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ICU Nursing - Comprehensive Clinical Notes

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1. THE FUNDAMENTALS OF CRITICAL CARE

• Continuous assessment and early recognition of deterioration
• Titration of life-sustaining therapies (ventilators, vasopressors, sedatives)
• Prevention of ICU-acquired complications (infections, delirium, weakness, pressure injuries)
• Coordination of the care team and family communication

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2. HEMODYNAMIC MONITORING

Key Monitored Parameters

Arterial Lines

• Continuous beat-to-beat blood pressure monitoring
• Frequent blood sampling without repeated punctures
• Check waveform quality; zero the transducer at the phlebostatic axis
• Monitor insertion site for signs of infection or ischemia

Chest Radiography in the ICU

• Up to 65% of ICU images show malposition of a monitoring device or significant cardiopulmonary change
• 35% show at least one clinically unsuspected finding leading to management change
• 43% of intubated medical ICU patients showed significant worsening or new abnormality on X-ray
• Daily routine CXRs are most valuable for patients with pulmonary or unstable cardiac disease (57% yield a management change in this group)

1. ETT position (tip should be 2-4 cm above carina)
2. Central line tip position (SVC/RA junction)
3. NG/OG tube position
4. Pneumothorax, pleural effusion
5. New infiltrates, consolidation, pulmonary edema

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3. MECHANICAL VENTILATION

Core Goals of Ventilatory Support

1. Maintain adequate gas exchange (oxygenation + ventilation)
2. Rest fatigued respiratory muscles
3. Reduce oxygen cost of breathing
4. Minimize ventilator-induced lung injury (VILI)

Ventilation Modes (Simplified)

Key Ventilator Settings (ICU Nurse Must Know)

Oxygen Targets

• Goal PaO2: 70-100 mmHg (conservative)
• SpO2 target: 94-98%
• Targeting very high PaO2 (>150 mmHg) is not recommended
• Targeting very low PaO2 (55-75 mmHg) also provides no benefit

Ventilator Alarms - Common Causes

Weaning & Extubation

• Daily Spontaneous Awakening Trial (SAT): Turn off sedation
• Daily Spontaneous Breathing Trial (SBT): PS/CPAP trial 30-120 min
• SAT + SBT bundle reduces ICU length of stay and mortality
• Extubation criteria: patient awake, following commands, protecting airway, can handle secretions, stable hemodynamics

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4. ARDS (ACUTE RESPIRATORY DISTRESS SYNDROME)

Definition

• Abrupt onset of diffuse lung injury
• Severe hypoxemia with bilateral pulmonary infiltrates
• NOT explained by left-heart failure
• Diagnosed by P/F ratio (PaO2 ÷ FiO2) with PEEP ≥ 5 cmH2O

Common Triggers

• Pneumonia, aspiration, sepsis (most common worldwide)
• Severe trauma, pancreatitis
• COVID-19 (dramatically increased ARDS incidence)

ARDS Nursing Management

1. Lung-protective ventilation: VT 6 mL/kg IBW, plateau pressure ≤ 30 cmH2O
2. Prone positioning for moderate-severe ARDS (P/F < 150): at least 12 hours/day - shown to reduce mortality
3. Neuromuscular blockade: May be needed for proning; intermittent bolus preferred over continuous infusion
4. Conservative fluid management: Avoid fluid overload
5. Monitor: SpO2, ABGs, plateau pressures, breath sounds
6. ECMO considered for severe ARDS failing conventional ventilation (at specialized centers)

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5. SEPSIS & SEPTIC SHOCK

Definitions

• Sepsis: Life-threatening organ dysfunction caused by dysregulated host response to infection
• Septic Shock: Sepsis + persistent hypotension requiring vasopressors + lactate > 2 mmol/L

Surviving Sepsis Bundle - Nursing Key Points

1. Measure lactate (remeasure if initial > 2 mmol/L)
2. Obtain blood cultures before antibiotics
3. Administer broad-spectrum antibiotics
4. Give 30 mL/kg IV crystalloid (balanced crystalloids preferred) for hypotension or lactate ≥ 4
5. Apply vasopressors if MAP < 65 mmHg

• Corticosteroids (hydrocortisone 200 mg/day) if shock persists despite adequate fluids + vasopressors
• Transfusion target: hemoglobin 7-9 g/dL (avoid over-transfusion unless active ischemia or hemorrhage)
• Serial lactate monitoring to assess resuscitation adequacy
• Source control: identify and control infection source promptly
• Head of bed elevation: 30-45 degrees semi-recumbent position (prevents VAP)
• Procalcitonin: do NOT use to start antibiotics, but CAN help guide de-escalation

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6. SEDATION, ANALGESIA & DELIRIUM (the "A-B-C-D-E-F" Bundle)

Principle: Analgesia First

RASS Scale (Richmond Agitation-Sedation Scale)

Sedative Agents - Comparison

ICU Delirium

• Hypoactive (most common, most missed) - quiet, withdrawn, appears "calm"
• Hyperactive - agitated, pulling tubes; often mistaken as the only form
• Mixed - fluctuates between both

• CAM-ICU (Confusion Assessment Method for ICU)
• ICDSC (Intensive Care Delirium Screening Checklist)

• A - Assess pain (treat first)
• B - Spontaneous Breathing Trials
• C - Choice of analgesia/sedation (minimize benzodiazepines)
• D - Delirium screening (CAM-ICU)
• E - Early mobility/Exercise
• F - Family engagement/sleep promotion (orient patient, daylight, reduce noise at night)

