Critical Care Patients with Special Needs

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CHAPTER 11

Critical Care Patients with Special Needs

INTRODUCTION

1. Description: Obesity is a multifaceted condition of excess stores of body fat

2. Etiology: Complex and multifactorial

3. Definitions (American Society of Bariatric Surgery)

a. Body mass index (BMI): Ratio of weight (in kilograms) to the square of height (in meters)

b. Overweight: Excess body weight compared to established standards (e.g., National Center for Health Statistics defines overweight as a BMI of ≥ 27.8 in men and ≥ 27.3 in women). Excess weight may come from muscle, bone, fat, and/or water.

c. Obesity: BMI of 30 or higher

d. Morbid obesity

e. Bariatrics (from the Greek baros for “weight”): Health care related to the treatment of obesity and associated conditions

4. Prevalence

5. Pathophysiology of obesity: Physiologic sequelae of excess body weight adversely affect most body systems (Table 11-1)

6. Clinical significance to critical care nursing

a. Recent evidence suggests that high BMI may be an independent prognostic risk factor for mortality in intensive care unit (ICU) patients

b. Obesity is directly and indirectly associated with a wide spectrum of serious health disorders (see Table 11-1) that may accompany, underlie, and complicate whatever caused the patient to be admitted into a critical care unit

c. When obese patients are hospitalized, they pose a number of additional challenges to health care facilities and staff

i. Increased risk for all complications related to the immobility imposed by their size (i.e., skin breakdown, cardiac deconditioning, atelectasis, deep venous thrombosis, muscle atrophy, urinary stasis, constipation, bone demineralization)

ii. Likelihood of longer length of stay than nonobese

iii. Vulnerability to care issues more or less unique to this population

NURSING CARE OF THE CRITICALLY ILL BARIATRIC PATIENT

1. Pulmonary complications

a. Obesity hypoventilation syndrome (also known as Pickwickian syndrome)

i. Definition: Oxygenation decreases as BMI increases, likely due to elevated intraabdominal pressure in which mass and weight compress the thoracic cavity and limit diaphragmatic excursion. Chronic CO2 retention leads to hypercapnia, respiratory acidosis, and dependence on hypoxia for ventilatory drive.

ii. Related to obstructive sleep apnea, characterized by drowsiness, narcosis, daytime napping, difficulty sleeping at night, fatigue, hypersomnolence, depression, right heart failure, and further weight gain

iii. Incidence of respiratory complications has a direct relationship to BMI, especially among those over 350 lb

iv. Risk factors include male gender, middle age, mild sedation, BMI over 30

v. Intervention: Noninvasive positive pressure ventilation can be tried; however, mechanical ventilation must be readily available

b. Respiratory failure

i. Obese patients are at risk for respiratory failure due to their high oxygen consumption, decreased functional residual capacity (FRC) (which decreases exponentially with increased BMI), decreased expiratory reserve volume, and decreased total lung capacity

ii. FRC may fall into the range of closing capacity, which leads to small airway closure, ventilation/perfusion mismatch, arterial hypoxemia, and limited oxygen reserve

iii. Obese patients often experience diaphragmatic fatigue. Pressure-supported ventilation alone or with backup allows resting of the diaphragm.

iv. Interventions

v. Airway management requires securing of the airway, intubation, secretion control, use of special equipment, and proper positioning

vi. Failure to control tracheostomy secretions leads to skin breakdown, odor, and threat to a patent airway. For patients with a thick, short neck and excessive parapharyngeal fat deposits, tracheostomy surgery can be difficult, because the trachea may be buried deep in tissues. Wound is managed like any other open wound: Nonadhesive, absorbent, ¼-inch foam dressing is used to absorb excess drainage, protect the wound, and prevent injury from adhesives. Tracheostomy ties should be longer and wider to prevent trauma within skin folds.

vii. Equipment should be tailored to best serve patient and caregiver needs

c. Pneumonia (see also Chapter 2)

i. Most common cause of death from hospital-associated infection, with a prevalence of 5 to 10 per 1000 admissions. Incidence is fourfold higher in intubated, mechanically ventilated patients, because of decreased VT, decreased mucociliary transport, increased atelectasis, and infectious complications, which lead to increased morbidity and mortality.

ii. Interventions

d. Pulmonary embolism (PE) (see also Chapter 2)

2. Potential skin integrity complications: Pressure ulcers

a. Result from pressure, friction, and/or shear; often related to insufficient frequency of and/or ineffective repositioning of the very obese patient as well as the presence of multiple overlapping skin folds that can foster the growth of bacteria or yeast

b. Contributing factors include moisture, dehydration, and malnutrition

c. Staging depends on the depth of damage to underlying tissue

d. Obese patients are at risk for atypical pressure ulcers caused by pressure within skin folds related to tubes, catheters, or an ill-fitting chair or wheelchair

e. Rotation therapy can afford effective and timely repositioning for very large patients who otherwise pose a considerable challenge to frequent turning. Even when rotation therapy is used, precautions must be taken to prevent friction and shear by using correct pressure settings, using an appropriately sized surface, and monitoring skin integrity frequently.

