SPCMC Intensive Care Unit  Obtunded – responds to vigorous

 iso certified shaking

 10 bed capacity  Stupor / stuporous - only responses to
 2 PICU (pedia intensive care unit) pain stimulation
 Unconscious- comatose
 6 rooms for any cases
CONTRAPTIONS ON ICU
 consist of cardiac monitor, suction machine,
 NGT (change every 7 days: regular -
infusion pumps
1month - silicone)
 negative swab results (rtpcr/swab result)
 IV line incl. iv tubing, iv cathether (change
every 3 days)
5 Dispositions
 Regular Room: if patient is stable with
IV Gauge:

💚: gauge 18 for bt
doctor's order
 MGH

💖: gauge 20 for adult

 HAMA: (home against medical advise) -
with legal documentations to be
accomplish / with written statement
DAMA: discharge against medical advise) 💙: gauge 22
 Transfer to other health facilities
 Expired 💜: gauge 26 for pedia
ICU forms
💛: gauge 24 for pedia
 VS monitoring sheet
 I & O monitoring sheet
 Lab monitoring sheet (red pen means Foley catheter:

💚: fr 14
abnormal result)
 Neurovital sign monitoring sheet (mostly
🧡: fr 16
for cva patients)
 GCS sheet (mostly for patients with trauma
or VA)
: fr 18
 ICU admission sheet
 Monitoring bedsores sheet ET tube
 Logbook Adult: 6-8.5
Pedia: 2-5
GLASGOW COMA SCALE Suction machine, irrigating solution,
(E4, V5,M6) suction tip

Eye Opening  Oral - fr 14 💚

ET - fr 16 🧡
* 4 - highest score; spontaneous eye opening

* 3 - woke up to verbal stimulation
* 2 - woke up to pain stimulation
* 1 - none responsive to any stimulation

Verbal Response 👄
GENERAL PROCEDURE ICU AND IMCU

* 5 - oriented I. Purpose: establish documented care unit

* 4 - confused procedure in the ICU and IMCU
* 3 - inappropriate words II. Scope: The procedure starts from
* 2 - incomprehensible sounds admission to disposition of patients
* 1 - no verbal response

