial hypertension I recording is achieved by operative (burr-hole) placement of an epidural pressure transducer or alternatively by insertion of an intraventricular catheter. AOA 16.03.04 Standards of Care; Standards of care describes the application nursing technique / intervention to specific patient problems, needs, and nursing diagnoses. AOA 29.00.01 Special Care Units (SCU); Special Care Units (SCU) exist to provide the focused use of intensive staff and technologic resources for patients. CONTENT STEPS: 1. Position patient to prevent flexion of the neck or hips. Neck, head and extreme head flexion increase I. Head rotation of 90 degrees to either side may also result in increased I. Head of bed should be elevated 30-45 degrees (unless otherwise ordered) to improve venous drainage from the head. Normal levels I 415mm hg. 2. Initially record I, MAP, P every 15 minutes to establish a trend. A. MAP – mean arterial pressure by A-line or by non-invasive blood pressure monitoring with the following formula: MAP = diastolic BP x 2 + systolic BP ÷ 3 B. P – cerebral perfusion pressure may be altered by hypertension or hypotension. It may also be affected by increased I. Normal range P= 60-90 mmHg. In patients being monitored with I, P is not allowed to fall below 50mmHg. P is calculated with the following formula: P = MAP – I mmHg

3. Subsequently record I, MAP, P every 1 hour. 4. Inform physician if:  MAP < 60  I > 20  P < 50 5. Utilize neurological assessment sheet to record level of consciousness, GCS, MAP, I, P. 6. Concentrate nursing care activities into schedule blocks of time to avoid over stimulation of the patient. 7. Avoid frequent inducement of cough reflex. Hyperventilate prior to suctioning patient. 8. Monitor for HA, nausea, vomiting, seizure activity, changes in ventilator patterns, hyperthermia, posturing, decerebrate or decorticate, increased diuresis, papilledema and Cushing’s triad (irregular respiratory pattern, widening pulse pressure and bradycardia. 9. Avoid hypothermia and hyperthermia. 10. Avoid excessive fluid intake. 11. Avoid stimulating valsalva movements. 12. The site must be kept clean and dry and should be covered with an occlusive dressings at all times. CROSS REFERENCE: Intracranial Pressure Monitoring Camino, Becker, Goeltec REFERENCE: AACN Procedure manual for critical care 4th edition LynnMcHale, Carlson; WB Saunders Zool, 2001 pp 561-569 Nursing Assessment and Management of Patients with Head Injuries, LeJeune, Gerard M., Howard-Fain, Tamara. Dimensions of Critical Care Nursing, Nov 2002 Vol 21. Caring for patient swith increased intracrancial pressure. Le Jeune, M.RN, Howard-Fain, Tamara, RN, Nursing 2002 Evidence Based Rating Scale: Level II Nursing Procedures and Protocols Lippincott, Williams, and Wilkins 2003 pp 393-398 Evidence Based Rating Scale: Level II Critical Care Nursing Reference, Fourth Edition, Mosby, 2006 Pp 463-468 Evidence Based Rating Scale: Level II

APPROVAL: Critical Care Committee Neurology Department DISTRIBUTION: Critical Care Unit Based Clinical Policy and Procedure Manual REVIEW: 6/99, 5/2000, 7/03, 1/05, 11/06, 10/08 REVISION: 6/99, 1/05

GARDEN CITY HOSPITAL CRITICAL CARE SERVICES PROCEDURE BECKER INTRACRANIAL PRESSURE MONITORING SYSTEM INSERTION PROCEDURE

PURPOSE: To direct the caregiver in preparing the patient and the equipment for the insertion of the Becker Intracranial Pressure Monitoring System. IVE DATA: A physician order is required. Intracranial pressure monitoring is utilized to monitor intracranial pressure and evaluate for trends in pressures and therapeutic interventions. Danger signals of increased intracranial pressure (I) 1. Level of consciousness (LOC) changes 2. Increased blood pressure 3. Decreased apical rate 4. Onset hemiparesis 5. Pupillary changes 6. Sudden headache or worsening headache 7. Vomiting AOA 16.03.04 Standards of Care: Standards of care describe the application of nursing technique / intervention o specific patient problems, needs, and nursing diagnoses. AOA 29.00.01 Special Care Units (SCU): Special Care Units exist to provide the focused use of intensive staff and technologic resources for patients. SCOPE:

