Critical Care Manual of Clinical Procedures and Competencies Critical Care Manual of Clinical Procedures and Competencies Edited by Jane Mallett RN, BSc (Hons), MSc, PhD Consultant in Health Care Development Dorset, UK John W Albarran RN, Dip N (Lon), BSc (Hons), PG Dip Ed, MSc, DPhil Associate Professor in Cardiovascular Critical Care Nursing Associate Head of Department for Research and Knowledge Exchange (Nursing & Midwifery) Programme Manager for Doctorate in Health and Social Care University of the West of England Bristol, UK Annette Richardson RN, BSc (Hons), MBA Nurse Consultant in Critical Care Newcastle upon Tyne Hospitals NHS Foundation Trust Newcastle upon Tyne, UK This edition first published 2013 © 2013 by John Wiley & Sons, Ltd Registered office:â•… John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK â•… The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK â•… 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not associated with any product or vendor mentioned in this book It is sold on the understanding that the publisher is not engaged in rendering professional services If professional advice or other expert assistance is required, the services of a competent professional should be sought The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the 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Cataloging-in-Publication Data Critical care manual of clinical procedures and competencies / edited by Jane Mallett, John W Albarran, Annette Richardson â•…â•…â•… p ; cm Includes bibliographical references and index ISBN 978-1-4051-2252-8 (pbk : alk paper) I.╇ Mallett, Jane, RGN.â•… II.╇ Albarran, John W.â•… III.╇ Richardson, Annette [DNLM:â•… 1.╇ Critical Care.â•… 2.╇ Critical Illness–therapy.â•… 3.╇ Monitoring, Physiologic.â•… 4.╇ Needs Assessment.â•… WX 218] 616.02'8–dc23 2012044642 A catalogue record for this book is available from the British Library Wiley also publishes its books in a variety of electronic formats Some content that appears in print may not be available in electronic books Cover image courtesy of the Editors Cover design by Andy Meaden Set in 9.5/11.5pt Sabon by Toppan Best-set Premedia Limited, Hong Kong 1â•… 2013 Contents List of contributors Foreword by Julian Bion Foreword by Ged Williams xv xvii xix Preface List of abbreviations Chapter 1â•… Scope and delivery of evidence-based care xxi xxiii John W Albarran and Annette Richardson Importance of critical care Background and classification of critically ill patients National guidance Evidence-based practice Definitions Debates on the nature of ‘evidence’ Supporting evidence-based practice Integrated governance Using this book 7 References Chapter 2â•… Competency-based practice 11 Julie Scholes, Jo Richmond and Jane Mallett Introduction Defining competence Competence acquisition Defining the specialty Competency-based curriculum Competency and the relationship with integrated governance 12 12 12 13 13 Assessing competence: when and how Objective Structured Clinical Evaluation (OSCE) and simulation Linking the technical with humanistic care References and further reading 16 17 17 24 15 Chapter 3â•… Recognizing and managing the critically ill and ‘at risk’ patient on a ward 27 Mandy Odell Definition Aims and indications Background Rapid response systems Assessing and managing the deteriorating patient ABCDE assessment process Summary 28 28 28 29 31 31 40 Procedure guidelines for Chapter 3.1 Blood pressure measurement (manual) for a patient in bed 40 3.2 Automated blood pressure measurement 3.3 Pulse measurement 3.4 Temperature measurement 42 44 45 Competency statements for Chapter 3.1 Specific procedure competency statements for recognizing and managing the deteriorating patient 46 References and further reading 47 vi  Contents Chapter 4â•… Admitting a critically ill patient 49 Vanessa Gibson and Karen Hill Definition Aims and indications Background Calling for appropriate assistance Admission of a patient to a level or care facility Recording status on admission Establishing a rapport with the patient Establishing a rapport with family and carers 50 50 50 52 Procedure guidelines for Chapter 52 53 54 Competency statements for Chapter 4.1 Admitting a patient to the critical care unit 4.2 Recording status on admission 55 56 4.1 Specific procedure competency statements for admission to the critical care unit 59 References and further reading 61 54 Chapter 5â•… Assessment, monitoring and interventions for the respiratory system 63 Maureen Coombs, Judy Dyos, David Waters and Ian Nesbitt Clinical Assessment Chest auscultation Definition Indications for chest auscultation Background Chest auscultation in critical care Arterial blood gas sampling Definition Indications for arterial blood gas sampling Background Arterial blood sampling in critical care Pulse oximetry Definition Indications for pulse oximetry monitoring Background Pulse oximetry in critical care Airway management and care with adjunct airways Definition Aims and indications Background Airway management in critical care Monitoring Airway Adjuncts Partial pressure of end tidal carbon dioxide (ETCO2) monitoring Definition Indications for end tidal CO2 monitoring Background ETCO2 monitoring in critical care Measuring endotracheal/tracheostomy tube cuff pressure Definition Indications for measuring endotracheal/tracheostomy tube cuff pressure Background Endotracheal/tracheostomy tubes in critical care 64 64 64 64 64 64 66 66 66 66 67 69 69 69 69 69 71 71 71 71 72 76 76 76 76 76 76 77 77 77 77 78 Interventions for the Respiratory System Ventilatory support Indications for ventilatory support Background Non-invasive ventilation Definition of non-invasive ventilatory (NIV) support NIV in critical care – an overview Invasive ventilation Definition of invasive ventilator support Background Invasive ventilation in critical care Invasive ventilation modes Weaning from mechanical ventilation Definition Aim Background Reduction of mechanical support Extubation/decannulation Other respiratory interventions Intermittent positive pressure breathing (IPPB, e.g Bird, Bennett PR2) Definition Indications for intermittent positive pressure breathing Contraindications Complications Background Intermittent positive pressure breathing in critical care Suctioning via a tracheal tube (endotracheal or tracheostomy) Definition Aim and indications Background Suctioning through endotracheal and tracheal tubes 78 78 78 79 80 80 80 82 82 83 83 83 87 87 87 87 88 89 90 90 90 90 90 90 90 90 91 91 91 92 93 Contents  vii Humidification Definition Aims and indications Background Humidifiers Manual hyperinflation and hyperoxygenation Definition Aims and indications Background Manual hyperinflation and hyperoxygenation in critical care Prone ventilation Definition Aims and indications Background Risks of prone ventilation Chest drains Definition Aims and indications Background Pneumothorax Pleural fluid Chest drain insertion Management of chest drains Chest drain removal Flexible fibreoptic bronchoscopy Definition Indications for flexible bronchoscopy Contraindications and complications Background Bronchoscopy in critical care Competency and troubleshooting Summary 94 94 94 94 94 96 96 96 97 97 98 98 98 98 98 100 100 100 100 100 100 101 101 103 105 105 105 105 105 105 105 105 Procedure guidelines for Chapter 5.1 5.2 5.3 5.4 5.5 Chest auscultation Arterial puncture: radial artery Arterial blood gas sampling: arterial cannula Pulse oximetry Insertion and removal of a nasopharyngeal (NP) tube 5.6 Insertion and removal of an oropharyngeal airway 5.7 Endotracheal tube insertion 5.8 Tracheostomy formation and tube insertion 5.9 Tracheostomy care: stoma care and dressing changes 5.10 Inner cannula care 5.11 Tracheostomy removal (decannulation) 5.12 End tidal CO2 monitoring 5.13 Tracheal cuff pressure measurement 5.14 Continuous positive airway pressure 5.15 BiPAP 5.16 