The webinar link will appear here just before the session starts

Introduction

Unconscious patients are extremely vulnerable. They are dependent on those caring for them for safety, dignity and for all of the activities of daily living. They are often at increased risk due to the severity of their condition, the treatment they are receiving and inability to do things which most people take for granted. Issues to consider when caring for the unconscious patient include:

Vulnerability
Maintaining a patent airway (including artificial airways)
Invasive vascular devices such as arterial cannulas or central venous catheters - Line care is covered in the IPC module.
Pressure area care
Inability to swallow leading to issues with oral care
Inability to blink
Elimination
Personal hygiene

In addition to these issues the patient may often be able to hear although there may be reduced awareness of what is heard. Unconscious patients in areas such as critical care or emergency departments may also be accompanied by family and friends who are often extremely anxious.

The reasons for unconsciousness are varied, but for the purpose of this education package we will be considering patients who are COVID 19 positive with associated pneumonia and hypoxaemia requiring mechanical ventilation.

Try to use a systematic approach dependent on need. Here we are using a 'top to toe assessment' to guide you and highligh some of the complications patients may develop when they are critically ill.

Below is a summary of the main points of the webinar with a variety of linked resources for you to use as a foundation in your ICU journey.

Click here to watch a Recording of the Webinar presentation

Safety All hyperlinked images in this section are for equipment identification purposes only.

First things first, SAFETY, yours, the patients and your environment.

YOU

Have you had something to eat and drink prior to commencing your shift?
Have you used the bathroom?
Have you decontaminated your hands?
Have you corretly 'donned' your PPE?

PATIENT

Check the patients ID bracelet against their drug card and with the nurse or AHP who is handing over to you.
Check your infusions against your drug card ensuring infusions are in date and the correct drug, dose and concentration.
Check your infusion lines are in date, 12 hours for lipids and upto 72 hours for other infusions (check your local trust policy). All lines should be labelled with this information.
Check the ventilator settings against the observation chart to ensure a baseline.
Check arterial and central transducers, ensure these are re-zeroed on the phlebostatic axis (4th intercostal space or right atrium of the heart).

ENVIRONMENT

Situations can change rapidly in the critical care setting. Ensuring your environment is safe and you have checkyou emergency equipment is paramount for patient safety.

AIRWAY - do you have spare intubation equipment in your bed area or accessable in an emergency? This should consist of:
- Endotracheal tubes (ETT) in the same size as the patients, a size bigger and a size smaller.
- A cuff manometer - to ensure suff pressure is between 20-30 cmH₂O.
- ETT tape or spare ETT securing device to secure the ETT.
- A Laryngoscope handle with working batteries, and spare blades, size dependent on what was used to intubate the patient, this shoud be clean and protected by its sterile packaging with the conection end attached to the Laryngoscope handle. The light in the blade should be tested on each shift.
- 10ml syringe for inflation or deflation of the cuff on itubation or extubation.
- A pack of sterile gauze.
- Water-based lubricating gel.
- Oxygen mask with tubing.
- A pair of scissors.
- Closed cuircuit suction ensure the wall suction unit is working and set at a pressure in line with hospital policy. Ensure the canister is changed when it is 3/4 full or as per hospital policy.
- Yanker sucker

If the patient has a Tracheostomy you will also need:

- Spare Tracheostomy in the same size and a size smaller.
- Tracheal Dilators
- Spare inner cannula
- Spare Ties
- A hydrocolloid dressing
- A flange protection dressing if required.

BREATHING
- Spare emergency Oxygen port
- Waters circuit with bacterial filter (You should test this each shift with 15L O₂ to ensure full inflation)
- Have you checked your alarm limits?
CIRCULATION
- Ensure Central and Arterial Transducers are in date, have enough fluid left in the bag and that the pressure bag is inflated to a pressure of 300mmHg (this enables lines to stay patent with a flow of approximately 3mls/hr). The trasducer should be re zeroed post changing patients position and at the start of each shift.
- Have you checked your alarm limits?
MISCELANEOUS -
- Check all other equipment:
  - Continuous Renal Replacement Therapy (CRRT)
  - Under Water Sealed Chest Drains +/- low suction
  - Iner-aortic Ballon Pump
  - Extra Corporeal Membrane Oxygenation (ECMO)

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Essential Nursing Care

Communication

Take a moment to reflect....

How must it feel to be a patient on ICU?

You may be sedated but can you feel pain?

