Project transfer-our skills to

Transcription

1 11 Subglottic Aspiration 6 Project transfer-our skills to help AICU 12 Lung Protective Ventilation 7 13 VAP Bundle 7 14 Why is my Ventilator Alarming? 7 15 Airway Pressure Release Ventilation (APRV) 8 16 Prone Positioning the Adult patient 8 17 Cardiovascular Support (CVS) in AICU 9 18 Atrial Fibrillation (AF) management Fluid management 10 Keep it simple, do the basics well, the expectation is not to be an expert Table of Contents 1 Responsibilities of a nurse when caring for a patient in AICU 3 2 Top tips to survive 3 3 AICU housekeeping at GSTT/ELCH during COVID Admission and Discharge to AICU 4 5 Routine Elements during COVID-19 surge 4 20 Analgesia Sedation Delirium Analgesia Sedation Delirium is common in COVID Nursing considerations for Delirium Gastro-intestinal (GI) Feeding NGT Position Infection Considerations Basic Nursing Care Degree Tilt Communicating with Patients/Relatives during COVID End-of life nursing care Nursing Care of the Deceased Adult Patient Specific Considerations for COVID COVID-19 Complications Management of Respiratory Failure in Confirmed/Suspected COVID Final Words of Wisdom 18 6 FLAAATCHUG (This will be done daily on the ward round) 4 7 What is Normal? 5 8 Endotracheal Tubes 5 9 Securing ETT with ties 5 10 Tracheostomy Tubes 6 1 2

2 1 Responsibilities of a nurse when caring for a patient in AICU Nursing care Plan expected treatments Finding ways to communicate with the patient Finding ways to help the patient Provide support services Adult ICU is busy. Patients require support in larger quantities, present with multiple co-morbidities that you continue to treat along with their presenting diagnosis The main difference is interventions consume more of your time and require more than one staff member In these times, more than ever this workload will continue to increase It is therefore important to have a strict structure to your day ASSESS, PLAN, IMPLEMENT & EVALUATE 2 Top tips to survive Remember we also do this as PICU nurses, we regularly look after 50kg children these days Know the routine of the unit. What time will you be doing interventions (if you are)? Be ready to do these when your support team arrive Who is coming to help you/who do you have around you? If you have multiple drugs due, start preparing these in the hour ahead Always be ahead of the game Delegate amongst your team Use our incredible HCA s who are highly skilled valued members of our team in delivering patient care Don t forget to have fun with your team, while delivering the best possible care you can NEVER BE AFRAID TO ASK FOR HELP IN ANY SITUATION! 3 AICU housekeeping at GSTT/ELCH during COVID-19 Keep it simple, do the basics well, the expectation is not to be an expert Download Clinibee (available on mobile phone app and beside computers. Register with gstt.nhs.uk CRT Bleep 0610 ICM Consultant Rota Rotawatch ICM consultant mobile contact details on each unit nurse s station and on Clinibee During the pandemic there will be a daytime float Intensivist who will touch base with all the outlying areas to aid with patient management plans At night the CRT consultant will be available for advice All local guidelines including pandemic specific guidance are on Clinibee/Gti Standard ICU guidance also on Gti 4 Admission and Discharge to AICU Similar to PICU Compete all relevant documentation via Carevue Standard admission bundle will be prescribed Remember to complete all admission swabs Ensure your patient has a med chart prescription before discharge/step down 5 Routine Elements during COVID-19 surge Respiratory Target lung protective ventilation (6ml/kg ideal body weight). Generally, PEEP 10 if > 50% FiO2. Management of respiratory failure COVID/suspected-COVID on Clinibee/GTi Cardiovascular Noradrenaline is the vasopressor of choice. Consider adding hydrocortisone 50mg 6 hourly if noradrenaline > 0.2mcg/kg/hr, once volume resuscitated CNS Propofol/Fentanyl standard Renal Replacement Therapy Seek support from ICU renal specialist nurses: Guideline on Clinibee/Gti. Citrate anticoagulation (instead of Heparin). Use hemodialysis instead of hemofiltration as 1 st line (CVVHD instead of CVVHF). Gastrointestinal Laxatives on standard order set (remove if immediate post GI surgery). Aim 1-2 bowel motions a day. Feed from admission if not contra-indicated. ICU enteral feeding policy on Clinibee/Gti Infection Up-trending WCC/CRP needs investigation. NB: Lines! 6 FLAAATCHUG (This will be done daily on the ward round) F Feeding enteral/parenteral, absorbing? L Lines Clean? Age? Femoral 5 days max A Aperients (1-2 bowel motions/day) A Angle of the bed 30 degrees A Awakening daily sedation hold T Thromboprophylaxis appropriate? C Communication: patient, family, nursing staff (plan) H Hydration set fluid a balance U Ulcer prophylaxis (stop if fully fed and no risk factors) G Glucose control 4-10mmol/L 3 4

