Page 79 - Critical Care Nursing Demystified

64 CRITICAL CARE NURSING DeMYSTIFIED

Nursing Interventions

Continuous vital sign and total body system assessments as hypoxemia
affects all organs.

Assess daily weights as they are the most important indicator of fluid status.
Assess for peripheral edema as a sign of fluid excess.
Administer intravenous fluids to rehydrate the patient.
Insert indwelling urinary catheter with hourly intake and output to monitor
cardiac/renal function.
Strict intake and output to determine if overhydration/underhydration is
occurring.
Frequent position changes to prevent skin breakdown and facilitate oxygen
exchange.
Oral care at least once per shift and prn to prevent ventilator-associated
pneumonia.
Provide rest by pacing activities to prevent increased oxygen consumption
(position changes, chest x-rays, suctioning, and bathing increase O use).
2
Pneumonia Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.

What Went Wrong?
Pneumonia is caused when pathogenic organisms invade the lung and produce
exudate that interferes with oxygen delivery to the alveolus and carbon dioxide
removal. Usually a patient’s defense mechanisms prevent this from occurring,
unless the patient is immunocompromised. Because hypoxemia and hypercarbia
result, the patient can develop ARF. Types of pneumonia include ventilator-
associated pneumonia (VAP), community acquired pneumonia (CAP), and aspira-
tion pneumonia. VAP and aspiration are hospital-acquired pneumonias (HAPs).

Prognosis
The prevalence of HAP in critical care represents one-quarter of all nosocomial
infections. One-half of all antibiotics ordered are for the treatment of HAP. This is
a serious infection control issue for the critical care areas. This is also a financial issue
for the patient and hospital staff, as Medicare will no longer reimburse for HAP.

Hallmark Signs and Symptoms

Elevated TPR and BP; fever
Chills and diaphoresis
Pleuritic chest pain, myalgia, and joint pain