Critical Care Standards of Practice



Network

Critical Care Standards of Practice

Directions for Completion

1. This information is specifically for nurses throughout the network who work in critical care units and who work with intermediate level of care patients.

• Some components of this information may not directly apply to care of the intermediate patients but nurses’ awareness of the information is important.

2. Before proceeding to the acknowledgement (“Take Test”), be sure you have read, in its entirety, the Network Critical Care Standards of Practice.

• For your reference, the Standards of Practice are attached starting on the following page.

• Please note the Standards of Practice actually live on the common drive in the folder titled “Network Critical Care Division.”

3. Complete the acknowledgement statement (“Take Test”).

• Remember, no attendance record is needed.

• Print the Certificate of Completion for your records.

Critical Care Standards of Practice

The following standards of practice have been established to ensure consistency in our approach to patient care in the critical care and intermediate care setting. They have been developed by the Network Critical Care nursing standards group, Critical Care division management team and the Critical Care Education Council. All network critical care and intermediate units are under jurisdiction of these standards. The Post Anesthesia Recovery Unit is included in the critical care division, but has specific guidelines for care of their varied patient population. In addition to these standards, please refer to unit specific admission criteria and/or protocols.

The standards are consistent with our hospital’s mission to provide the highest quality care to our patients. The standards are designed to be used in conjunction with hospital policies, the AACN Procedure Manual for Critical Care (6th edition), AACN Practice Alerts, Micromedix, and Gahart’s Intravenous Medication Administration Reference.

This resource is intended to describe practices that address specific diagnoses, clinical conditions or needs of a particular patient or patient population. While the resources are developed by and represent SLUHN practice, the delivery of patient care requires the appropriate application of professional/clinical judgment, including but not limited to the consideration of individualized patient needs and responses.

This resource is based on a combination of accepted practice and the evidence currently available in literature. It does not dictate the exclusive course of treatment in any situation. Variations in practice are to be expected based upon the needs of the specific patient and the reasoned decision making of the practitioner. Deviations from the guidelines are expected when deemed medically necessary. Any exceptions should be discussed with the attending physician and documented.

Table of Contents

1. Monitoring........................................................................................Pages 3-9

2. Vital Signs and Physical Assessment……………………….Pages 9-13

3. Central Lines/PICC/Intravenous Catheters/Intravenous Infusion Guidelines……………………………………………...Pages 14-16

4. Respiratory…………………………………………………………Pages 16-21

5. Pacing (temporary)……………………………………………..Pages 21-22

6. Continuous Renal Replacement Therapy ……………...Pages 23-24

7. Chest Tubes……………………………………………………………….Page 24

8. Gastrointestinal…………………………………………………...Pages 25-26

9. Genitourinary…………………………………………………………….Page 26

10. General Care………………………………………………………Page 27

11. Safety.………………………………………………………………..Page 28

Monitoring

1 Cardiac Monitoring

1 Upon admission to the critical are unit, patients will be “admitted” to the monitor system by typing the patient’s last name, first initial, birthdate, and medical record number. The lead display should also be set on Lead II, V1. Height and weight are added as needed for hemodynamic calculations.

2 Patients will have continuous ECG monitoring. Electrodes are to be replaced at a minimum of every 72 hours and as needed. No automatic discontinuation of telemetry at 48 hours for intermediate level patients.

3 Patients will have a rhythm strip of at least 6 seconds in length printed and placed in the chart upon admission and at the beginning of each shift. An ECG strip should be recorded whenever there is a true change in cardiac rhythm and if the effects of antidysrythmic agents are being evaluated. The rhythm strip is to be interpreted and placed in the progress notes section by the registered nurse (RN).

4 Alarms are to be reviewed and false alarms discarded each shift. Note the range limits for heart rate, NBP and/or ABP, SPO2, and ST segment monitoring (if applicable). Alarm limits should be customized to each patient per nursing discretion. Document that you have reviewed the alarms.

5 Document in electronic medical record(EMR)/nurses notes the appropriate: started, maintained, discontinued, alarms set, and/or alarms reviewed.

2 Central Venous Access Monitoring (PICC, MLC)

(Arterial, PA, CVP, IABP, FloTrac)

1 General Information

1 Pressure monitoring lines will be continuously flushed with 0.9% NSS. The pressure bag is to be maintained at 300mmHg to assure constant flow of the flush solution and system fidelity.

2 Flush bags and pressure monitoring tubing are to be changed EVERY 96 HOURS. All air is to be purged from the flush bag prior to priming to ensure the most accurate pressure readings.

3 The caps/valves are to be changed with each tubing change and/or if residual blood is present.

4 Pressure monitoring transducers are to be recalibrated at the phlebostatic axis (1/2 AP diameter of the chest, 4th intercostal space), preferably every shift and with position changes. The cap on the transducer vent port is to be changed with recalibration.

5 Arterial, CVP, and PA catheters must be monitored with audible alarms. Monitored line waveforms or pressures are to be visible on the monitor at all times.

6 Upon recalibration, perform the square wave test to ensure optimal readings.

4 Arterial Pressure Monitoring

1 A cuff blood pressure (NBP) should be performed at the beginning of every shift and as needed. The two pressure readings are to be compared in order to assess validity of readings.

2 Extremities with indwelling arterial catheters should have neurovascular checks assessed and documented immediately after insertion and at least every 4 hours. Observe the site for signs of hemostasis and infection.