Invasive ventilator therapy care 5.17 Weaning from mechanical ventilation 106 107 109 110 111 113 114 116 118 119 121 122 124 125 126 128 130 5.18 Intermittent positive pressure breathing (Bird) 5.19 Endotracheal extubation 5.20 Suctioning 5.21 Humidification 5.22 Manual hyperinflation 5.23 Prone positioning 5.24 Insertion of a chest drain 5.25 Chest drain removal on a ventilated patient 131 132 134 138 139 140 143 145 Competency statements for Chapter 5.1 Specific procedure competency statements for chest auscultation 5.2 Specific procedure competency statements for arterial blood sampling 5.3 Specific procedure competency statements for pulse oximetry 5.4 Specific procedure competency statements for nasopharyngeal airway and oropharyngeal airway 5.5 Specific procedure competency statements for insertion of an endotracheal tube 5.6 Specific procedure competency statements for tracheostomy formation and tube insertion auscultation 5.7 Specific procedure competency statements for tracheostomy removal/decannulation 5.8 Specific procedure competency statements for end tidal CO2 (ETCO2) monitoring 5.9 Specific procedure competency statements for tracheal cuff pressure measurement 5.10 Specific procedure competency statements for non-invasive ventilator (NIV) therapy 5.11 Specific procedure competency statements for invasive ventilator therapy care 5.12 Specific procedure competency statements for intermittent positive pressure breathing (IPPB) (Bird) 5.13 Specific procedure competency statements for endotracheal tube extubation 5.14 Specific procedure competency statements for suctioning 5.15 Specific procedure competency statements for humidification 5.16 Specific procedure competency statements for manual hyperinflation 5.17 Specific procedure competency statements for prone positioning 5.18 Specific procedure competency statements for insertion of a chest drain 5.19 Specific procedure competency statements for removal of a chest drain References and further reading 147 148 149 149 150 152 153 155 156 157 158 159 159 161 162 163 164 165 166 167 viii  Contents Chapter 6â•… Monitoring of the cardiovascular system: insertion and assessment 173 Alan T Platt, Sarah Conolly and Jonathan Round Introduction Electrocardiogram monitoring Definition Aims and indications Background The 12-lead ECG Continuous cardiac monitoring Applying ECG monitoring Assessing an ECG Arterial blood pressure monitoring Non-invasive arterial blood pressure monitoring Definition Aims and indications Background Invasive arterial blood pressure monitoring Definition Aims and indications Background Evidence and current debates Insertion of and monitoring using an invasive blood pressure monitoring system Central venous pressure monitoring Definition Aims and indications Background CVP trace Efficacy of CVP monitoring Insertion of and monitoring using a CVP monitoring system Safety and risk issues Advanced haemodynamic monitoring Introduction Definition Aims and indications Background Haemodynamic monitoring The measurement of cardiac output Pulmonary thermodilution method Transpulmonary dilution method Summary 174 174 174 174 174 177 177 178 178 180 180 180 180 181 181 181 181 181 183 211 213 215 References 184 187 187 187 187 189 189 189 190 192 192 192 192 192 193 193 194 201 205 206 207 209 216 217 219 220 222 223 Competency statements for Chapter 6.1 Specific procedure competency statements for the application and use of continuous ECG monitoring 6.2 Specific procedure competency statements for insertion and use of invasive blood pressure monitoring 6.3 Specific procedure competency statements for insertion and use of central pressure monitoring 6.4 Specific procedure competency statements for insertion of a pulmonary artery catheter 6.5 Specific procedure competency statements for pulmonary artery catheter monitoring 6.6 Specific procedure competency statements for undertaking pulmonary artery wedge pressure – measurement 6.7 Specific procedure competency statements for undertaking CO studies with a pulmonary artery catheter 6.8 Specific procedure competency statements for insertion of a transpulmonary cardiac output device using lithium dilution (e.g LiDCOplus) 6.9 Specific procedure competency statements for transpulmonary cardiac output monitoring using lithium dilution (e.g LiDCOplus) 6.10 Specific procedure competency statements for insertion of a transpulmonary cardiac output device using thermodilution (e.g PiCCO) 6.11 Specific procedure competency statements for transpulmonary cardiac output monitoring using thermodilution (e.g PiCCO) 6.12 Specific procedure competency statements for insertion of an oesophageal Doppler probe (e.g CardioQ) 6.13 Specific procedure competency statements for oesophageal Doppler monitoring (ODM) (e.g CardioQ) Procedure guidelines for Chapter 6.1 Application of continuous ECG monitoring 6.2 Setting up the arterial pressure monitoring system and insertion of an arterial cannula 6.3 Setting up the CVP monitoring system and insertion of a central venous catheter 6.4 Insertion of a pulmonary artery catheter (PAC) 6.5 Pulmonary artery catheter monitoring 6.6 Undertaking pulmonary artery wedge pressure measurement 6.7 Insertion of a transpulmonary cardiac output monitoring device using lithium dilution (e.g LiDCOTMplus) 6.8 Transpulmonary cardiac output monitoring lithium dilution (e.g LiDCOplus) 6.9 Insertion of a transpulmonary cardiac output monitoring device using thermodilution (e.g PiCCO®) 6.10 Transpulmonary cardiac output monitoring using thermodilution (e.g PiCCO) 6.11 Insertion of the oesophageal Doppler probe (e.g CardioQTM) 6.12 Oesophageal Doppler monitoring (ODM) (e.g CardioQ) 224 225 226 227 230 233 234 235 237 239 241 243 245 246 Critical Care Manual of Clinical Procedures and Competencies Competency statement 18.4:╇ Specific procedure competency statements for airway assessment and ventilation Complete assessment against relevant fundamental competency statements (see Chapter 2, pp 20, 21) Evidence Specific procedure competency statements for airway assessment and ventilation Evidence of competency for airway assessment and ventilation Demonstrate ability to:  teach and assess or  learn from assessment Examples of evidence of teaching, assessing and learning Open the airway using head tilt/chin lift and jaw thrust manoeuvre, establishing patency Demonstrates use of suction On manikin – airway is cleared and opened Demonstrate correct sizing and insertion of oropharyngeal and nasopharyngeal airway On manikin – open airway with use of adjuncts Demonstrate effective ventilation using a self-inflating bag-mask with supplemental oxygen On-manikin – ensure visible chest rise on ventilation at correct rate Demonstrates the use of a supraglottic airway, e.g laryngeal mask airway On manikin – correct insertion procedure and visible chest rise on ventilation Can prepare equipment and assist during rapid sequence induction and tracheal intubation On manikin – prepares equipment, including waveform capnography, demonstrates assistance during tracheal intubation References 550 Abella BS, Alvarado JP, Myklebust H et al (2005) Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest Journal of the American Medical Association 293: 305–310 Aiken LH, Clarke SP, Sloane DM et al (2002) Hospital nurse staffing and patient 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Edelson D et al (2009) The use of CPR feedback/ prompt devices during training and CPR performance: a systematic review Resuscitation 80: 743–751 Useful websites European Resuscitation Council: www.erc.edu International Liaison Committee on Resuscitation (ILCOR): www.ilcor.org Resuscitation Council UK: www.resus.org.uk Index Page numbers in italics refer to Figures; those in bold to Tables ABCDE assessment, 28, 31–9, 32 on admission, 53, 56–9 see also airway; breathing; circulation; disability; environment and ‘everything