3 7 What is Normal? RR b/min SpO2 >96% Temperature BP 120/80mmHg MAP 65mmHg Pulse rate bpm Level of consciousness AVPU *Complete NEWS (2) on TrustOle* to familiarise values training e-learning package yourself with normal adult 10 Tracheostomy Tubes Tracheostomy tubes can be uncuffed, cuffed and fenestrated; similar to PICU Tube selection will depend on patient s condition, availability and preference Familiarise yourself and follow the National Tracheostomy Safety Project (NTSP) guidelines as well as local policy 11 Subglottic Aspiration Tracheal tubes (endotracheal or tracheostomy) may have a subglottic secretion drainage port This is a suction port at the rear of the tube above the cuff Important for subglottic port to be aspirated with standard 10ml syringe 1-2 hourly as prescribed This is to avoid secretions pooling below the vocal cords and leaking into the lungs, which will increase the risk of ventilator-associated pneumonia (VAP) This is part of your VAP bundle 8 Endotracheal Tubes Adults are generally intubated orally with a cuffed tube A typical size for an oral ET tube is mm for women and mm for men Nasal intubation is more difficult to do than oral intubation and causes more tissue damage Important to monitor cuff pressure Cuff pressure should be 1-2cmH2O above PEAK pressure, however, in COVID-19 it could be up to 5cmH2O 9 Securing ETT with ties Follow guideline on intranet and seek support Familiarise yourself with the step-by-step process below (guideline available on Gti)

4 12 Lung Protective Ventilation Adequate PEEP: Start with PEEP 10cmH2O (usually need to aim for FiO2/6) Adjust respiratory rate to give pco2 6kPa Aim PO2 8 and SpO % Peak Pressures = 28cmH2O or if obese 32-34cmH2O TV=6ml/kg PBW Ensure expiration long enough (expiratory flow should return to 0) 15 Airway Pressure Release Ventilation (APRV) APRV can be used when conventional pressure ventilation is not working It is a form of continuous positive airway pressure (CPAP) which releases the CPAP to a pressure of zero intermittently Essentially, it is a very long inspiratory breath followed by a quick expiatory breath It can look like breath-holding and the patient may only receive 5-10 breaths per minute Seek AICU support if your patient is on APRV 13 VAP Bundle Elevate bed degrees Sedation level assessment (RASS score) Unless patient is awake and comfortable, sedation is reduced/held for assessment at least daily Teeth brushed twice a day (12 hourly with standard toothpaste) Subglottic aspiration (aspirate 2 hourly) ETT cuff pressure monitoring (4 hourly) 20-30cmH2O or 2cmH2O above peak inspiratory pressure (PIP) Stress ulcer prophylaxis (only prescribed to high-risk patients) 16 Prone Positioning the Adult patient Used for gravitational effects on lung inflation Refractory hypoxemia Prone position duration is at least of 16 consecutive hours a day until prone positioning criteria is stopped Refer to available guideline on how to carry out prone positioning, as well as deproning your patient on Clinibee/Gti 14 Why is my Ventilator Alarming? Increased airway pressure or decreased lung compliance caused by worsening disease Patient biting on oral ETT Secretions in airway Condensation in tubing Intubation of right main stem bronchus Patient coughing, gagging or attempting to talk Chest wall resistance Bronchospasm High Pressure Alarm Low Pressure ETT tube disconnected from ventilator Alarm Tube displaced above vocal cords or tracheostomy displaced Leaking TV from low cuff pressure (underinflated/ruptured cuff, or a leak in the cuff) Ventilator malfunction Remember to always ask for help 7 8