RN CCU/ICU

EQUIPMENT LIST: 1. Becker External Drainage and Monitoring System 2. Mounting bracket 3. IV pole 4. Transducer pressure monitoring system (no flush system: Baxter Tru-Wave Disposable Pressure Transducer with Stopcock.) 5. Preservative free 0.9% NS Solution 250 ml 6. Surgical mask, gown, sterile gloves, towels 7. Standard Monitoring set 8. Cranial Access (separate package) in Pyxis

CONTENT STEPS: Refer to figure 1.0 – 1.3 for the following content steps A. Equipment Set-Up 1. Obtain all equipment 2. Remove Becker system wearing a surgical face mask and sterile gloves. 3. Check to ensure that all components are assembled and all connections are tight and leak free. 4. Remove air from saline bag by inserting a 23 gauge 1-inch needle into additive port and squeezing bag. 5. Connect standard monitoring set to main stopcock, flush tubing from main stopcock through patient line, then from main stopcock through Becker tubing system. 6. Discard standard monitoring tubing and IV bag and attach the non- flush tru-wave valve to the main stopcock. Keep clamp open to drainage bag while flushing (this is done by removing red dead end plug and tightening transducer to stopcock. 7.

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

8.

Check system for any residual air bubbles. Air can be removed by combined injection of saline and aspiration of air via 25 gauge needle at injection sites on patient line stopcock or patient line.

9.

Ensure no fluid comes through filter at top of collection chamber. (If filter becomes wet a new system must be obtained).

B. Equipment Connection to Patient – To be completed by Physician. 1. Before attaching system to patient; zero, drainage/monitoring system to Foramen of Monroe. 2. Connect catheter to pre-filled system; * to turn patient line stopcock to “off” position. Remove patient line dead end cap and connect. 3. Care should be taken to ensure that the catheter and complete system is devoid of any air bubbles.

C. System Calibration 1. Level transducer with Foramen of Monroe. (Between top of ear and end of eyebrow). 2. Turn stopcock off to patient and open to air 3. Drop flow chamber to zero; monitor will read zero (0), when zero on monitor pressed. Then raise chamber to 20-22 mmHg to accuracy monitor should read 22+ or – one.

4. Use cm H20 and set scale ( physician order for measurement units) 5. If catheter changed, system is changed. D. Sampling needed: 1. Open sample port stopcock. 2. Use a syringe with barrel pulled back 1cc before needle placed in port. a. Place needle in port and let drain; then pull cut needle and send specimen. b. “DO NOT” pull on barrel of syringe. c. Document color of specimen and amount taken. E.Trouble Shooting for system malfunction 1. Turn stopcock near patient off to patient. 2. Mount on IV pull set up. 3. Flush collection chamber if not done. See step 1 of original setup 4. Take needle and syringe and pull back for fluid fill and air bubble removal or flush forward to where stopcock is. Can use 20cc syringe with normal syringe and flush up to chamber with bag open at bottom. 5. All injection sites should be cleaned with alcohol and then alcohol allowed to dry before a needle is inserted into them. 6. Sterile technique should be observed in setting up the system. 7. The main stopcock must be correctly aligned with the patient for accurate pressure monitoring. 8. Mounting must be securely mounted. If the is allowed to drop, reduction in system pressure will result and overdrainage of CSF may occur. 9. Always ensure stopcocks are in the proper position for the maneuver being carried out. 10. Be aware waveform – if it dampens, check entire system.

F. To Replace Drain Bag 1. Close flow chamber slide clamp. 2. Remove the bag from the system mounting using sterile technique. 3. Disconnect the drainage bag connection line. Discard the bag. DOCUMENTATION: 1. Document date and time of initial insertion and set up of the Becker I system. 2. Tag the line for start date and change date. 3. Document in nurses notes initial readings and readings at least 2 hours or at intervals as ordered. Document any procedures performed that may increase or decrease I. SEE ATTACHMENTS. REFERENCES: Becker EDMSII Booklet AACN Procedure Manual for Critical Care 4th edition. Lynn-McHale, Carlson; WB Saunders Zool, pp 561-569. Evidence Base: Level II Sole, Klein, Moseley, Introduction to Critical Care Nursing, 5th Edition; Chapter 13, Nervous System Alterations, p. 393 Evidence Based Rating Scale: Level II APPROVAL: Critical Care Committee DISTRIBUTION: Critical Care Unit Based Clinical Policy and Procedure Manual REVIEW: 3/91, 1/05, 11/06, 10/08 REVISION: 11/95, 1/97, 1/98, 8/00, 7/03, 1/05, 8/06