else’ absent-mindedness, 492 absorption, 279 Academic Health Science Networks, acidaemia, 67 actigraphy, 423 activated partial thromboplastin time, 320 acute kidney injury (AKI), 311–13 causes, 311–13 classification, 313 definition, 37 staging system, 313, 313 acute lung injury (ALI), 98 acute quadriplegic myopathy syndrome, 342 acute respiratory distress syndrome see ARDS adjunct airways see airway adjuncts admission to critical care unit, 50–61 assessments, 53–4 definition, 50 emergency, 53 establishing rapport with family and carers, 54–5 with patient, 54 indications, 50 planned, 52–3 preparation of ICU and bed space, 55–6 recording status on, 53–4, 56–9 SPCSs, 59–61 adrenal corticotrophin hormone (ACTH), 473 adrenaline actions, 251, 252 during CPR, 540 advanced haemodynamic monitoring, 192–3 aims, 192 anatomy and physiology, 192–3 definition, 192 indications, 192 Advanced Life Support (ALS), 535 advanced life support algorithm, 537, 538 after-death care, 510–12 procedure guideline, 520–2 afterload, 35, 193 definition, 250 agonal breathing, 536 air spaces, expansion, 473 airway anatomy and physiology, 71–2, 71 assessment, 31–3, 32 maintaining safe, 38–9 management and care with airway adjuncts, 71–6 in critical care, 72–6 airway adjuncts, 33, 71–8 aims, 71 definition, 71 indications, 71 monitoring, 76–8 airway obstruction, 33, 71–2 complete, 72 partial, 71–2 treatment, 32, 33 airway suction, 33 AKI see acute kidney injury albumin, 285, 286 alimentary canal see gastrointestinal (GI) tract alkalaemia, 67 Allen test, 66 α-receptors, activation, 251, 252 altitude, physiological effects, 471–3, 472, 472 alveolar air equation, 472 alveoli, 79 ambulation, 443–4 amiodarone, during CPR, 540 anaesthetics, 342–4 analgesia, 345 definition, 334 angina, 532 anticoagulation, 319–20 antipsychotics, 346 arachnoid mater, 361, 361 ARDS, 98 cognitive impairment with, 491–2 HFOV in, 85 as hypoxaemia cause, 98 long term functional status, 437 respiratory failure in, 80 arterial blood gas (ABG) sampling, 34, 66–8, 107–11, 147–8 anatomy and physiology, 66 in critical care, 67 definition, 66 indications, 66 normal values, 34 procedure guideline, 109–10 SPCSs, 147 via arterial cannula, 66, 67, 68 arterial cannula insertion, 184 procedure guideline, 207–8 problem solving, 184–5 arterial oxygen saturation see SaO2 arterial pressure waveform, 187 arterial puncture radial artery, 66 procedure guideline, 107–8 sampling via, 66, 67, 68 assisted spontaneous breathing (ASB), 88 Critical Care Manual of Clinical Procedures and Competencies, First Edition Edited by Jane Mallett, John W Albarran, and Annette Richardson © 2013 John Wiley & Sons, Ltd Published 2013 by John Wiley & Sons, Ltd 554  Index atelectasis causes, 97 development, 97 ATP, 533 atrial fibrillation, 179, 181 atrioventricular (AV) node, 175, 175 automated external defibrillators (AEDs), 535, 539–40 SPCSs, 549 automatic tube compensation (ATC), 89 autoregulation, 362 AVPU system, 38 azotaemia, 312 bacterial filter, 94 barbiturates, 344–5 barotrauma, prevention, 97 base excess (BE), 67 basic life support (BLS), 535 behavioural pain scale (BPS), 335–6, 336 benzodiazepines, 344 withdrawal, 337 bereavement care, 512 β-receptors, activation, 251, 252 bi-level airway pressure release ventilation (APRV), 84 bi-level positive airway pressure ventilation see BiPAP bi-level ventilation see BiPAP bicarbonate, 67 lactate as substitute for, 319 BiPAP, 80–1, 84 contraindications, 81 indications, 81 problem solving, 81–2 procedure guideline, 126–8 BiPAP APRV, 84 Bispectral Index (BIS), 338–9 blepharitis, 401 blinking, 400 blood–brain barrier, 364 blood glucose level, 67 control, 67, 292 monitoring, 38, 67 procedure guideline, 296–7 SPCSs, 302 blood pressure (BP) anatomy and physiology, 250 determinants, 250, 250 how improved, 250, 251 measurement, 36, 40–3 normal, 36 blood pressure monitoring, 180–7, 365 choice of method, 183 see also invasive arterial blood pressure monitoring; noninvasive arterial blood pressure monitoring body fluid, 280–1 compartments, 281, 281, 282 composition, 282 rate of loss, 282 Body Mass Index (BMI) assessment, 54, 58, 289 bone demineralization, 437 BORG breathlessness scale, 444 Bowman’s capsule, 310 Boyle’s law, 473 brachial artery, 181, 182 brain, 358–64, 359 brainstem, 358, 359, 360 brainstem death, 509, 510 care following, 510 brainstem function measurement, 509–10 breath sounds abnormal adventitious, 64, 65 bronchial, 64 bronchiovesicular, 64 vesicular, 64 breathing anatomy and physiology, 79, 87–8 assessment, 32, 34 treating abnormalities, 32, 34–5 bronchial breath sounds, 64 bronchiovesicular breath sounds, 64 bronchoscopy anatomy and physiology, 105 in critical care, 105 definition, 105 flexible fibreoptic complications, 105 contraindications, 105 indications, 105 guidelines, 105 rigid, 105 buffers, 67 bundle of His, 175, 175 CAM-ICU tool, 340 cannulation inner cannula care procedure, 119–20 of trachea SPCSs, 152–3 tube insertion procedure, 116–8 capillary leak syndrome, 100, 282, 287 capillary refill time (CRT), 37 capnography, 76, 76 complications, 77 normal waveform, 76 carbon dioxide see CO2 carbon monoxide poisoning, 69 carboxyhaemoglobin, 69 cardiac arrest, 532 anatomy and physiology, 532, 533, 534 calling for help, 536 care interventions after, 541, 542 causes, 534 reversible, 541, 542 Chain of Survival, 534, 534 incidence, 534 prevention, 29 recognition, 536–7 SPCSs, 548 standard of care, 534–5 see also cardiopulmonary resuscitation cardiac arrest call, 31, 33 cardiac cycle, 176, 193 conduction system, 174–5, 175 cardiac function index (CFI), 201 cardiac index (CI), 198, 198–9 cardiac ischaemia, 179 cardiac output (CO), 193–4, 198 definition, 35, 250 measurement, 193–4 devices, 194 techniques, 193–4 see also oesophageal Doppler monitoring; pulmonary thermodilution method; transpulmonary dilution method SPCSs for studies with pulmonary artery catheter, 234 cardiopulmonary resuscitation (CPR), 532–42 aims, 532 airway and ventilation, 538–9 SPCSs, and coronary perfusion pressure, 533 defibrillation, 539–40 SPCSs, 549 definition, 532 diagnosing death, 541 drugs, 540 equipment, 535 evidence for guidelines, 534 in-hospital, 535 problem solving, 540 indications, 532 initial management of ‘collapsed’ patient, 536–42 procedure guideline, 543–8 starting, 537 SPCSs, 548 vascular access, 540 see also cardiac arrest CardioQ system, 194 insertion procedure guideline, 222 SPCS, 243–4 monitoring procedure guideline, 223 SPCSs, 245–6 problem solving, 206 cardiorespiratory arrest, 532 cardiovascular function critical illness and, 436–7 physiological effects of transfer, 470–1 care activities, and levels of care, 50–1 care bundles, 7, 83 CCO teams see critical care outreach (CCO) teams CCPOT scale, 336 cellular dysfunction, 282 central nervous system (CNS), 358 see also brain Index  555 central venous catheter (CVC; central line), 187, 251 inotrope/vasopressor administration via, 251 insertion, 189 problem solving, 190–2 procedure guideline, 209–10 SPCSs, 226 central venous pressure (CVP) monitoring, 187–90 aims, 187 anatomy, 187–8 definition, 187 efficacy, 189 indications, 187 infection risk, 190 normal values, 250 physiology, 188 problem solving, 186–7 procedure guideline, 209–10 waveform, 189, 189 cerebellum, 358, 359 cerebral blood flow, increased, 371 cerebral circulation, 362, 364 cerebral oedema, 323 cerebral perfusion pressure (CPP), 364, 365 cerebrospinal fluid (CSF), 362 cerebrum, 358, 359 Chain of Survival, 534, 534 chest auscultation, 34, 64–6 anatomy and physiology, 64, 65 complications, 66 in critical care, 64 definition, 64 indications, 64 procedure guideline, 106 SPCSs, 147 chest compression, 537–8 chest (intrapleural) drains, 100–3 anatomy and physiology, 100 definition, 100 indications, 100 insertion, 101 problem solving, 104 procedure guideline, 143–5 SPCSs, 165–6 management, 101–3 removal, 103 problem solving, 104 