5 17 Cardiovascular Support (CVS) in AICU Assess your patient Is your patient well filled? Administer 250mls PLASYMALYTE via distal port on CVC (this allows the maximum rate of infusion) RE-ASSESS Has your patient been fluid responsive? (guideline available on Clinibee/Gti) After 1-2L of filling, rethink? Do you have a capillary leak? Very high-risk complications following fluid resuscitation in COVID-19 always seek support Do you need to start vasopressors? Do you need to start inotropes? Do we need an ECHO? Adrenaline generally not used as causes issues with arrhythmias in adults CRYSTALLOIDS GENERALLY OVER COLLOIDS 250mls PLASAMLYTE Fluid Challenge 2 x 100mlm 20% albumin in sepsis (rare in COVID-19) NORMAL MAP targets 65mmHg 60mmHg (younger/sick) 70mmHg (hypertensive elderly) Milrinone causes too much vasodilation NORADRENALINE (vasopressor) Maintain BP in acute hypotensive states Hypotension in septic shock 4mg/50mls (single strength) 8mg/50mls (double strength) 16mg/50mls (quadruplestrength) DOBUTAMINE (inotrope) Increase CO in short-term treatment of cardiac decompensation from depressed contractility 250mg/50mls 18 Atrial Fibrillation (AF) management AF is common in the sick adult o Identify and manage Optimise electrolytes o Magnesium - 1.4mmol o Potassium - 4-5mmol o Ionised Calcium - > 1.1 Amiodarone 300mg loading dose then start 900mg IV infusion Consider a screening ECHO if possible If you start a beta-blocker remember it will cause hypotension 19 Fluid management Medical team will set fluid balance target for 6am the following day On Noradrenaline: Aim + 500mls Not on Noradrenaline but oedematous: Aim - 1/2Litres Not on Noradrenaline, no oedema: Aim Neutral Use Plasmalyte as resuscitation fluid 250mls challenged and ASSESS response 2 x 100ml 20% albumin in sepsis (rare to use in COVID-19) Administer via distal port on CVC to allow the maximum rate of infusion Maintenance fluid: 0.5ml 1 ml/kg/hr (if not absorbing feed) Match patient losses with replacement fluid Trigger for transfusion: 70g/L ABG Sampling Seek support from a member of the AICU team to teach you how to use this set. We have some on PICU to practice with METARAMINOL Alpha agonist 10mg ampoule which you dilute to 20mls = 0.5mg/ml This can bolused peripherally while gaining central access ASD but not as we know it! 9 10

6 20 Analgesia Sedation Delirium 20.1 Analgesia Fentanyl 20.2 Sedation Propofol Consider changing strength if triglycerides are high Consider Midazolam infusion if continuing concerns Assess your patients Richmond Agitation Sedation Score (RASS) + 2 to 4 Agitated Combative + 1 Restless 0 Awake normal person - 1 Drowsy - 2 Light sedation eye contact - 3 Moves to voice, no eye contact - 4 Deep sedation - 5 Unarousable Guideline available on Clinibee/Gti 20.3 Delirium is common in COVID-19 Firstly, teat the cause: Pain Sepsis Dehydration Constipation Acute withdrawal Hypoxia Altered sleep-wake cycle Electrolyte abnormalities Pharmacological treatment: o 1 st line Haloperidol (IV) o 2 nd line Olanzapine (SL) o Benzodiazepines (BDZ) work for alcohol and BDZ withdrawal (otherwise they can contribute to delirium) o Melatonin 2mg at night restore the sleep/wake cycle 20.4 Nursing considerations for Delirium Assess using the Confusion Assessment Method (CAM)-ICU (guideline available on Clinibee/Gti) Minimise common contributors Promote rest and facilitate sleep Decrease noise and artificial light Encourage mobility when possible Provide repeated orientation and reassurance to the patient Remove monitors, lines and catheters as soon as possible Provide cognitive stimulation Use communication adjuncts Involve family if you can, familiar faces may help (facetime/ipad etc.) 21 Gastro-intestinal (GI) Aim 1-2 bowel motions a day Senna and lactulose on standard order set (remove if immediate post GI surgery) If no bowel movement for 2 days o PR o Enema/Movicol Feed from admission if not contra-indicated following ICU enteral feeding policy (available on Clinibee/Gti) Manage diarrhoea o Stop aperients (anything that could be contributing) o Check for C-Diff and Norovirus o Consider bowel management system (refer to guideline on Clinibee/Gti) Check glucose o Aim 6-10mmol/L (> 10 = sliding scale) o Insulin requirements go up during sepsis and cooling o Once recovering/warming may wean off o SC if insulin if persists after recovery Ongoing evidence showing hyperglycemia in COVID Feeding Where possible, enteral nutrition via naso-gastric (NG) feeding is the preferred route Nasogastric (NG) and jejunal (NJ) tubes Corflo 12FR standard tube used on ICU Other sizes may be used as clinically indicated Ryles tubes should not be used for enteral feeding but can be used for aspiration of gastric contents Feed with Nutrison Protein Plus Multifibre 24-hour feed Aspirate gastric contents 4 hourly < 300mls = absorbing 300mls = return 200mls and start 1st line treatment of metoclopramide 11 12