Do you have an awareness of what is happening around you?

Can you hear what is been said by nurses, doctors or other visitors?

How must it feel been a patients relative, being unable to see them due to restricted visiting or because they are in a risk group?

Communication within ICU are fundamentally one of the most important skills that we possess. The use of verbal communication and theraputic touch with an unconscious patient is a principal that can sometimes get forgotten when we are busy learning a new role. Remember, always tell the patient what you are going to do before you do it. Give lots of reassurance and remind the patient they are safe. Aim to keep your patient orientated to time and place. This is very important when someone is having a sedation hold or is more lightly sedated. Pick a good role model and see how they do it.

Eye Care

In the sedated patient blinking is impaired, when a patient is sedated and paralysed (treatment commonly required in patients with Acute Respiratory Distress Syndrome [ARDS]) blink responses are abscent. The atmosphere in ICU is very drying and this effects the eyes ability to stay moist. Patients eyes tend to become dry and sticky, add to that scleral oedema that can be caused by high pressure ventilation and it will not take long for a patients eyes to become infected. Below is Yorkshire and Humberside Region (2019) Eye Care in Critical Care Guide. This guide does not remove clinical judgement.

Eye Care in Critical Care.jpg

Mouth Care

Mouth care in the unconscious patient is paramount due to the inability to swallow plust having an ETT in situ. You are all experienced health care professionals who have given 1000's of episodes of care, there are a couple of things you need to consider before commencing mouth care.

Is their ETT secure? - If the ties become wet from salivation the tube can slip and become dislodged.
What is the patients clotting ? - Many critically ill patients develp a coagulopathy due to the progression of the disease process. Gums bleed extensivly in these cases.
Is the patient prescribed any kind of oral treatments such a Chlorhexidine or Nystating? - Remember Chlorhexidine neutralises the action of Nystating so you should alternate using these products.
Mouth care sponges, yes or no? - No, this is because the sponge can come off of the stick. Especially if the patient is lightly sedated and biting. Always use a soft bristled tooth brush, a babys first toothbrush are great for this as the not only have soft bristles they have a small head which is easier for navigating around the patients mouth.
Ensure you check the patients lips for pressure sores from the ETT. The ETT should be repositioned every 2-4 hours ( your experienced collegue will need to help you with this until you become competent.

The Yanker sucker is used to remove the debris of mouth care, if the patient is biting try using a soft suction catheter

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Nasogastric Tubes

The majority of patients in ICU will be NG fed. This is not only to provide nutrition, this is also a gut protection stratergy. Initially patients may have a Ryles Tube in situ, this is usually changed to a feeding tube once feeding is established.

When a patient is critically ill they can have issues with absorbing feed, gastric aspirate volume is checked every 4 hours. The theory behind this practice is to reduce the risk of aspiration. However, there is little evidence to support or contradict this practice. Your ICU will have guidance on the amount of gastric aspirate you return and how much you discard.

If a patient is having high volumes of gastric aspirate they may be rested for 6 hours and then feed will be recommenced. High gastric aspirates can occur for a number of reasons;

Ileus
Paralysing agents
Sepsis
Use of opioids - common side effect is vomiting.
Having a stimulated gag reflex.

Treatments for high gastric aspirated include administering prokinetic drugs such as IV Metocloprimide (mechanism of action - increases gastric motility and encourages stomach emptying) or low dose Erythromycin via NG tube (mechanism of action - increases gut motility).

All patients recieving NG feed should NOT be nursed flat, they shoud be head up at least 30-45 degrees. This reduces the risk of aspiration.

NG Tube Care

Ensure the tube is well secured at the nostril - if the tube migrates, the risk of aspiration increases.
Ensure the nostril is not developing and pressure sores - the nostril should be observed every shift.
Measure the external length of the NG tube each shift and document on your ICU chart.
Check pH of gastric aspirate every shift and before commencing feed. Follow trust policy.
Check the bag of NG feed at the start of your shift - ensure it is changed every 24 hours along with the giving set.
Dont forget to document your NG feed in the fluid balance section of the ICU chart.

Hygiene

All ICU patients should have a full bed bath and linnen change in a 24 hour period. You should consider cardiovascular and respiratory stability before commencing this. Check your local policy on the use of MRSA skin cleansing prophylaxis in the ICU patient. Due to the fever component of COVID 19 and the effects of antipyretic agents you may find your patients produce more perspiration and require more regular bathing. Perpiration will effect how well monitoring adheres to the patient, such as ECG dots and dressings.