procedure guideline, 145–7 SPCSs, 166–7 types, 101 chest X-ray positioning patient for, procedure guideline, 454–5 SPCSs, 464–5 cholesterol, 532 chronic obstructive pulmonary disease (COPD), respiratory failure in, 80 chyle, 100 circulation assessment, 32, 35–7 treating problems with, 32, 37–8 circulatory failure, 250 citrate, regional, 320 clinical apprenticeships, reduction in time for, 14–15 clinical audit, Clinical Governance framework, clotting cascade, 319 CO2, transportation, 76 coarse crackles, 64, 65 CoBaTrICE project, 16–17 cognitive behavioural therapy (CBT), 493 cognitive deficits, 491–2 colloids, 285 COMFORT scale, 336 communication improving clarity of, 39 in patient transfer, 475 procedure guideline, 479 SPCSs, 485 compassion, 512 compassion fatigue, 512 competence acquisition, 12–13 assessment, 16–17 definition, 12 competency-based practice, 12–24 curriculum, 13–15 defining specialty, 13 integrated governance and, 15–16 linking technical with humanistic care, 17–18 competency frameworks, integrated governance and, 15–16 competency statements see specific procedure competency statements conducting zone, 92, 94 conduction defects, 179 confidentiality, 54 conjunctiva, 400–1 consciousness, 360 consciousness level assessment, 366–7 treating disorders of, 38–9 continuous passive motion (CPM), 438–9 continuous positive airway pressure ventilation see CPAP continuous renal replacement therapy (CRRT), 310–23 aims, 310, 314 anatomy and physiology of kidney, 310–11, 311 cardiovascular control, 321 circuit, 310 commencement, procedure guideline, 326–7 complications, 321–3 definition, 310 disconnection, procedure guideline, 328–9 electrolyte monitoring, 322 fluid management, 321 indications in AKI, 313 infection control, 321 intravenous access, 321–2 machine alarms, 323 maintaining circuit, 319–21 anticoagulation use, 319–20 with no anticoagulation, 320 post-dilution, 321 pre-dilution, 320–1 managing patient on, procedure guideline, 327 mechanisms, 314, 314 metabolic status monitoring, 322 monitoring of circuit, 323, 323 neurological care, 323 nutritional support, 322 priming of machine, 315 procedure guideline, 325 principles, 314 problem solving, 323–5 rate of filtration, 315 replacement fluid, 319 respiratory management, 322 SPCSs, 329–30 treatment choices, 315, 318–19 types, 314–15 continuous veno-venous haemodiafiltration (CVVHDF), 315, 316, 318 continuous veno-venous haemodialysis (CVVHD), 315, 316, 318 continuous veno-venous haemofiltration (CVVH), 314, 316, 317 contractility, 36, 184, 193 definition, 250 convection, 314, 314 cornea, 401 coronary artery disease, 532 coronary circulation, 532, 533, 534 coronary perfusion pressure (CPP), 534 coroner referral, 521 cough reflex, 92, 360 counselling, 493 Court of Protection, 506 CPAP, 80, 85 contraindications, 80 indications, 80 problem solving, 81–2 procedure guideline, 125–6 CPR see cardiopulmonary resuscitation crackles, 64, 65 cranial nerves, 358, 360 critical care defining specialty, 13 definition, critical care assistants (CCAs), 14 critical care networks, 474 critical care outreach (CCO) teams, 2, 29–30, 52 critical care unit admission to see admission to critical care unit aims, 50 critical illness, definition, 28 critical illness polyneuromyopathy (CIPNM), 436 critically ill patients, classification, 556  Index CRRT see continuous renal replacement therapy CRUSE, 512 crystalloids, 285 cultural issues at end of life, 508 last offices, 510–11 curriculum, expanding, 14 Cushing response, 365, 367 cyclo-oxygenase (COX) system, 345 Dalton’s Law of Partial Pressures, 67 dead space, 79 death communicating procedures around, 510–11 definition, 509 diagnosing, 541 dignified, 517 sudden/unexpected, 509 decannulation, 76, 89 procedure guideline, 121–2 SPCSs, 153–4 decisions to forego life-sustaining treatment see DFLSTs defibrillation, 539–40 SPCSs, 549 delirium, 339–40 aims in treating, 339 assessment and monitoring, 340 procedure guideline, 349–50 SPCSs, 353–4 definition, 339 drugs and, 340 risk factors, 340 delta receptors, 345 dentures, 400 cleaning procedure guideline, 407–8 depression, sedation and, 337 dermis, 382–3 deteriorating patients assessing and managing, 31–9 SPCSs, 46 see also ABCDE assessment calling for help, 39, 52 care, 29 signs and symptoms, 28 dexmedetomidine, 345 dextrose, 285–6, 285 ‘dextrose-saline’, 285 DFLSTs, 501, 504, 507 diaries, 493 diarrhoea, and skin breakdown, 386 diastolic pressure, 181 dicrotic notch, 184 diffusion, 79, 314, 314 digestion, 279 digestive system functions, 279–80 organs, 278, 279 DINAMAP, 181 disability assessing, 32, 38 treating, 32, 38–9 DNACPR orders, 31, 501, 504, 535 assessment of need for, 503 process for obtaining, 503–4 DNMBDs, 341, 345–6 ‘Do Not Attempt Cardiopulmonary Resuscitation’ orders see DNACPR orders dobutamine, actions, 252 ‘DOLOREA’ study, 335 dopamine, actions, 252 dopaminergic receptors, activation, 252 dopexamine, actions, 252 double-lumen CVC, 319, 321–2 drug adjustments, in CRRT, 319 ‘dry eye’, 402 dry mouth see xerostomia dura mater, 360–1, 361 dying avoiding prolongation of, 504–5 diagnosing, 505 stages, 505 early warning scoring (EWS) systems, 29–31, 30, 52 ‘ebb’ phase, 281–2 ECG monitoring see electrocardiogram (ECG) monitoring ECMO, 85 electrical muscle stimulation (EMS), 440 electrocardiogram (ECG) monitoring, 174–80 3-lead ECG, 178, 178, 179 5-lead ECG, 178, 179, 179 12-lead ECG, 177, 177, 178, 179 aims, 174 anatomy and physiology, 174–7, 174 applying, 178, 206 assessment, 178–9 continuous cardiac monitoring, 177–8 application procedure, 206 specific procedure competency statements, 224 definition, 174 electrodes, 177, 177 limb lead orientation, 178 problem solving, 179–80 empathy, 512 empyema, 100 end diastolic pressure volume relationship curve, 188, 188 end of life, 500 end of life care (EOLC), 500–9 aims, 500 care in last days and hours, 505, 509 communication with family, 506–7, 507–8 communication strategies, procedure guideline, 513–4 competencies, 512 consultation, 506–7 cultural issues, 508 definition, 500 guidance, 502–3 nurses and, 507 practical components, 508–9 pre-EOLC considerations, 501 procedure guideline, 517–20 prognosis, 501–2 SPCSs, 522–3 tools, 502 transfer decisions and, 505 see also DNACPR orders End of Life Care Quality Assessment, 502 end tidal carbon dioxide monitoring see ETCO2 monitoring endotracheal tube (ETT), 33, 74–5, 74 in critical care, 78 displacement, 86 intubation, 74, 114–5 removal see extubation SPCSs for insertion, 150–1 suctioning through, 93 see also tracheal cuff enteral feeding, 291–2, 293–5 aspiration of stomach contents following, 295 benefits, 291 fine-bore versus wide-bore, 293–4 general principles, 291 procedure guideline, 300–1 SPCSs, 304–5 tube types, 293 see also nasogastric (NG) tube environment and ‘everything else’, assessment, 32, 39 EPAP, 80 epic2 project, 190 epidermis, 382 epithelium, 278 erythropoietin, 311 ETCO2 monitoring, 76, 76, 77 anatomy and physiology, 76 in critical care, 76 definition, 76 indications, 76 procedure guideline, 122–3 SPCSs, 155 evidence hierarchy of levels, nature, 5–7 evidence-based practice (EBP), 3–5 aims, definition, supporting, expiratory positive airway pressure see EPAP extracellular fluid compartment, 281 extracorporeal membrane oxygenation (ECMO), 85 extradural catheter, 369 extravascular lung water (EVLW), 201 extubation, 74–5, 89 at end of life, 508–9 procedure guideline, 516 post-extubation management, 89 prerequisites, 89 Index  557 problem solving, 90 procedure, 89 procedure guideline, 132–3 SPCSs, 159–60 eye care, 400–3 aims, 400 anatomy and physiology, 400–1, 402 assessment, 403 procedure guideline, 408–9 cleansing, procedure guideline, 409–10 definition, 400 instillation of eye drops, 410 problem solving, 403–4 problems, 401–2 SPCSs, 414–15 eye movement desensitization and reprocessing (EMDR), 493 falls assessment, on admission, 54, 59 families