7 23 NGT Position Advice/assistance from consultant after two failed attempted at NGT insertion Document failed attempts The NEX (nose, earlobe, xiphisternum) measurement should be measured and documented for all new NG tube insertions Final placement length (at upper lip) and ongoing checks of this must be documented in patient care flowsheet Nothing, including sterile water should be flushed via the NG tube prior to position being confirmed Flushing substances via the NG tube may give a false positive ph Position of all new tube insertions should be checked by CXR Reported by radiology within 2 hours If delayed, seek consultant to review It must be documented that it is safe to feed using separate entry on Carevue ph alone should not be used to confirm NG position in critical care Interrupting feeds can lead to serious hypoglycemia & adverse consequences for the patient o After all patient turns o After patient transfers (CT/MRI) o After procedures o Intubation o Tracheostomy insertion o Bronchoscopy 24 Infection Considerations Rising CRP/PCT with +/-a fever then send culture Blood/urine Sputum/NBL Change lines if day 5 or over with infection triggers Generally femoral lines should only stay in-situ for 5 days max ABX Pseudomonas cover after day 3 When sending ALL (suspected & confirmed) COVID-19 respiratory panels to the labs: they MUST be DOUBLE BAGGED When to check tube position NGT Position using CXR as 1st line On initial placement When tubes have been reinserted, repositioned or suspicion of displacement (vomiting, excessive suctioning or coughing, agitation) If starting/restarting enteral feed following suspicion of displacement (change in measurement/condition) Unexplained change in patient respiratory status After procedures that the tube could have moved: o OGD o TOE o Extubation NGT position should be checked at the upper lip and recorded on Carevue o Minimum once per shift o Before giving each medication dose/series of doses o After physiotherapy/mobilisation in or out of bed 25 Basic Nursing Care Assist/facilitate every patient to have their teeth brushed 12 hourly using soft bristled toothbrush and fluoride toothpaste Perform/encourage 6 hourly mouthcare as prescribed Use sterile water with sponges and yankeur Apply paraffin gel to lips 6 hourly Clean dentures with a toothbrush and fluoride toothpaste. Rinse and leave overnight in cold water, then brush again in the morning Protect the eyes to avoid infection and potential sight loss Each patient should have their eyelids closed and eyes assessed daily If patients have inadequate blink reflex, instill lacrilube every 4 hours, cleaning the outside of the eye before each application Reassess lid-closure and blink reflex regularly If lid does not close following lacrilube instillation, close eye and place sterile jelonet over the lids to keep the eye closed If further concern: contact the on-call Ophthalmologist Degree Tilt Pressure ulcers commonly occur in those who cannot position themselves Important to relieve pressure on the bony prominences Reposition patients to redistribute pressure from particular parts of the body It is repositioning technique that can be achieved by rolling patients 30 degrees to a slightly tilted position with pillow support at the back Follow local policy/guidance when performing and how regularly, while always being aware of lines and tube 13 14

