Critical Care

Concepts
Archer Review

Airways
What is an endotracheal tube
(ETT)?
● Invasive, artificial airway used when the client is unable to protect their own
airway.
● Plastic tube inserted into the
tracheal through the mouth or
nose
● Maintains an airway to deliver
oxygen and positive pressure
to the lungs
● “Breathing tube”

Nursing Must Know

● After placement of an ETT, placement should be verified by a chest x-ray
● Assess for equal breath sounds bilaterally
○ The ETT can become displaced into the R main stem bronchus
○ Ensure that breath sounds are heard equally bilaterally or the tube may need to be
repositioned.
What is a tracheostomy tube?
● An artificial airway used for
long-term needs.
● Stoma is made in the neck and the
tube inserted into the trachea.
● Breathing is through the
tracheostomy tube, not the nose and
mouth.
● Used for:
○ Tracheal obstruction
○ Slow vent weaning
○ Tracheal damage
○ Neuromuscular damage

Nursing Must Know

● INFECTION PREVENTION
○ The natural defenses of the nose and mouth are bypassed - higher risk for infection
○ Daily trach care
○ Suctioning
○ Oral care
● Only suction to the pre measured depth
○ Suctioning too deep can cause damage or cause laryngospasm
○ Don’t suction longer than 10 seconds
○ Some clients may need pre-oxygenated with 100% FiO2
● Safety
○ You must keep two back up trachs at the bedside incase of emergency
■ 1 of same size
■ 1 a half size smaller
○ If the trach comes out, first try to insert the back up of the same size
○ If unsuccessful, try to insert the half size smaller
 Ventilators

Terminology
● Peak Inspiratory Pressure (PIP): The highest level of pressure in the lungs during
inhalation.
● Positive End Expiratory Pressure (PEEP): The amount of pressure in the alveoli at
the end of expiration.
● Fraction of inspired oxygen (FiO2): How much oxygen the patient is getting.
21-100%
● Tidal volume (TV): The amount of air that is inhaled during one respiratory cycle.
● End-Tidal Carbon Dioxide (ETCO2): The partial pressure of CO2 detected at the
end of exhalation.
● Room air: The atmospheric air we breathe under normal circumstances. It has an
FiO2 of 21%.
Ventilator Modes
Volume-controlled: There is a certain volume of air delivered to the patient with each
breath.

Pressure-controlled: The lungs are inflated to a certain pressure.

CPAP: Continuous Positive Airway Pressure. There is continuous positive airway pressure,
while the patient controls their respiratory rates and volumes.

BiPAP. Bilevel Positive Airway Pressure. There is positive airway pressure, set at different
pressures for inspiration and expiration.

Alarms
High Pressure Alarms Low Pressure Alarms
Pressure in the circuit is too high. Pressure in the circuit is too low.

Causes: Causes:
Patient coughing Tubing is disconnected
Gagging Loose connections
Bronchospasm Leak
Fighting the ventilator Extubation
ETT occlusion Cuffed ETT or trach is deflated
Kink in the tubing Poorly fitting CPAP/BiPAP mask
Increased secretions
Thick secretions
Water in ventilator circuit
NCLEX Question
The ICU nurse is caring for a sedated client on a ventilator. The ventilator alarm is
beeping persistently for low pressure despite the fact the client is calm and has
stable vitals. What is the most appropriate action for the RN to take first?

A. Suction secretions
B. Check the tubing for holes
C. Call respiratory therapy
D. Continue to monitor

Answer: B
Choice B is the correct answer. If the client’s presentation and vitals are stable, the nurse should check for any apparent equipment
malfunction. If no air leaks or kinks are immediately identifiable, the nurse should call respiratory therapy or the rapid response team
(RRT). Persistent alarms despite stable vitals may indicate the client is trying to talk, is developing a pneumothorax from increased
intrathoracic pressure, is biting/gagging on the endotracheal tube, or is experiencing bronchospasms. These alarms should never be
ignored or turned off, as they may indicate early signs of a change in the patient’s condition.

Choice A is incorrect. The nurse should assess the patient and breath sounds before performing suction.

Choice C is incorrect. The nurse should assess the client, suction if needed, check the ventilator and tubing, remove excess water from
the pipe, and check the endotracheal cuff pressure. If no clear cause for alarm, the nurse should then remove the client from the
ventilator and manually ventilate with an Ambu bag, then call respiratory therapy (STAT). After that, the nurse can continue to assess
until mechanical ventilation is resumed.

Choice D is incorrect. Alarms should not be ignored or silenced. If unable to determine the cause, the nurse should call for assistance.
Neurological Status
 Posturing

Intracranial Pressure
● The pressure inside of the skull
● Normal = 5-15
● Monro-Kellie hypothesis
○ The skull is a rigid container filled with: blood, brain, and CSF. If one of those three increases,
another must decrease.
● Causes of increased ICP:
○ Tumor
○ Bleeding
○ Hydrocephalus
○ Edema
External Ventricular Drain
(EVD)

Increased Intracranial Pressure

NCLEX Question
The ICU nurse is taking care of a client who sustained a head injury due to a
motorcycle accident. In the morning, the client is responsive to pain and assumes
a decorticate position. After 4 hours, which assessment would indicate to the
nurse that the client needs immediate intervention?

A. The client displays purposeful movement when the nurse performs a sternal
rub.
B. The client extends his arms and legs when the nurse rubs his sternum.
C. The client flails his arms and legs when a noxious stimulus is applied.
D. The client moves his fingers upon request.

Answer: B
Choice B is correct. Extension of the arms and legs indicates decerebrate posturing, an
indication of increased intracranial pressure. The nurse should intervene when the client
displays this.