bereavement care, 512 breaking bad news to, 507–8 effect of critical illness on, 490–1 websites, 490 end of life consultation with, 506–7, 507–8 time with patient after death, 511 femoral artery, 181, 183 femoral vein, 183, 188 fentanyl, 345 fever, 37 fine crackles, 64, 65 FiO2, 472, 472 first degree heart block, 179 FLACC scale, 336 flexibility, of staff, 14 ‘flow’ phase, 281, 282 flow time corrected (FTc), 205 fluids, giving intravenously, 37–8 flush bag, heparin use in, 183 fractional inspired oxygen see FiO2 Frank–Starling curve, 188, 188 Frank–Starling Law of the Heart/ mechanism, 250, 287 friction, 386 Full Outline of UnResponsiveness (FOUR) score, 366–7 functional residual capacity (FRC), 440 fundamental competencies, challenges of meeting, 18, 18–19 fundamental competency statements (FCSs), 18, 20–1 use, 21, 24 gag reflex, 360 gas exchange, measurement, 67 gastrointestinal (GI) tract, 278–9 layers, 278–9, 280 gelatin, 285 gingivitis, 398 Glasgow Coma Score (GCS), 366–7, 366 global ejection fraction (GEF), 201 global end-diastolic volume (GEDV), 201 glomerulus, 310 glutamine, 292 glycaemic control, 67, 292 glyceryltrinitrate (GTN), dosages, 253 grasp reflex, 367 gravitational forces, 471, 471 guidelines, definition, HADS, 492, 493 haemodynamic monitoring, 193–205 see also advanced haemodynamic monitoring haemodynamics, 192 haemofilter, 318, 319 types, 318 haemothorax, 100 haloperidol, 346 Hartmann’s solution, 285, 286 head tilt/chin lift manoeuvre, 537, 537 Healthtalkonline, 490 heart anatomy and physiology, 532, 533, 534 critical illness and, 436–7 internal anatomy, 174 heart blocks, 179 heart cycle see cardiac cycle heart rate (HR), 193 calculation, 178 definition, 250 measurement, 36 normal, 36 heat and moisture exchanger (HME), 94, 95 with bacterial filter (HMEF), 94 heels, pressure damage risks, 388 Heimlich-type flutter valve, 101, 102 heparin, 320 use in flush bag, 183 heparin-induced thrombocytopenia, 320 herniation syndromes, 367, 368 high-frequency oscillation ventilation (HFOV), 85 high side lying posture procedure guideline, 448–9 SPCSs, 460 high sitting posture, 440, 441 procedure guideline, 447–8 SPCSs, 459 hoist overhead, 446 standing, 446 hoist transfer procedure guideline, 456–8 SPCSs, 465–6 Hospital Anxiety and Depression Scale (HADS), 492, 493 humidification, 35, 94–6 aims, 94 anatomy and physiology, 94 definition, 94 problem solving, 96 procedure guideline, 138 SPCSs, 162 humidifiers, 94–6 active, 94–5 choosing, 95–6 passive, 94 problems with, 95 humidity, 94 variation with temperature, 94 hydration anatomy and physiology, 278–81 definition, 278 effect of critical illness on, 281–3 enhanced recovery programmes, 290 ethical considerations, 296 fluid deficit indications, 284–5 fluid input and output sources, 283, 283 fluid overload indications, 284–5 importance, 283 maintaining fluid balance, 283–8 assessment of fluid status, 278, 283, 284–5, 285 distribution of administered fluid, 285 fluid replacement issues, 283 fluid replacement requirements, 287, 287 patent vascular access maintenance, 287–8 physiological endpoints choice, 287 studies, 287, 288 optimizing, 388 problems with providing, 292–3 support aims, 278 indications, 278 see also intravenous fluids hygiene, maintaining, 387 hypercapnia, 80 with NIV, 82 hyperchloraemia, 286 hyperglycaemia, 292 hyperinflation, manual see manual hyperinflation hyperosmolarity, 281 hyperoxygenation, 97 hyperpyrexia, 37 hyperthermia, 37, 366 hyperventilation, 473 hypoalbuminaemia, 286 hypocapnia, with NIV, 81 hypoglycaemia, 38, 292 treatment, 39 hypokalaemia, 322 hypophosphataemia, 293, 322 hypotension effects, 250 treatment, 250 hypothermia, 37, 322 treatment, 542 hypovolaemia, 37, 532 treatment, 37–8, 542 558  Index hypoxaemia, 79, 532 hypoxia, 33, 34 altitude and potential for, 471–3 with NIV, 81 treatment during CPR, 542 hypoxic pulmonary vasoconstriction (HPV), 473 ICP see intracranial pressure ‘ICU Recovery Manual Rehabilitation Programme’, 492 ICUSteps, 490–1 Immediate Life Support (ILS), 535 immune function, 280 immune response, mounting, 280 immunity, skin and, 383 IMV-directed weaning, 88 independent mental capacity advocates (IMCAs), 506 infection risk, from contact with body, 511 ingestion, 279 inotropes, 250–5 actions, 251, 252 administration via syringe pump, 251, 253 procedure guideline, 262–4 SPCSs, 272–3 aims, 250, 253 anatomy and physiology, 250 changeover of infusions, 254–5, 256 procedure guideline, 265–70 SPCSs, 274 choice, 251 definition, 250 dosages, 253, 254 procedure guideline, 271–2 SPCSs, 271–2 indications, 250 monitoring, 254 preparation procedure guideline, 259–61 SPCSs, 270–1 side effects, 253–4 titration to meet patient requirements, 253–4 procedure guideline, 264–5 SPCSs, 273–4 troubleshooting, 255, 257, 258 withdrawing, 254 inspiration, anatomy and physiology, 83 inspiratory positive airway pressure see IPAP insulin titration, 292, 292 integrated governance, 7–8, 15–16 competency frameworks and, 15–16 intermittent positive pressure breathing see IPPB intermittent renal replacement therapy (IRRT), 314, 321 characteristics, 315 internal jugular vein, 187, 188 interstitial compartment, 281, 281, 282 composition, 282 intracellular fluid compartment, 281, 281, 282 composition, 282 intracranial pressure (ICP), 362–3, 365 aspects of care impacting on, 371–2 monitor with external ventricular drain recalibrating procedure guideline, 376–7 recalibrating SPCSs, 378–9 recording procedure guideline, 374–5 recording SPCSs, 377–8 monitoring, 368–71 devices, 368, 369, 371 problem solving, 370 positioning patient with raised procedure guideline, 451–2 SPCSs, 462–3 signs and symptoms of raised, 367 waveforms, 370–1, 371, 371 intraparenchymal catheter, 368, 369 intrathoracic blood volume (ITBV), 201 intravascular compartment, 281, 281, 282 composition, 282 intravenous access, 37 intravenous fluids choice, 285 composition, 285 distribution, 285 theoretical effects of administration, 286 intraventricular catheter, 368, 369 intrinsic AKI uraemia, 312–13 invasive arterial blood pressure monitoring, 181–7 aims, 181 anatomy and physiology, 181–3 definition, 181 indications, 181 problem solving, 186–7 procedure guideline, 207–8 SPCSs, 225 invasive ventilation, 78, 82–5, 86–7 anatomy and physiology, 83 contraindications, 82–3 in critical care, 83 definition, 82 hybrid modes, 84–5 indications, 82 novel modes, 85 pressure modes, 83–4 problem solving, 86–7 procedure guideline, 128–30 SPCSs, 158 spontaneous, 85 volume modes, 84 IPAL-ICU, 502 IPAP, 80 IPPB, 90–1 complications, 90 contraindications, 90 controls (Bird), 91 in critical care, 90–1 definition, 90 indications, 90 problem solving (Bird), 91 procedure guideline (Bird), 131–2 SPCSs (Bird), 159–60 IRRT see intermittent renal replacement therapy ischaemia-reperfusion injury, 534, 542 jugular venous oxygen saturation (SjVO2), 372 kappa receptors, 345 keratitis, 401–2, 403 keratopathy, 403 kidney anatomy and physiology, 310–11, 311 functions, 311 Korotkoff sounds, 181 lactate, 67 normal values, 67, 250 as substitute for bicarbonate, 319 lamina propria, 278 landmark technique, 189 laryngeal mask airway (LMA), 33, 74, 74 last offices (care of body after death), 510–11 left bundle branch block, 179 levels of care, 50–2, 50–1 care activities and, 50–1 LiDCO system, 194, 204 benefits, 195 complications, 195 limitations, 195 normal limits of haemodynamic status, 201–2 LiDCOplus system, 194 device insertion procedure guideline, 216–7 SPCSs, 235–6 monitoring procedure guideline, 217–8 SPCSs, 237–8 problem solving, 205 lips, 397 Liverpool Care Pathway for Intensive Care Units (LCP-ICU), 502, 508, 512 log roll, 442 procedure guideline, 452–4 SPCS, 463–4 loop of Henle, 310 lorazepam, 344 lower respiratory tract, 92 lungs, anatomy and physiology, 64, 65, 100 lymphatic nodules see mucosa– associated lymphatic tissue lymphatic system, 280 Index  559 malnutrition, 283, 289 Malnutrition