8 25.2 Communicating with Patients/Relatives during COVID-19 Communicate with relatives where possible using ordinary video/audio applications Refer to information governance guideline on how you document this in your notes Re-orientate and provide regular reassurance Find out information about your patient from relatives that you can communicate with your patient to make them feel safer/familiar Think of things that would relax/comfort you Use communication tools where appropriate Whiteboards ipads Wound sites must be properly covered with an absorbent material and sealed with a clear occlusive dressing If a catheter is in situ this can either remain in position, be spigoted/removed Orifices can be packed with an absorbent material such as gauze if needed Ensure two identification bands are placed securely on the patient: One band should be on the wrist and one on the ankle where possible Patient s name, hospital number, NHS number, DOB and ward clearly visible Refer to the guideline on GTi and seek support/assistance 25.3 End-of life nursing care The nurse s role does not stop until the patient has left the unit Perform last offices according to hospital protocol (guideline available on Gti) Coroner referral not needed with COVID-19 deaths COVID-19 patients will not be suitable for organ donation, however, SNOD wishes to still be informed of eligible organ donors (seek support with this) Be prepared for quick turn-over of patients in this situation with high demand for ICU beds You may receive another admission directly following this Seek support amongst your peers we are not robots! Make use of the health & wellbeing facilities we are creating for PICU staff on the 6 th floor 25.4 Nursing Care of the Deceased Adult Patient Gently clean the patient s face and body with the same care dignity and respect you would give if the patient was still alive Always close the eyelids apply light pressure for 20 seconds (a small amount of Micropore tape may be used to keep the eyelids closed) The mouth should be cleaned to remove debris and secretions and then closed If there is leakage of gastric contents, suctioning and/or some packing in the mouth may be necessary Replaces dentures to retain the natural contours of the face In hospital, if unable to replace dentures due to weight loss, please send with patients to the mortuary and document this on the Removal of Deceased Patient Request form on the electronic patient record Dentures should never be returned in the patient s property Gently clean the patient s face and body with the same care dignity and respect you would give if the patient was still alive Brush/comb their hair You must check with the family before you proceed to shave the patient. Where family members are not available to ask, a wet shave should be performed Do not perform a dry shave as this can cause marking of the face a few hours later Be aware that some faith groups prohibit shaving In hospital, all lines, drains and catheters should be left in-situ and capped off. 26 Specific Considerations for COVID-19 Generally presenting in single-organ respiratory failure The cause of death from COVID-19 is nearly always ARDS Generally, not presenting in cardiogenic shock, BP is generally normal on admission and lactate elevations are mild to moderate APRV ventilation will reduce venous blood return Avoid fluid resuscitation where possible as may exacerbate ARDS as well as CVS complication Elevated triglycerides need assessment: review contributing factors (e.g. Propofol, TPN) WBC tends to be normal, however, lymphopenia and mild thrombocytopenia is common COVID-19 will increase CRP but does not appear to increase procalcitonin (PCT) 26.1 COVID-19 Complications Cardiomyopathy is a highly evidenced complication (caution with fluid resuscitation) Troponin (protein present in heart muscle break down) level elevation is a strong prognostic indicator for mortality Persistently high or rising CRP Elevated PCT suggests alternative diagnosis (perform full infection screen) Low lymphocyte and high neutrophil count suggest poor prognosis Platelet count < 100 suggests poor sign of prognosis Coagulation is generally normal although Disseminated intravascular coagulation (DIC) suggests poor prognosis Elevated D-Dimer does not always suggest pulmonary embolism (PE), may be an acute phase response D-Dimer is a fibrin degradation product; indicating thrombosis and elevated levels are being seen in COVID-19 patients

9 27 Management of Respiratory Failure in Confirmed/Suspected COVID Final Words of Wisdom This is a guide of as much information as we know but the expectation is not for you to know it all Please do not work outside of your scope of practice Inform the NIC on the unit of your skill level so they are aware of your limitations. If you are pre-course or currently on the course, then you MUST NOT change ventilation settings YOU MUST not look after a patient on CRRT independently if you have not been signed off on PICU Always follow local policy If you feel uncomfortable with what you are being asked of you, then please speak up and voice your concerns If you go to AICU you need to wear washable shoes: there is now a selection available on Sky for you to use Scrubs will become available ASAP In the meantime use the laundry facilities at the plaza if required Familiarise yourself daily with PPE guidance/policy Familiarise yourself with the daily breifings from our CEO We will all get through this We have the skills to help AICU and should not forget this We get HLHS children to school, therefore we can get adults on and off ventilators If in doubt PROPOFOL, PROPOFOL, PROPOFOL Look after yourself and each other Seek support if required Utilise our new Adult team on the unit if you have any questions/concerns Your safety and well-being are always paramount and should be respected at all times Adults was fine, they are just like big Bronchs! They cough a lot and desaturate (PICU Sister/RNP/ Future AICU nurse and Voice of Reason) 17 18