Hair Washing

Always risk assess prior to commencing, things to consider;

Can the patient lay flat
Is their ETT secure
Have you stopped their NG feed, if so have you paused any insulin infusions - dont forget to recommence these once the procedure is over. If they have high gastric aspirates is it safe to lay the patient flat?
Could you use a shower cap rather than a full hair wash? This is easy if the patient has short hair but is more problematic with longer hair.

Wet Shaving

Does the patient have thier own razor and shaving foam?
Have you checked the patients clotting? If deranged, is it appropriate to shave them?
If you have to undo ETT ties to shave the patient ensure you have a collegue hold the ETT for you.
Ensure you move the ETT pilot ballon out of the way so as not to inadvertantly cut it.

Electric Shaving

Is the device charged?
Is it clean?
Again ask a collegue to help if you are undoing ETT ties.
Ensure you move the ETT pilot ballon out of the way so as not to inadvertantly cut it.

Skin Care

Does the patient have a skin care routine?
Do they have their own products? Use a water based emolient like E45 for patients without products.
Remember when applying moisturiser that areas treated will be less adherent so avoid areas on the chest where you will sick ECG dots.

Catheter Care

Ensure the size, type and date of insertion is documented on you ICU chart
Ensure drainage bags are labelled with either the date connected or the date of change - this is usually weekly but check your local policy.
Ensure catheters are secured to the patients leg with a stat lock.
Always used a closed system.
Only obtain catheter samples if clinically indicated, using the sample port and ANTT. Remember that a biofilm forms on a catheter within 24 hours so do not perform a dip stick test looking for infection of catheter stream urine. CSU should be sent to the laboratory for MC&S indicating clinical urinary symptoms.
Ensure when emptying the drainage bag you clean the drainage port with a detergent wipe before and after emptying.
You should observe the urethra for signs of pressure damage - this should not be an issue if the stat lock is used correctly.
Catheter care should be given regularly using plain water. If the urethra has a discharge, crustation or offensive smell increase frequency of cleaning. If there are clinical signs of infection then swab and send for MC&S.
Remember catheter associated urinary tract infection (CAUTI) could be catastrophic in your already critically ill patient.
Assess the need for a catheter on the patients daily review - if a patient is anuric, remove the catheter as this will become a source of infection. If urine production resumes you can recatheterise at that point, in discussion with a senior colleague.

Bowel Care

Due to critical illness most ICU patients will have an altered bowel habit. The type and consistency of stools will also change from the patients norm. Due to the pathophysiology of the disease process, the medication used to support the patient, decreased blood flow to the bowel and systemic oedema patients often suffer with loose stools. Loose stools are classed as a type 5, 6 or 7 on the 'Bristol Stool Chart'. To ensure stools are not infectious you should send a sample to the laboratory for MC&S after the second episode. Patients should not be commenced on antidiarrheal agents until we are sure the cause is not infective.

One of the issues with loose stools are the excoriating effects on the skin. This is very painful for the patient and is another potential source for infection.

There is a fine balance between constipation and diarrhoea in the critically ill patient. You should expect your patient to have their bowels opened once in a 24 hour period - check their normal bowel pattern or underlying bowel pathology such as inflamatory bowel disease. Does the patient have hemorrhoids or any other altered pathophysiology of the rectum or anus? If a patient has not had their bowels opend for 24 hours, is on establishe NG feeding and has bowel sounds you should perform a PR examination. If stools are felt medics may prescibe aperients such as laxatives or enemas. Once the patient starts having thier bowels opened we have to consider the patients skin integrity.

Use a barrier cream such as Cavilon to protect the patients skin.
Ensure any continence products have the correct absorbancy and are checked regularly.
Ensure your continence products are repositioned regularly to prevent pressure damage.
If the stools are a type 5, 6 or 7 consider a rectal bag or a bowel management system. You will require training if you are not competent in the use of these methods.
Clean the skin with a pH neutral cleanser - check you local policy for products.
Ensure you give catheter care post episode of incontinence.
Check the patients clotting prior to any PR examination.
Remember to explain to the patient what you are doing prior to touching them.