3 Apply arterial wrist support via an arm board, if needed, in order to maintain a proper waveform.

5 Venous/Arterial Sheaths

1 The care and maintenance of an arterial sheath should follow pressure monitoring guidelines as outlined above.

2 All sheaths are to be removed by physicians, IR department, and specially trained nursing staff.

6 Pulmonary Artery Pressure Monitoring

1 A 500ml or 1000ml bag of 0.9% NSS should be utilized as the injectate solution in order to provide an adequate amount of fluid used to perform cardiac outputs. The thermo-dilution catheter system is to be changed every 24 hours.

2 The depth (cm marking) of the PA catheter insertion is to be documented upon insertion and with assessments. The external catheter centimeter marking of the PA catheter at the introducer exit site is the number that is being documented. The thick line is equal to 50cm and the thin line is equal to 10cm.

3 The PAP and the PAWP readings are to performed at the end-expiration phase of respiration. They are ideally read with the head of bed (HOB) from 0-45 degrees and with the patient in a supine position. The RN should pass along the degree of the HOB used during obtaining PAP and PAWP in bedside report to ensure consistent and accurate measures.

4 PAWP and/or CO readings are to be performed as ordered by the physician. When not performing a PAWP, the balloon port is to remain locked and air is to be purged from syringe.

5 SVO2 catheters are to be recalibrated daily using the venous blood gas oxyhemoglobin value, which is obtained with morning lab work.

6 The RN does not remove a PA catheter in the presence of a permanent or temporary transvenous pacemaker. Additionally, the RN may not advance the PA catheter. If the catheter is not in the correct position, notify the appropriate practitioner for repositioning. If there is significant ventricular irritability induced by catheter position, the RN will notify the proper physician and RN may pull tip back to the right atrium. If forward migration is detected by waveform changes, pressure changes, and/or visual change in position by cm markings, the RN will notify the proper physician immediately so the catheter can be repositioned.

7 CVP

1 CVP monitoring via TLC must be performed via most distal port.

2 NEVER monitor pressures through a positive pressure valve. Connect the transducer tubing directly to line (hub to hub).

3 A Hi-Flo 4-way stopcock valve may be used if extra access is needed. Note that the values may be inaccurate if the extra port is being utilized to infuse something at a high rate.

8 FloTrac

1 Obtain Vigileo monitor and enter patient information.

2 A functional arterial line is necessary.

3 If applicable, the patient should be on assist control ventilation for optimal results.

4 Dysrhythmias may cause inaccurate readings.

5 Record CI, SVI, SVV, SVR, and BP in EMR or nursing notes.

9 Intra-Aortic Balloon Pump

1 Verify that the augmentation alarm is set 10-15 mmHg below the augmented diastolic pressure.

2 IABP values (IABP volume, IABP systolic/diastolic, IABP mean, augmentation, and ratio) are to be documented every hour.

3 Assess and document neurovascular checks as ordered by the physician.

4 Assess the insertion site for bleeding and/or hematoma every hour and document.

5 Ensure that the IABP is plugged into a red outlet after any traveling and/or receipt of the patient.

6 If patient tolerates, IABP should be placed briefly on hold to perform accurate assessment of heart, lungs, bowel sounds, and placement of OGT/NGT.

7 IABP should not lie dormant (on hold) for more than 30 minutes or it must be removed.

8 Assess the balloon tubing for the presence of blood every hour. Blood or discoloration in the helium tubing indicates that the balloon has perforated and that arterial blood is present. The dried blood may appear as a brownish, coffee-ground-like substance. If blood is detected in the IABP catheter, discontinue pumping and immediately notify physician/Advanced Practitioner. Prepare for the IABP catheter removal and/or reinsertion. Do not throw the catheter away. Save the catheter to send back to the company for inspection. Place in a red bag and give to your manager.

9 The IABP is not to be removed by the bedside RN.

10 Intracranial Pressure Monitoring, Lumbar Drains

1 Ventriculostomy

1 Ventriculostomies will be monitored with audible alarms.

2 Ventriculostomies will be leveled “0” at the tragus of the ear which corresponds to the Foramen of Monroe. To be assessed for proper leveling and zeroed every shift and with any repositioning.

3 Neurologic assessments are to be performed every hour.

4 ICP/CPP readings and CSF drainage amounts are to be measured and documented as ordered.

5 Maintain and document drain level as ordered by the physician.

2 Lumbar Drains

1 Check insertion site per shift, as needed, or per physician order.

2 Monitor patient’s neurological status and vital signs every hour or as ordered by a physician.

3 Zero the monitoring system with insertion, disconnection, or position changes as ordered.

4 Assess CSF color, clarity, and amount every hour or as ordered.

3 Intracranial Bolt Monitoring

1 Assess patient’s neurological status and vital signs every hour or more often as indicated.

2 Calculate and document CPPs hourly.

3 Set audible alarms and connect to bedside monitor “Cal/Step”.

4 Assess site of insertion every shift and as needed.

5 Assess and document ICPs hourly.

Vital Signs and Physical Assessment

1 Vital Signs

1 Patient care and hemodynamic monitoring will be adjusted according to level of care as ordered by physician. Vital signs are to be completed and documented at a minimum every 2 hours for critical care patients. Intermediate patients are to have vital signs completed and documented every 4 hours. Vital signs include pulse, blood pressure, respirations, hemodynamics, pain and pulse oximetry and blood glucose (if ordered). Some conditions or situations which may warrant more frequent vital signs include, but are not limited to: unstable patient, post-op or post procedure patient, and/or an unstable patient on continuous intravenous vasoactive infusions.

2 RN may delegate appropriate aspects of monitoring to PCA with the expectation that documentation in the medical record is completed immediately.

Intermediate Patients:

For any abnormal physiologic parameters (i.e. decreased urine output amount equivalent to ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download