Motor Response 🦿
III. Procedure:
1. Start
* 6 - obeys command routine preparation during admission:
* 5 - localizes pain - call from other station or ward
* 4 - withdrawal from pain - name, age, diagnosis, physician (ask if
* 3 - flexion to pain intubated to prepare mech vent)
* 2 - extension to pain
* 1 - no motor response 2. Preparation of room (bed side)
NEUROVITAL SIGNS (closu)  Suction Machine
Level of consciousness (loc)  Irrigating solution
 Conscious- alert and coherent  Suction Tip
 Lethargy - drowsy - easily arousable / 3. Prepare bed with linen draw sheet, pillow, and
stimulated to tap, verbal stimulation blanket
4. Set up and check functioning of the ff. 7. Refer to AP/ROD as appropriate/
equipment deterioration or any alteration in pt’s
 Cardiac monitor condition
 Suction machine with connecting tube Carry out AP/ ROD Order
suction tips 1. Diagnostic procedure
 suction bottles 2. Therapeutic treatment
 Autoclaved bottles for irrigating
solution 1. Carry out order based on sound judgement
5. Prepare and transcribe according to chart and
 E-cart Kardex
 Bag valve mask (ambu bag) 2. Forward request to appropriate department
3. Collaborate with other departments and
 Availability of the oxygen source pipe
healthcare unit
in
4. Obtain diagnostic results from other
6. Prepare admission materials (+exclusive forms
departments and relay to AP
of ICU)
5. Forward request for meds and supplies to
 Admission kit
pharmacy and CSS, via hospital system
 Electrodes
6. Administer nursing procedures and
 Thermometer prescribed treatment appropriately within
 Gloves the scope of nursing practice
 Face mask 7. Update AP regarding patient’s response to
 Patient’s needed supplies intervention and any progress/deterioration
7. Make appropriate door tag ensuring proper of condition
patient identification and color coding based 8. Accurately document
on attending physician 9. Continue monitoring VS
10. reporting and monitoring of Incidents
Receiving of patient
1. Greet patient and relatives and introduce Daily patient care/Routine nursing function
oneself 1. Endorsement
2. Accompany pt to his/her designated 2. Observe appropriate intervention control
bedroom protocol at all times
3. Assist in placing the patient in a comfortable 3. Perform thorough assessment
position at prescribed degree of elevation 4. Check for pt’s contraptions
(via stretcher) 5. Prepare plan of works and determine
4. Identify patient properly (ask the patient’s resources and priorities_______________
name, wrist tag, admission record) 6. Perform nursing assistance therapeutic
5. Initiate pt safety precaution (hook pt to CM, independent collaboration and dependent
mech vent) nursing care
6. Perform cephalocaudal assessment 7. Provide hygienic measures:
7. Assess LOC__________________ a. Oral care
8. Obtain VS, BP, temp, PR and RR b. Tracheostomy care
9. Check pt’s contraptions c. Bed bath
10. Orient pt to the hospital with rules, visitation d. Perineal care
policy 8. Monitor progress and deterioration of pt’s
11. Receive endorsement at bedside condition
12. Countercheck accuracy of details in the 9. Accompany doctor during rounds (to
chart from the Kardex validate and confirm endorsement)
10. Carry out doctor’s order
Referral to AP/ROD Disposition of Patient
1. Review chart for the completeness and 1. Transfer to other health facilities
properly carried out doctor’s order - Needs: final dx, medical abstract, lab
2. Accomplish ICU/IMCU admission checklist works
form - Coordinate to other HF, ambulance
3. Orient SO and have them sign the ICU - Explain with patient and SO the
rules and visitation policy____ needs for transfer and consequences
4. Enter the pt’s data in the admission if transfer is per patients request
logbook and include in census - Endorse to conducting nurse >
5. Identify the pt’s needs or problems prepare what is needed
6. Perform appropriate independent nursing - Charting
action - Inform the AP of transfer
- PDIN- Patient’s discharge
2. HAMA/DAMA
 - Written statement drugs will be administered as needed to
- Billing process control dysrhythmias.
- Diagnosis  Esophageal intubation: remove the et tube
- Clearance and ventilate with 100% oxygen: re-attempt
- Charting tracheal intubation even the patient is well
- Document oxygenated (95%)
- Logbook remarks (date &time)  Chipped or dislodge teeth: remove these
3. Cadaver from the airway to prevent their aspiration.
- Final diagnosis  Trauma to the airway mucosa or vocal
- Nurse death certificate and dx of cords: take steps to minimize further
the pt damage. suction the airway of blood if
- Meds, supplies, charge necessary / to maintain visualization of
- Return unused meds anatomical structures
4. Room transfer  Vagal stimulation: stop intubation attempt
- Doctors order and ventilate with 100% oxygen.
- Call to admitting p. (bradycardia = atropine sulfate 1mg/ml, max
- Partial payment of 3ml or 3amp)
- Transfer slip - Emergency meds will be administered
o Room, time, sign of relative, as needed
admitting and billing  Laryngospasm: stop intubation attempt
- Endorse (vent with 100% O2)
- Inform AP where room  Failure to intubate: emergency
- Documentation cricothyrotomy or tracheostomy must be
performed.
Assisting with Endotracheal Intubation
- can be performed by the AP, ROD, Equipment and materials:
anesthesiologist, acls certified nurse.  et tube of the estimated size needed, ½ size
- to assist in providing patient airway in large and ½ size smaller
emergency situation by introduction of tube
 manual resuscitator and appropriate sized
through the endotracheal.
mask (BVM- bag-valve mask)
Indications:
 oral and et suction tip
 Acute respiratory failure
 laryngoscope and blades with functional
 Upper airway obstruction
bulbs
 Cardio-respiratory shock / arrest
 stylet / guide wire
 Mech vent and oxygen therapy
 10cc syringe
 Fracture of cervical vertebrae with spinal
 xylocaine spray (if available) Lidocaine- for
cord requiring ventilatory assistance
numb
Complications:
 KY jelly / water soluble lubricant
 Vomiting and aspiration
 clean gloves, sterile gloves
 Hypoxemia -> dysrhythmias and or
 tape / et tube fixation device
hypotension
 oral airways- tongue guard
 Esophageal intubation
 suction equipment (suction machine with
 Chipped or dislodge teeth
connecting tube
 Trauma to upper airway, tracheal mucosa, or
 pulse oximeter
vocal cords
 cardiac monitor
 Vagal nerve stimulation with secondary
 mech vent
bradycardia or hypotension
 Laryngospasm Procedure:
 Failure to intubate  Explain proceed to the pt or relatives
- SO. If conscious/non-urgent
Relative contraindication: - If emergency and no one is available
 Presence of stomach contents to decide, AP/ROD responsible to
 Inadequate sedation (take bp and watch out decide for the later
for hypotension)  Secure written consent for the procedure
 Gather and prepare / test equipment (initiate
Adverse reactions and Interventions: cardiac monitoring, pulse oximetry)
 Vomiting: stop intubation attempt, suction  Do the appropriate universal precautions
oropharynx, and ventilate with 100% oxygen. apparel
 Hypoxemia: stop intubation attempt and  Connect the ambu bag and mask to oxygen
ventilate with 100% oxygen. emergency  Test the pilot balloon or the et, insert stylet and
lubricate tube.
 Test and tighten laryngoscope
 Position the patient
 Hyperoxygenate the patient with resuscitation
bag, mask 100%
 Assist physician as needed during intubation
with suctioning, patient repositioning; supplies,
cricoids pressure, and bag/mask ventilation.
 Monitor oxygen saturation using pulse ox.
notify ap if saturation falls below 90%
- Assist with reoxygenation
 Assure proper placement of ET through chest
expansion and auscultation of the chest
bilaterally for equal sounds (stet and ambu
bag) and the abdomen for evidence of
esophageal intubation.
- Keep the head of the bed elevated at
30 degrees after intubation
 Note level of the tube st the position of the lip
or teeth (cm)- document the cm
 Document: date and time, et tube size, et tube
level, position of tube and cuff pressure, Mech
vent settings as ordered by the physician
 Complications or adverse effects

Nursing the mechanically ventilated Patient

 Functions replacement for the bellows action
of the thoracic cage and diaphragm.
 Can maintain ventilation for prolonged periods
of time.
Indication
 Neuromuscular or neurogenic loss of
respiratory regulation.
 Usual reasons for intubation: airway
maintenance, secretion control., oxygenation
and ventilation.
In summary ……
 Failure to oxygenation & ventilation