3. Other potential complications related to obesity: See Table 11-1

CARE OF THE MORBIDLY OBESE BARIATRIC SURGERY PATIENT

1. Surgical options

2. Potential postoperative surgical problems (beyond usual surgical risks such as bleeding, infection, emboli, aspiration, etc.), especially for open abdominal (vs. laparoscopic) procedures, for the morbidly obese and for those with underlying cardiopulmonary disorders

RELATED BARIATRIC CARE ISSUES

1. Caregiver issues

2. Bariatric equipment issues

3. Policy issues

a. Policy makers, insurance carriers, health care facilities, and clinicians all need to use standardized measurements and definitions when developing policies, procedures, and protocols for critically ill bariatric patients

b. Bariatric patient criteria (e.g., actual weight, width at widest point, or BMI) should determine which health care professionals and resources are needed in patient care to prevent complications and improve outcomes

c. Health care professionals on the bariatric care team (physical therapist occupational therapist, or respiratory therapist; internist; bariatric surgeon; dietitian; bariatric clinical nurse specialist; wound, ostomy, and continence nurse; pharmacologist; home care coordinator; equipment vendors) need to be interested in improving critical care for the obese patient

AGE-RELATED BIOLOGIC AND BEHAVIORAL DIFFERENCES

1. Biologic and behavioral differences between older adults and younger adults require modification of nursing care

2. Age-related changes derive from three sources, according to Sloane’s rule of thirds (1992):

3. Normal age-related changes and implications for nursing care are summarized in Table 11-2

TABLE 11-2

Normal Changes with Aging

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Compiled from Beers MH, Jones TV, Berkwits M, et al: The Merck manual of health and aging, Whitehouse Station, NJ, 2004, Merck Research Laboratories; Ebersole P, Hess P, Luggen AS: Toward healthy aging, ed 6, St Louis, 2004, Mosby; Kane RL, Ouslander JG, Abrass IB: Essentials of clinical geriatrics, ed 5, New York, 2004, McGraw-Hill; and Timeras PS, editor: Physiological basis of aging and geriatrics, ed 3, Boca Raton, Fla, 2003, CRC Press. McGraw-Hill

AGE-RELATED CHANGES IN MEDICATION ACTION

1. Adverse drug reactions are more common in older adults than young adults (Routledge, Mahony, and Woodhouse, 2003)

2. Major reason older adults have more adverse drug reactions is that they have more diseases and take more medications, but age-related changes in drug pharmacokinetics also contribute. The most clinically significant pharmacokinetic changes in old age include the following (Pepper, 2004; Turnheim, 2003):

a. Absorption of drugs shows few age-related changes, although decreased gastric acid alters the dissolution of some drugs (e.g., enteric-coated tablets dissolve faster and may cause irritation)

b. Distribution of drugs is altered by changes in body composition. Greater fat mass increases the storage and half-life of lipid-soluble drugs (e.g., psychotropic drugs). Highly protein-bound drugs (>90% bound) are more likely to be involved in drug interactions.

c. Metabolism of high-clearance drugs (those that are avidly metabolized) is decreased due to decreased liver blood flow

d. Excretion of drugs that are eliminated unchanged or as active metabolites by the kidneys is markedly impaired with aging

3. Drug interaction is another important factor in adverse drug reactions in older adults, primarily due to the number of drugs taken. The most significant drug interactions include the following:

a. Drugs that decrease gastric acid production (e.g., H2-blockers, proton pump inhibitors, antacids) may alter the absorption of oral drugs

b. Concurrent use of two drugs highly bound (>90%) to plasma albumin will increase the effect of one or both drugs, especially if drug elimination is impaired by age or disease. Use a current drug handbook for data on the degree of protein binding.

c. Drugs that induce or inhibit cytochrome P450 (CYP) enzymes can cause drug toxicity. Use a reference source that is frequently updated, such as Drug-Interactions.com (2005). CYP inhibition is the most significant drug interaction–related cause of adverse drug effects in elderly patients.