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7. FLUID & RESUSCITATION MANAGEMENT

• Balanced crystalloids (Lactated Ringer's, PlasmaLyte) preferred over normal saline for large-volume resuscitation (reduced risk of hyperchloremic metabolic acidosis)
• Avoid hetastarch (HES) - associated with renal failure and increased mortality in sepsis
• Blood products: Use 1:1:1 ratio (PRBCs:FFP:Platelets) in massive transfusion/hemorrhagic shock
• Monitoring fluid status: Dynamic measures (pulse pressure variation, stroke volume variation) are superior to static CVP for fluid responsiveness assessment
• Avoid fluid overload: Leads to visceral edema, impaired wound healing, prolonged ventilation, and organ dysfunction
• Once initial resuscitation is complete (typically 24-48 hours), transition to conservative/restrictive fluid strategy

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8. COMMON ICU COMPLICATIONS TO MONITOR & PREVENT

Ventilator-Associated Pneumonia (VAP)

1. Head of bed 30-45 degrees
2. Daily sedation vacation + extubation readiness assessment
3. Oral care with chlorhexidine
4. Subglottic secretion drainage (specialty ETTs)
5. Cuff pressure maintenance 20-30 cmH2O

ICU-Acquired Weakness (ICU-AW)

• Occurs due to prolonged immobility, corticosteroids, NMB use, and critical illness itself
• Prevention: early progressive mobility, minimize NMB, avoid corticosteroids when possible
• Assess with MRC scale at awakening
• Physiotherapy referral as early as Day 1-2

Pressure Injuries

• Reposition every 2 hours
• Use pressure-relieving surfaces (gel/foam mattresses)
• Inspect skin with every turn - especially heels, sacrum, occiput
• Nutritional optimization

Catheter-Associated UTI (CAUTI)

• Use urinary catheters only when indicated
• Daily review of catheter necessity
• Aseptic technique during insertion and care
• Maintain closed drainage system

Central Line-Associated Bloodstream Infection (CLABSI)

• Sterile technique during insertion (maximal barrier precautions)
• Chlorhexidine skin prep
• Daily assessment of line necessity
• Dressing changes per protocol (every 7 days or when soiled)
• Chlorhexidine-impregnated dressings

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9. COMMON CRITICAL DRIPS (Nurse Must Know)

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10. KEY LABS & MONITORING IN THE ICU

Arterial Blood Gas (ABG) Interpretation

Lactate

• Normal: < 2 mmol/L
• > 2 mmol/L: Concerning for tissue hypoperfusion
• > 4 mmol/L: Septic shock criterion; aggressive resuscitation
• Serial lactate trending is key - falling lactate = improving perfusion

Other Critical Labs to Monitor

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11. COPD EXACERBATION / ACUTE RESPIRATORY FAILURE IN THE ICU

• First choice for respiratory support: Non-invasive positive pressure ventilation (NIPPV/BiPAP)
  • Must monitor closely; improvement in pH and PaCO2 within 30 minutes to 2 hours predicts success
  • If pH < 7.25, declining mental status, or worsening oxygenation on NIPPV → proceed to intubation
• Intubation triggers: pH < 7.25, altered mental status, hemodynamic instability, inability to protect airway
• ICU mortality for COPD with acute respiratory failure: 6-20%
• Higher mortality if pH < 7.25 and invasive MV required

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12. NUTRITION IN THE ICU

• Early enteral nutrition (EN) within 24-48 hours of ICU admission - shown to reduce complications and improve outcomes
• Enteral route preferred over parenteral (TPN) when GI tract is functional
• Account for propofol caloric load (1.1 kcal/mL) in nutrition calculations
• Elevate HOB 30-45 degrees during feeds to reduce aspiration risk
• Monitor gastric residual volumes per protocol
• Correct electrolytes (K+, Mg2+, Phos) before refeeding - watch for refeeding syndrome

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13. COMMUNICATION & CARE COORDINATION

• Structured shift handoff (SBAR or I-PASS format) to prevent errors
• Goals of care conversations with family within 72 hours of ICU admission
• Integrate palliative care principles for prolonged ICU stays
• Daily ICU rounds: participate actively - report overnight events, current vitals, lines/drains, nursing concerns
• Document all assessments, interventions, and patient responses

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Quick Reference: ICU Nursing Assessment Framework (Head to Toe Each Shift)

NEURO:    RASS/GCS, pupil check, pain score (CPOT/NRS), delirium screen (CAM-ICU)
CARDIAC:  HR, rhythm, MAP/BP, peripheral pulses, cap refill, edema, vasopressor requirements
RESP:     SpO2, RR, breath sounds, vent settings (mode/VT/PEEP/FiO2), ETT position/cuff pressure
GI:       Bowel sounds, NG/OG position, EN tolerance, BMs, abdomen soft/distended
RENAL:    Urine output (goal ≥ 0.5 mL/kg/hr), creatinine trend, fluid balance
INTEGUMENTARY: Skin integrity, pressure injuries, wound sites, IV/line sites
LINES/TUBES: Necessity review daily, dressing integrity, securement, positioning
LABS:     ABG, lactate, CBC, metabolic panel, coagulation

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• Barash, Cullen & Stoelting's Clinical Anesthesia, 9th Edition
• Goldman-Cecil Medicine, International Edition
• Murray & Nadel's Textbook of Respiratory Medicine
• Fishman's Pulmonary Diseases and Disorders
• Sabiston Textbook of Surgery, 21st Edition