Tranducer Hook Up

Name: ________________________ Date: ____________ Intracranial Pressure Monitoring Post-Test 1. Name two functions of a Becker I monitor/drainage system: _____________________________________________ _____________________________________________ 2. List the three components within the skull that determine I: _____________________________________________ 3. Calculate the P based on the values below: ___________ MAP=82 I=12 4. When would you expect an increase in P1 amplitude? a. Development of a mass b. Increased CSF volume c. Hypertension d. Increased Venous Volume 5. An elevation in which wave would indicate poor compliance within the skull? a. P1 b. P2 c. P3 6. List three symptoms associated with increased I: _______________________________________________ 7. What three components make up Cushings Triad? (circle all that apply) a. Irregular respiratory pattern b. Narrowing pulse pressure c. Widening pulse pressure d. Bradycardia e. Tachycardia 8. True or False: Maintenance of any I monitor should be done sterilely. FC/10

Becker I Set Up Competency for Agency Nurse Staff Name: ________________________________

Date: ________________________

Behavioral Objective:  Demonstrate proper set-up of equipment for Becker I.  Verbalize normal values I and P. Competency

Becker I VI. Verbalize and gather equipment. VII. Demonstrate set-up pressure line VIII. Verbalize zeroing after demonstration of leveling at Foramen of Monro IX. Verbalize maintaining pressure bag at ___ at all times X. Verbalize method for obtaining CSF specimen VI. Demonstration calculation of P IX. Verbalize normal I X. Verbalize nursing responsibilities and Troubleshooting XI. Verbalize signs and symptoms of increased I

Method of Verification

Reviewer Title, Initial and Date

Verbalize and Demonstrate

ing Signature: _________________________________

Date: ____________

Comments:

FC/10

Post Cardiac Arrest Therapeutic Hypothermia Self Learning Module For ICU RN’s

Why Use Therapeutic Hypothermia? Brain temperature during the first 24 hours after resuscitation from cardiac arrest may have a significant effect on survival and neurological recovery. Cooling to 32-34 degrees Celsius for 24 hours may decrease chance of death and increase the chance of neurological recovery. Hypothermia activates the sympathetic nervous system causing vasoconstriction and shivering. Shivering increases oxygen (O2) consumption by 40-100%. Sedatives, opiates, and neuromuscular blockers can counteract these responses and enhance the effectiveness of active cooling. How Does Therapeutic Hypothermia Work? Hypothermia shifts the oxyhemoglobin curve to the left and may result in decreased O2 delivery. However, the metabolic rate is also lowered, decreasing O2 consumption/carbon dioxide (CO2) production. Ventilator settings may need to be adjusted due to decreased CO2 production, using temperature corrected blood gases. Hypothermia initially causes sinus tachycardia, then bradycardia. It is extremely important to keep the patient’s temperature >30 degrees Celsius as temperatures <30 degrees Celsius place the patient at an increased risk for arrhythmias and core temperatures <28 degrees Celsius place the patient at an increased risk for ventricular fibrillation. Severely hypothermic myocardium (<30 degrees Celsius) is less responsive to defibrillation and medications, decreases cardiac output and increases systemic vascular resistance (SVR). Hypothermia can induce coagulopathy (which can be treated with platelets and fresh frozen plasma). Hypothermiainduced diuresis is to be expected and should be treated aggressively with fluid and electrolyte replacement. Magnesium, phosphorous and potassium should be monitored closely and maintained within a normal range. Decreased insulin secretion and sensitivity can lead to hyperglycemia, which should be treated aggressively. Re-warming must proceed slowly over 6-8 hours to prevent profuse vasodilation, leading to hypotension, rapid fluid and electrolyte shifting.

Who Is Eligible For Therapeutic Hypothermia at Garden City Hospital?  Adults over the age of 18 (Women must have a negative UCG)  Witnessed cardiac arrest with a ROSC (return of spontaneous circulation) to a systolic blood pressure >90, with or without the use of vasoactive medications  Unresponsive at enrollment with a GCS (Glasgow coma scale) < 8 after ROSC  No primary intracranial event or comatose due to other causes (CVA, head trauma, status epilepticus, drug overdose)  Less than 6 hours have elapsed since ROSC  Does not have an order for “Do Not Resuscitate” (DNR) or “Do Not Intubate” (DNI), patient must be a full code  Must be intubated and mechanically ventilated  Pulseless <60 minutes  Pre-arrest cognitive status is not severely impaired (i.e. can perform ADL’s independently) Who Is NOT Eligible For Therapeutic Hypothermia at Garden City Hospital?     