VTE Prophylaxis

ICU patients are at an incresed risk of venous thrombus embolism due to the nature of their illness. Patients are imobilised due to sedation and paralytic agents and are at a high risk of coagulopathy due to the disease process. This is compounded by the use of vasoactive drugs that are used to increase blood pressure by causing peripheral vasoconstriction. Some of the common ways you will see VTE prophylaxis utilised in ICU are;

Pressure Area Care

ICU patients have multiple reasons for having an increased risk of developing a pressure ulcer. These are identified but not limited to;

Reduced mobility
Poor nutritional intake
Vasoactive drugs reducing blood supply
Fever leading to skin moisture
Oedema
Hypoxia
Incontinence

Partiens should be repositioned every 2-4 hours depending on clinical condition. Ensure any tubing or wires are away from the patients skin. If a patient is too unstable to roll, try skin loading to relive pressure areas. Nurse on a pressure relieving matress, ensure there are no creases in the bottom sheet. Have an awareness that moving a patient increases their oxygen consumption and you may initially see sPO₂ drop. You can counteract this by pre oxygenating prior to the procedure. If you have ventilation issues with a patient tilted on their side you may need to reposition them back on their back.

The only time we do not reposition patients is when they are in the prone position. Patients should be left prone for upto 16 hours dependent on response. You would still skin load all accesable pressure areas 2 hourly.

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Prone Positioning

The North of England Critical Care Network (2019) describe;

"Lying PRONE is when we place a ventilated patient on to their front. The process of getting a patient onto their front is known as Proning.

Prone ventilation has been used for many years to improve oxygenation in the management of the critically unwell patient with Acute Respiratory Distress Syndrome (ARDS) (MacDonald and Armstrong, 2000). The physiological benefits of prone ventilation have been well described: with improved ventilation-perfusion mismatching, recruitment of dependent lung regions and enhanced drainage of tracheobronchial secretions.

Available evidence suggests that prone positioning must be considered early in the disease process of ARDS and acute lung injury.

The optimal duration of prone ventilation has not been identified; however there is meta-analysis study (Beitler, Shaefi, Montesi at al 2014) to suggest a fall in mortality in patients ventilated in the prone position for over 12 hours. It is therefore recommended to prone patients for a period of at least 12 hours up to 24 hours, ideally coordinating the periods of turning with increased numbers of medical and nursing staff.

The Collaborative Benchmarking Group have produced a Relative/Carer Information leaflet to explain why we are turning their loved one prone."

Thank you to our colleagues at Leeds Teaching Hospitals NHS Trust for providing this video.

Transfer to other Areas

Following initial resuscitation and stabilisation in hospital, critically ill patients frequently require transfer to another hospital. Indications for such transfers include specialist investigation or treatment not available in the referring unit, lack of availability of a staffed critical care bed and repatriation

West Yorkshire Critical Care Network have guidance on the Safe Transfer of ICU Patient's. You should not be transfering patients until you have been deemed competent to do so.

Thank you for taking part in the general care of the unconscious patient module. I hope you have found the information beneficial. Although you feel daunted at the moment in a month or two you will have forgotten what you were worried about. ICU is a steep learning curve for any health care professional, be kind to yourself and eachother, ask questions and act within your scope of practice. If you have any questions please access on of our online tutorial support sesions.

On a personal final note, thank you for stepping up to this challenge. Stay safe.

References

National Institute for Health and Care Excellence (2015) Urinary Tract Infection in Adults. [QS90]. Available Online at: https ://www.nice.org.uk/guidance/qs90 [Accessed 27/03/2020]
North Yorkshire and Humberside Critical Care Network (2019) Eye Care in Critical Care. Available Online at : https://portal.elfh.org.uk/Catalogue/Index?HierarchyId=0_45016&programmeId=45016 [Accessed 27/03/2020].
North Yorkshire and Humberside Critical Care Network (2019) Mouth Care in Critical Care. Available Online at : https ://portal.elfh.org.uk/Catalogue/Index?HierarchyId=0_45016&programmeId=45016 [Accessed 27/03/2020].
West Yorkshire Critical Care Operational Delivery Network (2019) Proning. Available Online at: https://www.wyccn.org/proning.html [Accessed 29/03/2020].
West Yorkshire Critical Care Operational Delivery Network (2019) Transfer of the Critically Ill Adult. Available Online at: https://www.wyccn.org/transfer1.html [Accessed 29/03/2020].
North Yorkshire and Humberside Critical Care Network (2019). Proning. Available Online at: https://www.wyccn.org/proning.html [Accessed 29/03/2020].