Choice A is incorrect. Purposeful movement when a painful stimulus is applied indicates an

improvement in the client’s condition.

Choice C is incorrect. Aimless flailing of the client's extremities would mean an

improvement in the client’s condition and would not need an intervention from the nurse.

Choice D is incorrect. This means that the client can follow simple commands. This
indicates that the client’s condition is improving and would not need any intervention from
the nurse.
 Hemodynamic Monitoring

●
Hemodynamics
Preload
○ Amount of blood returning to right side of the heart
● Afterload
○ Pressure against which the left ventricle must pump to eject blood
● Compliance
○ How easily the heart muscle expands when filled with blood
● Contractility
○ Strength of contraction of the heart muscle
● Stroke volume
○ Volume of blood pumped out of the ventricles with each contraction
● Cardiac output
○ The amount of blood the heart pumps through the circulatory system in a minute
Cardiac Output
WHY is cardiac output SO important?!

● Tissue perfusion!
● End organ function
● Delivery of oxygen and nutrients to each and every cell in the body!
● Poor cardiac output??
○ Decreased LOC (not enough blood flow to the BRAIN)
○ Chest pain, weak peripheral pulses (not enough blood flow to the HEART)
○ SOB, crackles, rales (not enough blood flow to the LUNGS)
○ Cool, clammy, mottled extremities (not enough blood flow to the SKIN)
○ Decreased UOP (not enough blood flow to the KIDNEYS)

CO = SV X HR
 Causes of Causes of
DECREASED CO INCREASED CO
● Bradycardia
● Arrhythmias ● Increased blood
○ Pulseless v-tach volume...sometimes
○ V-fib ● Tachycardia...sometimes
○ Asystole ● Medications
○ SVT ○ ACE Inhibitors
● Hypotension ○ ARBS
● MI ○ Nitrates
● Cardiac muscle disease ● Inotropes
Central Venous Catheter (CVC)
● IJ
● PICC
● Hickmann
● Broviac

Arterial line
NCLEX Question
The critical care nurse is caring for a client receiving hemodynamic monitoring. After reviewing the
client's central venous pressure, the nurse should take which action based on the client's 0100
CVP reading? See the image below.

A. Assess the client for fluid volume overload

B. Obtain a prescription for saline fluid bolus
C. Document the findings and continue to monitor
D. Place the client in a side-lying position

Answer: A
Choice A is correct. The normal central venous pressure (CVP) is 2-8 mmHg. CVP
measures the amount of fluid that returns to the right atrium (or preload). This client's CVP
has been trending upward, and the nurse should assess the client for hypervolemia,
specifically, manifestations of right-sided heart failure.

Choices B, C, and D are incorrect. Infusing additional volume may be detrimental. This
would be an appropriate intervention for a client with a low CVP. These values are
abnormal, and the nurse should not document and continue to monitor. This value requires
action on the part of the nurse. The side-lying position is unnecessary for this client, and if
the assessment confirms fluid volume overload, the client should be positioned as
high-Fowlers.
 Vasoactive Infusions

Vasoactive infusions
Inotropes

● Act by increasing the force of myocardial contractility

Vasopressors

● Mimic sympathetic nervous system to cause vasoconstriction

Common Indications
● Cardiac arrest
● Hypotension
● Shock refractory to fluid resuscitation
● Cardiac disease
○ Acquired
○ Congenital

Adrenergic Receptors

● Primarily found is ● Found in heart and ● Primarily found in

vascular smooth muscle intestinal smooth muscle bronchial vasculature
● Peripheral ● Increase contractility ● Bronchodilation
vasoconstriction ● Increase SV, HR, and CO● Coronary artery
● Increased SVR vasodilation
Epinephrine
Shock, cardiac arrest, asystole

● Low doses act on beta-1 receptors

○ Increase the cardiac output

● High doses act on alpha-1 receptors

○ Increase systemic vascular resistance → increase BP

Norepinephrine
Shock, hypotension

● Acts on alpha-1 receptors

● Causes peripheral vasoconstriction → increases BP
○ Increases cardiac output
Phenylephrine
Anesthesia-induced hypotension; Second line agent in some shock patients

● Only acts on alpha-1 receptors

● Causes only vasoconstriction - no inotropy
● Vasoconstriction → Increased BP

Dopamine
Shock, hypotension, trauma

● Low doses used in kidney failure to increase renal blood flow

○ ‘Renal dopa’
● Low doses increase contractility → Increase CO
● Higher doses cause vasoconstriction → Increase SVR → Increase BP

Acts on DOPAMINE receptors!

Vasopressin
● Antidiuretic hormone (ADH)
● ANTI-diuresis…. Less diuresis → more volume IN the vascular system.
○ More volume → more pressure!
○ Raises BP
● Second line in vasodilatory shock
● Third line in septic shock
○ 1st: Dopa or Norepi
○ 2nd: Epi or phenylephrine
○ 3rd: Vaso

Milrinone
● Used in patients with:
○ Cardiogenic shock
○ Decreased cardiac output
○ Congenital/acquired heart defects
● Causes
○ Systemic + pulmonary vasodilation → decreased afterload
○ Increased contractility.
● How it works: phosphodiesterase inhibitor
○ Phosphodiesterase breaks down cAMP
■ cAMP - Cyclic adenosine monophosphate → a derivative of adenosine triphosphate
(ATP) and used for intracellular signal transduction. Basically… helps the cells of the
heart muscle contract!
○ By inhibiting the breakdown of phosphodiesterase, there is more cAMP, which means more
contractility.
Complications and Side Effects

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