Pulseless >60 minutes > 12 hours since ROSC Glasgow Coma Scale >8 Minimal pre-morbid cognitive status Other reason for coma (i.e. drug overdose as etiology for arrest) and/or intracranial pathology (i.e. intracranial hemorrhage, ischemic stroke), subarachnoid hemorrhage (SAH), sedation  Sepsis as etiology for arrest  Uncontrollable bleeding/Pre-existing coagulopathy or bleeding if known: INR > 3.0, Platelets < 30,000  Significant trauma, especially intra-abdominal such as splenic or liver laceration (due to increased risk of bleeding) What Supplies Do I Need To Prepare?  Two one liter bags of 4 degrees Celsius 0.9% NS (stored in the ED/ICU refrigerators)

 Arterial line kits (both femoral and radial)  Central Venous Catheter  Gaymar External Cooling System with two complete sets of hoses, one torso wrap and two leg wraps  Foley catheter with temperature probe Preparation For Cooling Ensure the central venous catheter is inserted BEFORE initiating cooling. Once the patient is cooled venous access is difficult to obtain. Insertion of a triple lumen catheter is ideal, though any central venous catheter is acceptable. An arterial catheter should be placed concurrently if possible. Obtain baseline labs:  Urine HCG on all women of child bearing age  ABG with ionized calcium and magnesium  CBC, platelets, PT/PTT/INR, fibrinogen  Comprehensive metabolic  Amylase, Lipase  Lactate, CK, Troponin  Cortisol level  Pan Culture  Toxicology screen if appropriate Then, place the temperature probe indwelling foley catheter. Complete and document a thorough skin assessment before applying cooling system wraps. Insert an oral gastric tube and initiate low intermittent suction. Cooling Infuse 4 degrees Celsius 0.9 Normal Saline (30ml/kg) over 30 minutes. DO NOT INFUSE FLUIDS VIA JUGULAR OR SUBCLAVIANLINE. Infuse maintenance IV 0.9 Normal Saline at 100 ml/hr. Titrate to keep CVP between 8 and 12. Apply Gaymar cooling device wraps, first the chest and then the leg wraps connecting the appropriate hoses. Connect the temperature monitoring indwelling foley catheter to temperature monitoring port on Gaymar machine. Turn machine on, ensure that the cool fluid fills the body wraps. Check fluid volume in machine once wraps are full, you will need to add more fluid to the machine at this time. Keep 4 additional liters of fluid with the machine at all times. If the Gaymar machine is not available

pack the patient in ice (groin, sides of chest, axilla and neck). DO NOT STOP COOLING DURING TRANSPORT OF PATIENT. Gaymar Cooling Device Settings Initially set the machine to rapid cooling automatic mode with target temperature of 34 degrees Celsius. Once the patient reaches 34 degrees Celsius, set gradual cooling automatic mode to 33 degrees Celsius. Assess the cooling blanket settings and patient’s temperature in degrees Celsius. Cooling is maintained for 24 hours from the time the target temperature, between 3234 degrees Celsius is reached. KEEP THE GAYMAR UNIT PLUGGED IN AT ALL TIMES. Monitoring The Patient Temperature Our goal is to maintain the patient’s core temperature between 32-34 degrees Celsius for 24 hours. Maintain the patient blanket temperature at 33 degrees Celsius in gradual automatic mode, assess and document the patient temp hourly. If ice packs are being used, add or remove ice packs to maintain the core temperature of 32-34 degrees Celsius. If the patient’s temperature drops to < 31 degrees Celsius, consider infusing 250 ml boluses of warm 40 degree Celsius 0.9 Normal Saline or LR until temperature >32 degrees Celsius. Monitor closely for arrhythmias if patient temperature < 32 degrees Celsius. Skin assessments should be completed and documented every 6 hours. Hemodynamics Vital signs are to be documented every 15 minutes for the first hour, then hourly. Maintain a MAP 65-120 mmHg with IV fluids, vasopressors or nitrates if needed. Levophed is included in the standing orders to start at 1mcg/min, titrate to keep MAP 80-100mmHg (Max dose 30mcg/min, RN to call pharmacy when needed). Laboratory Request temperature correction when blood gas values are being calculated. Patient’s may require intensive glucose control. If the blood glucose is >150mg/dl X 1, initiate the Tight Glycemic Control Protocol. Urine output should be documented at least every two hours. Hypothermia induced diuresis is common, aggressive fluid replacement may be required. If an acute decreased in urine output is detected, confirm bladder contents with bladder