d. Drugs whose output is affected by urine pH (quinidine, amphetamines, ephedrine, phenobarbital) or that undergo tubular secretion (probenecid, cimetidine, omeprazole) can interact with and contribute to the toxicity of drugs like methotrexate, procainamide, acyclovir, nitrofurantoin, and cisplatin (Karyekar, Eddington, Briglia, et al, 2004)

4. Nonadherence to the drug regimen and prescribing error, in addition to physiologic and pharmacologic factors, may contribute to adverse drug reactions

a. Nonadherence with the prescribed drug regimen is a common cause of hospitalization among the elderly, although many comply closely with the regimen for prescribed medications (Beijer and de Blaey, 2002)

b. Often there is no accurate list of a patient’s medications during transitions (from home to hospital; from unit to unit in the hospital), which are times of high risk for prescription and transcription error

c. Expert consensus panels have identified medications to avoid prescribing for older adults; the guidelines regarding potentially inappropriate medication use are called the Beers criteria (Fick et al, 2003)

COMMON GERIATRIC SYNDROMES

1. Geriatric syndromes are broad categories of signs and symptoms that may have a variety of contributing factors, including normal aging changes, multiple diagnoses, and adverse effects of therapeutic interventions. Syndromes are a major focus of nursing research and best practice guidelines.

2. SPICES is a tool for assessing major geriatric syndromes (Wallace and Fulmer, 1998). Pain is another important geriatric syndrome.

3. Nutritional and hydration disorders

4. Confusion

a. “Geriatric triad” includes three conditions that can cause confusion: Delirium, depression, and dementia

b. Delirium is an acute, reversible, life-threatening syndrome characterized by fluctuating alteration in mental status, inattention, and altered level of consciousness. Stereotypy (repetitive behaviors such as picking at the bedding) may be present. It is a cognitive reaction to a physiologic state.

c. Dementia is a chronic, irreversible, progressive condition with insidious onset that is characterized by memory and thinking deficits involving orientation, visuospatial skills, language, judgment, concentration, and the ability to sequence tasks

d. Depression is common in older adults, affecting up to 43% of older adults in acute care. Can be reversed if detected early. Untreated depression can lead to cognitive impairment, physical debilitation, and suicide (Kurlowicz, 1999).

5. Fall syndrome

6. Pain

a. Pain management principles are the same as for other age groups

b. Regular assessment for pain is imperative. Cognitively impaired older adults can give reliable reports of whether they currently have pain. Pain scale most commonly preferred by older adults is a verbal descriptor scale, rather than a visual analogue, face, or numerical scale.

c. Due to age-related changes in pharmacokinetics, older adults do not tolerate some analgesics (Ferrell, 2004; McCaffery and Pasero, 1999):

i. Propoxyphene-containing drugs carry an excess risk of central nervous system (CNS) adverse effects with limited analgesic benefit

ii. Meperidine has a toxic metabolite that accumulates in older adults due to decreased renal function, which results in irritability or even seizures. Avoid repeated dosing if used at all.

iii. Mixed agonist-antagonist analgesics should be avoided in older adults due to their unreliable efficacy and cognitive and cardiovascular effects

iv. Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen carry a high risk of gastrointestinal adverse effects with prolonged or regular use. Cyclooxygenase-2 inhibitors (e.g., celecoxib) carry a cardiovascular risk.

v. Regular dosages of acetaminophen are preferred for osteoarthritis, but the total dose should not exceed 4 g/day. Some older adults have experienced hepatic damage at 3 g/day, so the minimum effective daily dose should be used.

vi. Long-acting opioids (e.g., methadone) and amitriptyline (Elavil) should be avoided due to potential adverse effects

END-OF-LIFE CARE

1. Advance directives: Legal in every state, but laws vary widely (Warm and Weismann, 2000)

a. There are two types of advance directive:

b. Nurses can help patients understand advance directives (Douglas and Brown, 2002)

2. Syndrome of imminent death (Weisman, 2000)

PHYSIOLOGIC CHANGES IN PREGNANCY

During pregnancy, nearly every body system undergoes adaptations that protect the growing fetus and prepare the mother for delivery. Some changes appear early and continue throughout gestation; others occur later. Tables 11-3, 11-4, and 11-5 summarize some of the most significant normal changes that critical care nurses need to keep in mind. Box 11-1 defines some common obstetric abbreviations that may be encountered in obstetric patients’ charts.

BOX 11-1   GLOSSARY OF OBSTETRIC TERMS

This list of common obstetric abbreviations can aid in interpreting the patient’s chart and prenatal record.

