Navigating the ICU

Introduction vi
How This Book Helps Patients and Families ix
How to Use This Book x
1 The Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
The Nurses 1
The Doctors 2
The Nurse Practitioners and Physician Assistants 4
The Respiratory Therapists 4
The Pharmacists 5
The Physical and Occupational Therapists 5
The Speech- Language Pathologists 5
The Social Workers and Case Managers 6
The Ethics Committee/Ethicists 6
The Nurse Aides 6
Other Vital Staff Who May Be Regularly Seen in the ICU 7
2 A Typical Day . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
The Most Important Part of the Day to Be at the Bedside 8
The Schedule for the Day 9
The Staff Shift Change 10
3 The Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Why the ICU 11
Admission Into the ICU 12
Monitoring the Patient 13
Intravenous Access 14
Medication Pumps 16
Computers and Electronic Medical Records 17
Prefer Another Language 17
Visiting the Patient 17
Preventing Infection 18
Transfer Out of the ICU 20
4 Common Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Informed Consent—Explaining All the Options 21
Questions to Ask for Informed Consent 22
Capacity—Can the Patient Make Their Own Decisions 23
Arterial Line 25
Blood Transfusion 26
Bronchoscopy 28
Central Line 29
Chest Tube 31
Esophagogastroduodenoscopy (EGD) 32
Feeding Tube for the Short Term—Nasogastric (NG), Orogastric (OG), and
Nasoduodenal (ND) Tubes 34
Feeding Tube for the Long Term—Percutaneous Endoscopic Gastrostomy (PEG)
and Gastrostomy/Jejunostomy (G/J) Tubes 36
ContentsPeripherally Inserted Central Catheter (PICC) 38
Pulmonary Artery Catheter 39
Swallow Test 41
Tracheostomy 42
Urinary Catheter 44
Sterile Precautions 46
5 Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Medication Timing 48
Pain 49
Managing Pain Without Medicine 51
Pain Medicine 52
Patient- Controlled Analgesia: Patient- Controlled Pain Medicine 54
Vasoactive Medications: Controlling Blood Pressure 55
Sedation: Calming the Patient 56
Mild Sedation: Reducing Anxiety 56
Moderate Sedation: Relaxing the Patient During a Procedure 57
Deep Sedation: Relaxation During Extended Therapy 57
Paralytic: Preventing Patients From Working Against Themselves 59
6 Lab Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
What the Labs Can Tell About the Patient 62
Illnesses and Their Labs 62
Bleeding 62
Infection 63
Kidney Injury 64
Liver Injury 64
Heart Injury 64
Diabetes 65
Other Labs 65
7 Possible Side Effects of the ICU . . . . . . . . . . . . . . . . . . . . . . . . 66
Delirium: When the Patient Becomes Confused 66
Restraints: Restraining Movement for Safety 69
Pressure Injuries: Skin Breakdown From Pressure 72
8 Therapies for Common Issues . . . . . . . . . . . . . . . . . . . . . . . . . 74
Cooling the Patient 74
Warming the Patient 75
Hemodialysis and Continuous Renal Replacement Therapy 75
Basics About Breathing 78
First Steps to Improve Breathing 79
A Non-Rebreather Mask: Quick Increase in Oxygen Levels 80
Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway
Pressure (BiPAP): Aid for Sleep Apnea or High-Level Help for
Breathing Difficulty 81
High-Flow Nasal Cannula: High-Level Help for Breathing Difficulty 83
The Ventilator: Total Help Breathing 84
Respiratory Distress and Respiratory Failure: When Trouble Breathing
Turns Into Needing a Breathing Tube 86
Intubation: Inserting the Breathing Tube 86
9 Essentials for the ICU Patient . . . . . . . . . . . . . . . . . . . . . . . . . 89
Feeding: Providing Nutrition to Help Recovery 90Sedation: Relaxation During Extended Therapy 92
Thromboembolic Prevention: Preventing Blood Clots 93
Head of Bed Elevation: Preventing Lung Infections 95
Ulcer Prevention: Preventing Stomach Damage 96
Glucose Control: Managing Blood Sugar 96
Spontaneous Breathing Trial: Testing if the Breathing Tube Can Be Removed 97
Bowel Regimen: Promoting Bowel Movements 97
Indwelling Catheter Removal: Preventing Infection of Lines 98
De-escalation of Antibiotics: Targeting the Infection 98
The “Get to Know Me” Board: Helping Everyone Know the Patient 98
ICU Journal: Better Insight for Now and Later 99
Extubation: Removing the Breathing Tube 100
Early Mobility: Exercising ASAP 100
10 How to Help the Patient During Downtime . . . . . . . . . . . . . . 102
1 1 How to Prepare Now for a Better Life After Hospitalization . . . 105
Preventing and Overcoming Post- Intensive Care Syndrome 108
1 2 Where the Patient Recovers After the Hospital . . . . . . . . . . . 112
Long-Term Acute Care Hospital 113
Inpatient Rehabilitation Facility 113
Skilled Nursing Facility 113
Home Health 113
Outpatient Rehabilitation 113
Questions to Ask the ICU Team About Leaving the Hospital 114
1 3 Common Concerns and Helpful Tips . . . . . . . . . . . . . . . . . . . 116
What to Bring to the Hospital and What to Leave at Home 116
How to Make the ICU Stay More Comfortable 117
How to Communicate With the ICU Team 118
Not Allowed to Eat or Drink—Nil Per Os (NPO) 120
Unable to Visit the Patient 120
Strategies for Reducing the Costs of Treatment 122
Questions to Ask When Making a Decision 123
Second Opinion 125
Full Code and Do Not Attempt Resuscitation 126
What Happens if the Heart Stops for a Full Code Patient (Code Blue) 127
What Happens After Surviving a Code Blue 128
What Happens if a Patient May Be Having a Stroke (Code Stroke) 129
The Most Serious Types of Brain Injury 131
A Quick Guide to Organ Donation 133
1 4 Critical Questions That Determine the Right Care . . . . . . . . . 135
Goals of Care 135
Advance Care Planning 136
Durable Power of Attorney 137
Responsibilities When Making Decisions for the Patient 138
Living Will 139
Goal of Living Until Death 142
A Story of the Importance of Advance Care Planning 144
Physician Orders for Life- Sustaining Treatment (POLST or Medical OLST) 146
Helpful Online Resources to Organize Thoughts 146
If the Patient Cannot Respond, and the Family Does Not Know 1 5 Important Topics When Discussing
the End of the Patient’s Life . . . . . . . . . . . . . . . . . . . . . . . . . 149
If More Time Is Needed to Decide About the Right Path for the Patient 151
Comfort Care: A Focus on Patient Comfort as Death Nears 152
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Appendix 1 – Helpful Tool for Organizing Patient Details
or to Use During Rounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Appendix 2 – Journal Outline . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Appendix 3 – Get to Know Me Board . . . . . . . . . . . . . . . . . . . . . . 184
Appendix 4 – Questions to Ask When Making a Decision
About Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Figure Credits 186
Index 189