Universal Screening Tool (MUST), 289 MALT see mucosa–associated lymphatic tissue Manual Cervical Spine Immobilization Technique, 452 manual handling moving and handling equipment, 446 risk measurement, 444–5, 445 manual hyperinflation, 96–7 aims, 96–7 anatomy and physiology, 97 contraindications, 97 in critical care, 97 definition, 96 indications, 97 problem solving, 97 procedure guideline, 139–40 SPCSs, 163 Mapleson C bagging system, 96, 96, 97, 139 mask, non-rebreathable, 35 mattresses, 388, 389 mean acceleration, 205 mean arterial pressure (MAP), 36, 181, 182–3, 193 normal values, 250 mechanical hoist see hoist mechanical slack, 253 medical emergency teams (METs), 30, 52 medulla oblongata, 358, 359, 360 meninges, 360–2, 361 mesentry dressing, 101, 101 metabolic acidosis, 67, 322 metabolic alkalosis, 67 metabolic measures, 67 midazolam, 342–3, 344 midbrain, 359, 360 Mini Nutritional Assessment (MNA), 289 mixed venous oxygen saturation (SvO2), 198, 198 mobility and exercise see physical mobility and exercise Mobitz type heart block, 179 Mobitz type heart block, 179 modified Allen’s test, 184 moisture lesions, 386, 387 Monro–Kellie hypothesis, 362 motor neurones, 341 mouth care, 390, 397–400 anatomy and physiology, 397 definition, 390 oral cavity assessment, 399–400, 399 procedure guideline, 405 oral pathophysiology, 398 problems in critical illness, 398 procedure guideline, 405–7 SPCSs, 413–14 see also dentures mouth hygiene aims, 397 definition, 390, 397 mu receptors, 345 mucosa gastrointestinal tract, 278 respiratory tract, 92, 94 mucosa–associated lymphatic tissue (MALT), 278, 280 muscle wasting, 436, 491, 491 muscularis, 278–9 muscularis mucosae, 278 myocardial contractility, 36, 184, 193 definition, 250 myocardial infarction, assessment, 177 myocardial ischaemia assessment, 177 transfer and, 470, 473 nasogastric bridle, 294, 294 nasogastric (NG) tube checking position, 294–5 complications, 294 contraindications, 293 insertion, 293 procedure guideline, 298–300 SPCSs, 303–4 nasopharyngeal airway (NPA), 33, 72, 72 contraindications, 72 indications, 72 insertion procedure, 111–2 removal procedure, 112 SPCSs, 149–50 National Cardiac Arrest Audit (NCAA), 534 National End of Life Care Programme, 500, 502 National Gold Standard Framework, 500, 502 national guidance, National Institute of Clinical Excellence (NICE), establishment, National Patient Safety Agency (NPSA), establishment, NAVA, 85 NDNMBDs, 341, 343, 346 nebulizers, 35, 95 nephrons, 310, 312 Nernst equation, 204 neurally adjusted ventilatory assist (NAVA), 85 neurological assessment, 358–71 advanced neuromonitoring, 372 aims, 358 anatomy and physiology, 358–64 clinical methods, 365–8 definition, 358 invasive monitoring, 368–71 procedure guideline, 371–3 neurological deterioration, 437 neuromuscular blockade, 340–2, 345–6 aims, 340–1 anatomy and physiology, 341, 341 assessment, 342 procedure guideline, 350–1 SPCSs, 354–5 definition, 340 neurotransmitters, 341 Newcastle Sleep Assessment Tool, 424–5, 425 NEX measurement, 298, 299 NIV see non-invasive ventilation NMBDs, 341, 342, 343 nociceptors, 334 non-invasive arterial blood pressure monitoring, 180–1 aims, 180 definition, 180 indications, 180 oscillations, 181 non-invasive ventilation (NIV), 78, 80–1, 81–2 in critical care, 80 definition, 80 SPCSs, 157 see also BiPAP; CPAP non-maleficence, 504 non-REM sleep, 422 non-shockable rhythms, 532 non-steroidal anti-inflammatory drugs (NSAIDs), 345 noradrenaline, actions, 252 nutrition adjustments pre and post CRRT, 319 anatomy and physiology, 278–81 assessment for nutrition route choice, 289–90 of status, 278, 288–9 definition, 278 effect of critical illness on, 281–3 enhanced recovery programmes, 290 ethical considerations, 296 feeding critically ill patients, 291–2 glycaemic control, 67, 292 importance, 283 maintaining, 288–90 optimizing, 388 problems with providing, 292–3 screening, 288 components, 289 support aims, 278 indications, 278 see also enteral feeding; parenteral nutrition nutritional assessment, 54, 58 Nutritional Risk Screening (NRS2002), 289 Objective Structured Clinical Evaluation (OSCE), 17 observations see vital signs 560  Index oesophageal Doppler monitoring (ODM), 194, 204–5 benefits, 195 complications, 195 insertion procedure guideline, 222 SPCSs, 243–4 limitations, 195 monitoring procedure guideline, 223 SPCSs, 245–6 normal limits of haemodynamic status, 201–2 problem solving, 206 waveform interpretation, 205 omental dressing, 101, 101 opiate reversal, 39 opioids, 345 withdrawal, 337 oral cavity assessment, 399–400, 399 procedure guideline, 405 see also mouth care oral intubation, trauma from, 398–9, 400 oral pathophysiology, 398 organ donation, 510, 521–2 orogastric tube, 293 oropharyngeal airway (OPA), 33, 72, 73 indications, 72 insertion procedure, 113 problem solving, 73 removal procedure, 113 SPCSs, 149–50 oscillometry, 181 accuracy, 183 overfeeding, 292–3 overhead hoist, 446 oxygen high-concentration, 35 transportation, 77, 532, 534 oxygen delivery (DO2), 199, 203, 204, 532, 534 oxygen delivery index (DO2I), 199, 203, 204 oxygen dissociation curve, 69, 70 oxygen haemoglobin dissociation curve, 472, 472 oxygen saturation, 34, 69, 536 target, 536 oxygen therapy, 536–7 oxygenation, optimizing, 388 oxyhaemoglobin, 69 PA catheter (line) see pulmonary artery (PA) catheter (line) PA introducer, 196–7 PaCO2, 67, 76 normal range, 67 pain acute, 334 anatomy and physiology, 334 assessment, 334–6 on admission, 54, 59 procedure guideline, 346–7 specific procedure competency statements, 351–2 chronic, 334 definition, 334 management, 336 aims, 334 numeric rating scales (NRSs), 335–6 pathway, 334, 335 prevention, aims, 334 referred, 334 scales, 335–6, 336, 517 see also analgesia; neuromuscular blockade; sedation palliative care, 500 teams, 506 see also end of life care palpation, 64 PaO2, 67, 472–3 normal range, 67 paracetamol, 345 parenteral nutrition, 295–6 see also total parenteral nutrition (TPN) parietal pleura, 87, 100 partial pressure of arterial oxygen see PaO2 partial pressure of carbon dioxide see PaCO2 partial pressure of end tidal CO2 (PETCO2) see ETCO2 monitoring partial pressure of inspired oxygen, 472, 472 patient-centred practice, sources of evidence, patient-focused practice, patient needs, fundamental, 18 patient positioning see positioning patslide, 446 PCV-VG, 84–5 peak velocity (PV), 205 percussion, 64 percutaneous endoscopic gastrostomy (PEG) tube, 293 perfusion, 79 periodontitis, 398 peripheral nervous system (PNS), 358 peripheral oxygen saturation see SpO2 personal safety, after patient collapses, 536 pH, 66–7 measurement, 66–7 phenylephrine, actions, 252 phosphodiesterase inhibitors (PDIs), action, 252 physical mobility and exercise, 436–45 aims, 436 assessment of readiness to mobilize, 437–8 evidence, 437 indications, 436 interventions, 438–45 benefits and precautions, 439 during acute phase of illness, 438 parameters for decision making, 438 safety considerations, 443–4 see also rehabilitation physical morbidity anatomy and physiology, 436–7 definition, 436 physiological stability, 443 pia mater, 361, 362 PiCCO system, 194, 201–3 benefits, 195 complications, 195 device insertion procedure guideline, 219–20 SPCSs, 239–40 limitations, 195 monitoring procedure guideline, 220–1 SPCSs, 22–3, 241–3 normal limits of haemodynamic status, 201–2 problem solving, 203–4 piggybacking technique, 255, 256, 273, 267–70 ‘pink eye’, 402 plaque, 398 pleural effusion, 100 pleural fluid, 100 pneumonia, respiratory failure in, 79–80 pneumothorax, 87, 100, 102–3 signs and symptoms, 100 polysomnography, 423 polyuria, 287 pons, 359, 360 positioning, 35, 388, 390, 391–2, 440–2 for chest X-ray procedure guideline, 454–5 SPCSs, 464–5 and diagnostic tests, 442 types, 441 see also specific positions post-cardiac arrest syndrome, 541 post-dilution, 321 post-mortem, 511, 521 post-pyloric tube, 293 post-renal (obstructive) uraemia, 313 post-traumatic stress disorder (PTSD), 337, 338, 341, 492, 493 Post Traumatic Syndrome 14 Question Inventory (PTSS-14), 492 postoperative patients, critical care facilities for, 53 potassium, 67 potential hydrogen see pH practice-competence gap, 17 pre-dilution, 320–1 pre-renal uraemia (azotaemia), 312 preload, 35 definition, 250 pressure, 386 Index  561 pressure control ventilation (PCV), 83–4 pressure control ventilation-volume guarantee (PCV-VG), 84–5 pressure escalation plan, 127 pressure redistributing equipment, 388, 389 pressure support (PS), 85 pressure support ventilation (PSV), reduction in, 88 pressure ulcers, 384–90 assessment, 386 SPCSs, 412–13 classification, 385, 385 definition, 384 dressings, 390, 395–6 extrinsic factors, 386 healing, 390 identifying, 387 incidence, 384–5 indications, 384 management, SPCSs, 412–13 prevention, 387–90 SPCSs, 411 reporting, 390 skin inspection, 386–7 websites, 390 wound assessment, 393–4 procedures, definition, prognosis, 501–2 prognostication, 502, 505 ‘Programme of Enhanced Physiotherapy & Structured Exercise’ (PEPSE), 492 prone ventilation, 98–9 aims, 98 anatomy and physiology, 98 contraindications, 99 definition, 98 indications, 98 problem solving, 99 procedure guideline, 140–2 risks, 98–9 SPCSs, 164 propofol, 342–4 withdrawal, 337 propofol infusion syndrome (PRIS), 343–4 propulsion, 279 prostacycline, 320 protocols, definition, psychological problems, 492 PTSD, 337, 338, 341, 492, 493 public expectation, 14 pulmonary artery (PA) measurement parameters, 197–9, 198 waveforms, 197, 197 pulmonary artery (PA) catheter (line), 194, 196–9, 196 CO studies with, SPCSs, 234 complications, 199 indications, 195 insertion procedure guideline, 211–12 SPCSs, 227–9 lumens, 196 monitoring procedure guideline, 213–4 problem solving, 199–200 SPCSs, 230–2 pulmonary artery pressure (PAP), 198, 198 pulmonary artery wedge pressure (PAWP), 197–8, 198 procedure guideline, 215 SPCSs for recording, 233 pulmonary oedema, respiratory failure in, 79–80 pulmonary thermodilution method, 193, 194–9 see also pulmonary artery (PA) catheter (line) pulmonary vascular permeability index (PVPI), 201, 203 pulmonary vascular resistance (PVR), 198, 199 pulse oximetry, 69–70 anatomy and physiology, 69 in critical care, 69 definition, 69 indications, 69 problem solving, 70 procedure guideline, 110–11 SPCSs, 149 pulse pressure, 36, 182 pulse pressure variation (PPV%), 203, 204 pulse rate, measurement, 44, 365 pupil reaction, assessment, 38 pupillary responses, assessment, 367, 367 Purjinke system, 175, 175 qualitative studies, Quality of Death and Dying (QODD), 502 quick change technique, 255, 256, 265–70 radial artery, 181, 182 randomized controlled trials (RCTs), 5–6 rapid eye movement (REM) sleep, 422 rapid response systems, 29–31 Rapid Shallow Breathing Index (RSBI), 88 RASS, 338, 339, 367 receptionist, role in waiting room, 54 recliner chairs, 446 refeeding syndrome, 293 rehabilitation, 490–6 aims, 490, 492 components, 491–2 counselling, 493 and critical care, 490 definition, 490 diaries, 493 effect on families of critical illness, 490–1 websites, 490 evidence, 437 indications, 490 interventions, 492–3 patient-centred strategies, 492 for patients ready to sit on edge of bed, 442–4, 443 ambulation, 443–4 for patients unable to sit on edge of bed, 438–42 active exercise, 438–40 electrical muscle stimulation (EMS), 440 passive movements, 438–40 positioning, 440–2, 441 post-critical care, 444 procedure guideline, 494–5 SPCSs, 495–6 see also manual handling; physical mobility and exercise REM sleep, 422 remifentanil, 345 renal replacement therapy CRRT versus IRRT, 314, 315 principles, 314 see also continuous renal replacement therapy; intermittent renal replacement therapy renin, 311 reperfusion, 534 rescue sedation, 338, 346 respiratory arrest, 532 respiratory failure type I, 79–80 type II, 80 respiratory function, 33–4 critical illness and, 436 see also breathing respiratory rate, 34 respiratory system anatomy and physiology, 92, 92, 94 clinical assessment, 64–76, 365 interventions for, 78–105 physiological effects of transfer, 471 respiratory zone, 92, 94 restoration of a spontaneous circulation (ROSC), 534, 537 resuscitation team, 535 number to summon, 537 reticular activating system (RAS), 360 Richmond Agitation and Sedation Scale (RASS), 338, 339, 367 RIFLE, 313 right atrial (RA) pressure, 198, 198 right bundle branch block, 179 right ventricular (RV) pressure, 198 risk management, rub, 64, 65 saline, ‘normal’ (sodium chloride), 285, 286 saliva, 397, 398 SaO2, 69 SAS, 338 SBAR communication tool, 39, 39, 52 562  Index second degree heart block, 179 secretion, 279 sedation, 336–9 aims, 336 assessment, 338 definition, 336 management procedure guideline, 348–9 SPCSs, 352–3 monitoring of sedated patients, 338–9 rescue, 338, 346 risks, 337 treatment, 342–5 withdrawal, 337, 438 sedation hold, 337 sedation scoring scales, 338 Seldinger technique, 101 sensitivity, 512 sepsis, CRRT in treatment, 313 serosa, 279 serum creatinine, levels, 313, 313 serum potassium, control, 322 shear force, 386 shockable rhythms, 532 shunt, 79 side lying posture, 440, 441, 442 procedure guideline, 450 SPCSs, 461–2 Simplified Motor Score (SMS), 366–7 SIMV-PC, 85 SIMV-VC, 84 sinoatrial (SA) node, 174, 175 sinus brachycardia, 178 sinus rhythm, 178 sinus tachycardia, 178 ‘skill fade’, 15 skin challenges to health, 384 cross-section, 383 functions, 383–4 inspection, 386–7 layers, 382–3 maceration avoidance, 387 sleep, 422–8 definition, 422 factors that disrupt and promote, 425, 426–8 importance, 422 indications, 422 stages, 422 sleep assessment, 423–5 on admission, 54, 59 non-physiological methods/tools, 423–5, 425 physiological methods, 423 procedure guideline, 429–30 SPCSs, 430 sleep cycle, 422 sleep deprivation, effects, 422–3 sleep promotion, 425, 426–8 procedure guideline, 429–30 SPCSs, 431 sliding sheets, 446 slow continuous ultrafiltration (SCUF), 314, 316, 317 slow extended daily dialysis (SLEDD), 315 sneeze reflex, 360 sodium chloride, 285, 286 specific procedure competency statements (SPCSs), 18 admission to ICU, 59–61 arterial blood sampling, 148 blood glucose monitoring, 302 cardiac arrest recognition, 548 cardiac output studies with pulmonary artery catheter, 234 central venous catheter (central line) insertion, 226 chest auscultation, 106 chest drain insertion, 165–6 chest drain removal, 166–7 continuous ECG monitoring, 215 continuous renal replacement therapy (CRRT), 329–30 CPR airway assessment and ventilation, 550 starting, 548 defibrillation, 549 delirium assessment, 353–4 end of life care, 522–3 endotracheal tube extubation, 159–60 insertion, 119–20 enteral feed administration, 304–5 ETCO2 monitoring, 155 eye care, 414–15 hoist transfer, 465–6 humidification, 162 inotropes administration via syringe pumps, 272–3 changeover of infusions, 274 dosages calculation, 271–2 preparation, 270–1 titration to meet patient requirements, 273–4 intermittent positive pressure breathing (IPPB) (Bird), 159 intracranial pressure monitor recalibrating, 378–9 intracranial pressure recording, 377–8 invasive arterial blood pressure monitoring, 225 invasive ventilator therapy care, 158 log rolling, 463–4 manual hyperinflation, 163 mouth care, 413–14 nasogastric tube insertion, 303–4 nasopharyngeal airway (NPA), 149–50 neuromuscular blockade assessment, 354–5 non-invasive ventilator (NIV) therapy, 157 oesophageal Doppler monitor insertion, 243–4 monitoring, 245–6 oropharyngeal airway (OPA), 149–50 pain assessment, 351–2 positioning for chest X-ray, 464–5 high side lying, 460 high sitting, 459 patient with raised ICP, 462 side lying, 461–2 pressure ulcer assessment and management, 412–13 pressure ulcer prevention, 411 prone positioning, 164 pulmonary artery catheter (line) insertion, 227–9 monitoring, 230–2 pulmonary artery wedge pressure recording, 233 pulse oximetry, 149 recognizing