scanner. The patient will have serial labs drawn throughout the procedure physician if:  Potassium < 3.4  Magnesium < 2  Calcium < 8  Uncontrolled shivering  Heart rate < 50 or > 110 beats per minute  Systolic blood pressure < 80mmHg or > 180 mmHg  Any change in Troponin value Shivering Shivering is a bodily response to early hypothermia. When the core body temperature drops, the shivering reflex is triggered. Muscle groups around the vital organs begin to shake in small movements in an attempt to create warmth by expending energy. The approach towards shiver control involves the combined us of pharmacological and non-pharmacological interventions. The goal of these therapies is to achieve a Bedside Shivering Assessment Scale score of 0. BSAS Score Treatment 0 = none None reassess in 30 minutes 1 = Mild (localized to neck and/or thorax only 2 = Moderate (gross movement of the upper extremities) 3 = Severe (gross movement of the trunk & upper & lower extremities

 Meperidine (Demerol) 25mg IVP, may repeat q15 minutes prn x 3 doses, if ineffective, in any 6 hour period (Maximum 75mg). PLUS  Buspirone 30mg down OGT (synergistic with Meperidine) Q 12 hours PRN X 24 hours.  If Meperidine ineffective, ister: Roccuronium (Zemuron) 50 mg every 30 mins PRN and reassess in 30 minutes (RN to call pharmacy when needed).  Magnesium Sulfate 1-3 grams/hour gtt for persistent shivering (RN to call pharmacy when needed).

Medications For Sedation/Analgesia ister sedatives using the Richmond Agitation Sedation Scale (RASS). Our goal is (-4) deep sedation, these scores should be documented hourly. Begin sedation with Propofol at 5mcg/kg/min, increase every 5 minutes by 5mcg/kg/min, with a maximum dose of 50mcg/kg/min. Add Fentanyl drip in addition when Propofol is maximized. Begin Fentanyl at 1mcg/kg slow IVP then start drip at 50mcg/hr. Increase infusion by 25mcg/hr every 30 minutes, if needed, with a maximum dose of 150mcg/hr (RN to call pharmacy when needed). Add Lorazepam in addition to Propofol and Fentanyl when they are maximized. Give Lorazepam 2mg IVP every 30 minutes until sedation goal achieved then start drip at 1mg/hr. Increase infusion by 1mg/hr every 30 minutes, if needed with a maximum dose of 10mg/hr (RN to call pharmacy when needed). RASS Scale

Re-Warming Begin re-warming 24 hours after target temperature reached. Re-warm gradually in a controlled manner to avoid vasodilatation and hypotension. Our goal is to re-warm the patient over 6-8 hours. Re-warming too rapidly can cause vasodilatation, hypotension, and rapid electrolyte shifts. Our goal is to maintain a MAP of 80-100mmHg. Anticipate a reduction in cardiac output and BP (decreased CVP) as the cooler blood shifts from the core to the

extremities. Follow the CVP closely; aggressive IV fluids may be necessary to maintain adequate volume status during re-warming.  Gaymar: Increase the blanket temperature setting by 0.5 degrees Celsius every 1-2 hours.  ive Re-warming: Remove all cooling devices and cover patient with a sheet. Assess and document vital signs with CVP every 1 hour until temperature reaches 36 degrees Celsius. Monitor K+ every 4 hours and prn. Monitor serum glucose levels every 1 hour until temperature reaches 36 degrees Celsius. As insulin resistance resolves, the patient is at risk for hyperglycemia. Follow ABG’s as needed with temperature corrected values. Adjust ventilator settings according to the physician orders. Maintain paralysis until patient temperature > 36 degrees Celsius, then discontinue. Titrate sedation to comfort and ventilator synchrony as per physician orders.

Celsius 30.0 30.5 31.0 31.5 32.0 32.5 33.0 33.5 34.0 34.5 35.0 35.5 36.0 36.5 37.0 37.5 38.0

Fahrenheit 86.0 86.9 87.8 88.7 89.6 90.5 91.4 92.3 93.2 94.1 95.0 95.9 96.8 97.7 98.6 99.5 100.4

Reference: Hypothermia after Cardiac Arrest Study Group. (2002). Mild Therapeutic Hypothermia to Improve the Neurologic Outcome After Cardiac Arrest. New England Journal of Medicine, 346(8):549-556.

Bernard SA, Gray TW, Buist MD, et al. (2002). Treatment of Comatose Survivors of Out-of-Hospital Cardiac Arrest With Induced Hypothermia. New England Journal of Medicine, 346(8): 557-563. Zeiner A, Holzer M, Sterz F, et al. (2001). Hyperthermia After Cardiac Arrest is Associated with an Unfavorable Neurologic Outcome. Arch Intern Med, 161(16): 2007-2012.