BOWI Bag of waters intact
EDC Estimated date of confinement (same as EDD)
EDD Estimated date of delivery
EFM External fetal monitoring
EGA Estimated gestational age
FHR Fetal heart rate
G Gravida (number of pregnancies)
+GFM Gross fetal movement present
IUP Intrauterine pregnancy
LMP Last menstrual period
P Parity (number of live births)
PIH Pregnancy-induced hypertension
PROM Premature rupture of membranes (rupture not followed by labor within an hour)
PPROM Preterm premature rupture of membranes
ROM Rupture of membranes
US Ultrasonography

TABLE 11-5

Comparison of Hemodynamic Profiles in Pregnant and Nonpregnant Women

Hemodynamic Parameter Pregnant Nonpregnant
Cardiac output (L/min) 6.2 4.3
Central venous pressure (mm Hg) 3.7 3.6
Colloid osmotic pressure (mm Hg) 18 20.8
Heart rate (beats/min) 83 71
Left ventricular stroke index (ml/beat) 48 41
Mean arterial pressure (mm Hg) 90 86
Pulmonary capillary wedge pressure (mm Hg) 7.5 6.3
Pulmonary vascular resistance (dyne/sec/cm−5) 78 119
Systemic vascular resistance (dyne/sec/cm−5) 1210 1530

POSTPARTUM HEMORRHAGE

1. One of the leading causes of maternal morbidity and mortality, contributing to 30% of obstetric deaths. Definitions include subjective assessments of blood loss greater than standard norms, a 10% decline in hematocrit, and need for blood transfusion.

2. Physiologic response to postpartum hemorrhage

3. Etiologic factors: Distinguished by the timing of the hemorrhage

4. Patient assessment

a. History of precipitous or prolonged stages of labor, overstretching of the uterus, administration of medications (e.g., magnesium sulfate for pregnancy-induced hypertension), past placental retention, use of forceps or other intra-vaginal manipulations

b. Related to blood loss

5. Patient care specific to obstetric patients (see Chapter 3 for hemorrhagic shock interventions)

6. Evaluation: Desired patient outcomes include the following:

HYPERTENSIVE DISORDERS OF PREGNANCY

Hypertensive disorders, the most common medical complications of pregnancy, affect 5% to 10% of pregnancies. About 30% of cases are due to chronic hypertension and 70% are due to gestational hypertension, or preeclampsia. Spectrum of the disorder ranges from mildly elevated blood pressure with minimal clinical significance to severe hypertension and multiorgan dysfunction.

1. Definitions: Hypertension is defined as systolic blood pressure 30 mm Hg above baseline and diastolic blood pressure 15 mm Hg above baseline. In pregnancy, abnormal proteinuria is 300 mg protein or more in 24 hours.

2. Classification of hypertensive states in pregnancy

a. Gestational hypertension: Occurs in the second half of pregnancy or the first 24 hours postpartum

b. Preeclampsia, or pregnancy-induced hypertension (PIH): Occurs at more than 20 weeks’ gestation

c. HELLP syndrome

3. Pathophysiology

a. Characterized by vasoconstriction, hemoconcentration, and possible ischemic changes in the placenta, kidney, liver, and brain

b. Intense vasoconstriction due to dysfunction of the normal interactions of vasodilatory and vasoconstrictive substances

c. Thrombocytopenia: Platelet count lower than 100,000/mm3

d. Decreased renal perfusion and reduced glomerular filtration rate

e. Hepatic system: Mildly elevated liver enzyme levels, subcapsular hematomas, or hepatic rupture

f. CNS: Eclamptic convulsions

g. HELLP syndrome

i. Chronic vasoconstriction that occurs in PIH causes fibrin deposits in hepatic sinusoids, which obstruct hepatic blood flow and alter liver function

ii. Liver swells, stretching Glisson’s capsule and producing epigastric and right upper abdominal quadrant pain

iii. Hemorrhagic periportal necrosis, subcapsular hemorrhages, and spontaneous liver rupture may occur in extreme cases. Serum liver enzyme levels rise, with aspartate aminotransferase values of 60 IU or higher (normal ≥35 IU). Jaundice and acute hepatic failure may occur.

iv. Maternal hypoglycemia is a serious prognostic indicator

v. Risk of developing DIC is compounded: Patients with severe HELLP syndrome (all three abnormalities) are at greater risk for developing DIC than patients with partial HELLP syndrome (one or two clotting abnormalities). Despite treatment, the syndrome can escalate into DIC because the production of many clotting factors is increased in pregnancy (Table 11-9). With DIC, the clinical picture is hemorrhage and shock (see Chapter 7).

TABLE 11-9

Comparison of HELLP Syndrome and Disseminated Intravascular Coagulation (DIC)

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