and managing deteriorating patient, 46 rehabilitation of critically ill patients, 495–6 sedation management, 352–3 sleep assessment, 430 sleep promotion, 431 suctioning, 161 tracheal cuff pressure measurement, 156 tracheostomy formation and tube insertion auscultation, 152–3 tracheostomy removal/decannulation, 153–4 transfer assessment and stabilization prior to, 485 communication, 485 decision to, 479 handover, 484, 487 preparation for, 486 safe, 486–7 transpulmonary cardiac output monitoring using lithium dilution, 235–6, 237–8 using thermodilution, 22–3, 239–40, 241–3 vasopressors administration via syringe pumps, 272–3 changeover of infusions, 274 dosages calculation, 271–2 preparation, 270–1 titration to meet patient requirements, 273–4 SPIKES, 507–8 spinal reflexes, 367, 510 SpO2, 69 spontaneous breathing trial (SBT), 88, 337 St Mary’s Hospital Sleep Questionnaire, 424 standing hoist, 446 Index  563 starch solutions, 285, 287 Stewart–Hamilton equation, 196, 201 stretcher chairs, 446 stridor, 33, 64, 65 stroke distance (SD), 205 stroke volume (SV), 181, 193, 198 definition, 250 stroke volume variation (SVV%), 203, 204 subarachnoid bolt/screw, 369 subclavian vein, 187, 188 subcutaneous layer, 383 subdural catheter, 369 submucosa, 278 suctioning, 91–3 aim, 91 anatomy and physiology, 92, 92 closed endotracheal, procedure guideline, 136–7 indications, 91–2 open endotracheal, procedure guideline, 134–7 problem solving, 93 risks, 93 SPCSs, 161 subglottic, 93 through tracheal tubes, 93 sugammadex, 346 suxamethonium, 345–6 swallow reflex, 360, 397 swallowing, assessment, 289–90 Swedish nose, 120, 120 synchronized intermittent mandatory ventilation (SIMV-VC), 84 synchronized intermittent mandatory ventilation – pressure controlled (SIMV-PC), 85 syringe pumps, 251, 253 problem solving, 257 procedure guideline, 262–4 systemic vascular resistance (SVR), 198, 199, 204 definition, 250 systemic vascular resistance index (SVRI), 204 systolic pressure, 181 normal values, 250 systolic pressure variation (SPV), 204 T-piecing, 515 tamponade, treatment, 542 tears, 401 telemetry, 177 temperature measurement, 36–7, 45 monitoring, 366 normal, 36 tension pneumothorax, treatment, 542 terminal weaning, 508–9 thermometer devices, 36–7 thermoregulation, 383 thiopental, 344–5 third degree heart block, 179 third space losses, 282 thrombin inhibitors, 320 thrombosis, treatment during CPR, 542 TILE assessment, 444, 445 tilt table, 446 tissue viability, 382–4 anatomy and physiology, 382–3 definition, 382 support indications, 382 Toolkit of Instruments to Measure End of Life Care (TIME), 502 toothbrushing, 398, 401, 405–6 total parenteral nutrition (TPN), 295–6 complications, 296 tracheal cuff pressure measurement, 77–8 anatomy and physiology, 77–8 complications, 78 indications, 77 procedure guideline, 124 SPCSs, 156 tracheostomy tube (TT), 75–6, 75 complications, 75 contraindications, 75 in critical care, 78 definition, 75 displacement, 86 dressing change procedure, 118–9 indications, 75 inner cannula care procedure, 119–10 insertion procedure, 120–2 insertion SPCSs, 152–3 removal see decannulation stoma care procedure, 118–9 suctioning through, 93 see also tracheal cuff track and trigger systems, 52 ‘Train-of-Four’ (TOF) monitoring, 341, 342, 342, 343 transfer, 470–8 aims, 470 assessment and stabilization prior to, 475 procedure guideline, 480–1 SPCSs, 485 communication, 475 procedure guideline, 479 SPCSs, 485 components of process, 474–8 critical care networks role, 474 decision to, 475 end of life care and, 505 procedure guideline, 479 SPCSs, 484 definitions, 470 equipment guidelines, 478 evidence, 473–4 handover, 478 procedure guideline, 484 SPCSs, 487 indications, 470 organization, 474 physiological effects, 470–3 of altitude, 471–3, 472, 472 cardiovascular system, 470–1 of movement/gravitational forces, 471, 471 respiratory system, 471 stress response, 473 temperature control, 473 preparation for, 476 procedure guideline, 482–3 SPCSs, 486 primary, 470 quality, 473–4 safe, 476–8 procedure guideline, 483 SPCSs, 486–7 secondary, 470 selection of transport mode, 475–6, 475, 476 specialist transfer teams, 474 timing, 474 transfer trolley, 477, 477, 478 transpulmonary dilution method, 193–4, 201–4 transpulmonary thermodilution, 193–4, 201–3 device insertion procedure guideline, 219–20 SPCSs, 239–40 monitoring procedure guideline, 220–1 SPCSs, 22–3, 241–3 problem solving, 203–4, 205 see also PiCCO system using dye or chemical, 194, 204 device insertion procedure guideline, 216–7 SPCSs, 235–6 monitoring procedure guideline, 217–8 SPCSs, 237–8 see also LiDCO system; LiDCOplus system truth-telling, 508 two-bottle drainage system, 102, 103 ultrafiltration, 310, 314, 314, 319 underwater seal system, 102, 102 upper respiratory tract, 92 urine output levels, 313, 313 maintaining optimal, 37 normal values, 37, 250 vacuum-assisted closure (VAC), 390 vasomotor paresis, 287 vasopressin actions, 252 dosages, 253 vasopressin receptors, activation, 252 564  Index vasopressors, 250–5 actions, 251, 252 administration via syringe pump, 251, 253 procedure guideline, 262–4 SPCSs, 272–3 aims, 250, 253 anatomy and physiology, 250 changeover of infusions, 254–5, 256 procedure guideline, 265–70 SPCSs, 274 choice, 251 definition, 250 dosages, 253, 254 procedure guideline, 271–2 SPCSs, 271–2 indications, 250 monitoring, 254 preparation procedure guideline, 259–61 SPCSs, 270–1 side effects, 253–4 titration to meet patient requirements, 253–4 procedure guideline, 264–5 SPCSs, 273–4 troubleshooting, 255, 257, 258 withdrawing, 254 venous outflow obstruction, 371 venous thromboembolism (VTE), 440 ventilation, anatomy and physiology, 79–80 ventilation perfusion (V/Q) ratio, 79 ventilator-associated pneumonias (VAPs), 79, 390 incidence reduction, 83, 93 ‘ventilator eye’, 401 ventilatory support, 78–80 indications, 78–9 types, 79 withdrawing at end of life, 509 see also invasive ventilation; nonnon-invasive ventilation; weaning from mechanical ventilation ventricular pathways, 362, 363 Venturi effect, 95, 95 vesicular breath sounds, 64 visceral pleura, 87, 100 vision, 400 see also eye care vital signs (observations), assessment, 365 VitalPac Early Warning Score (ViEWS), 30, 31 vitamin D synthesis, 384 volume control ventilation (VCV), 84 VTE risk assessment, 54, 58 waiting, 54 ward patients critically ill or ‘at risk’, 28–46 see also, deteriorating patients Waters’ circuit see Mapleson C bagging system weaning from mechanical ventilation, 87–9, 89–90 aim, 87 anatomy and physiology, 87–8 definition, 87 procedure guideline, 130 reduction of mechanical support, 88–9 testing patient readiness, 88–9 see also decannulation; extubation Wenckebach phenomenon, 179 Wesseling algorithm, 203 wheezes, 64, 65 WHO analgesic ladder, 336, 347 withdrawal of treatment, 501 assessment of need for discussion of, 504 avoiding prolongation of dying, 504–5 cultural issues, 508 diagnosing dying, 505 extubation, 508–9 procedure guideline, 516 how and when, 508 incidence, 504 legal and ethical issues, 504 procedure guideline, 514–15 see also end of life care withholding treatment, 501 cultural issues, 508 incidence, 504 legal and ethical issues, 504 wound assessment, 393–4 wound management dressings, 390, 395–6 xerostomia (dry mouth), 398 with non-invasive ventilation, 82 ... concerning cancer care The RMH Manual was (and still is) viewed as an essential text and a ‘bible’ for nursing The Critical Care Manual of Clinical Procedures and Competencies (Critical Care Manual) has... Federation of Critical Care Nurses Former Director, World Federation of Societies of Intensive Care and Critical Care Medicine Founding President, Australian College of Critical Care Nurses Preface... developed and incorporated into the chapters The emphasis of the Critical Care Manual is ‘general’ critical care Specialist critical care, such as that provided for patients with severe burns and/or