SPECIAL POPULATIONSPECIAL POPULATION

By By

Yasmeen RahimYasmeen Rahim

OBJECTIVESOBJECTIVES By the end of this presentation, By the end of this presentation,

learners will be able to:learners will be able to: Identify special population for critical Identify special population for critical

care.care.Pediatric patientPediatric patientPregnant womanPregnant womanOld patientOld patientPost anesthesia patientPost anesthesia patient

PEDIATRIC PATIENTPEDIATRIC PATIENT

ANATOMICAL & ANATOMICAL & PHYSIOLOGICAL DIFFERENCE:PHYSIOLOGICAL DIFFERENCE:

VITAL SIGNS:VITAL SIGNS:• Normals change with ageNormals change with age• Children have high HR and RR to meet a need Children have high HR and RR to meet a need

of higher COof higher CO• Blood pressure is the last vital sign to change Blood pressure is the last vital sign to change

in a child with shock.in a child with shock.• Children can compensate up to 25% of blood Children can compensate up to 25% of blood

loss.loss.• Bradycardia is not well tolerated in young Bradycardia is not well tolerated in young

children and can be precipitated by hypoxia.children and can be precipitated by hypoxia.

CONTCONT

• It can be due to vagal stimulation for e.g. It can be due to vagal stimulation for e.g. while doing suctioning or while inserting NG while doing suctioning or while inserting NG tube.tube.

• Bradycardia is not acceptable because high Bradycardia is not acceptable because high cardiac output is needed to fulfill increase cardiac output is needed to fulfill increase metabolic demands of the body.metabolic demands of the body.

• Tachycardia can be a nonspecific response Tachycardia can be a nonspecific response to many conditions like fever, anxiety, to many conditions like fever, anxiety, shock, hypoxemia etc.shock, hypoxemia etc.

• Tachypnea might indicate respiratory Tachypnea might indicate respiratory distress for eg in fever and in seizures etc.distress for eg in fever and in seizures etc.

• Bradypnea may indicate respiratory arrest.Bradypnea may indicate respiratory arrest.

CONT.CONT. NEUROLOGICAL SYSTEM:NEUROLOGICAL SYSTEM:

• Needs to be age appropriateNeeds to be age appropriate• Head circumference measurement is Head circumference measurement is

important until 2 years of ageimportant until 2 years of age• Reflexes Reflexes

Grasp reflex, babinski reflex, rooting etc.Grasp reflex, babinski reflex, rooting etc.

• FontanelsFontanels Posterior fontanel close by 3 months and Posterior fontanel close by 3 months and

anterior closes by 9 – 18 months.anterior closes by 9 – 18 months. Fontanels are also used to assess hydration Fontanels are also used to assess hydration

status and ICP.status and ICP.

CONT.CONT.

• High risk for ineffective thermoregulationHigh risk for ineffective thermoregulation• Mental statusMental status

LOC is assessed whether child is arousable LOC is assessed whether child is arousable and orientedand oriented

Interaction with the environment Interaction with the environment Knows Mom and Dad Knows Mom and Dad Awake, looking aroundAwake, looking aroundAssessment should be same like adults but Assessment should be same like adults but

technique would be different.technique would be different.

CONT.CONT.

CARDIOVASCULAR SYSTEM:CARDIOVASCULAR SYSTEM:• Cardiac assessmentCardiac assessment• Skin colorSkin color

Peripheral cyanosis normal for newborn onlyPeripheral cyanosis normal for newborn only Central cyanosis always abnormalCentral cyanosis always abnormal Mottling – take into consideration room Mottling – take into consideration room

temperaturetemperature

• Capillary refill time is less then 2 Capillary refill time is less then 2 seconds seconds

• Estimated blood volume varies with age Estimated blood volume varies with age and body weight.and body weight.

CONT.CONT. RESPIRATORY SYSTEM:RESPIRATORY SYSTEM:

• Infants under 6 months are obligatory nose Infants under 6 months are obligatory nose breathersbreathers

• Smaller airway in diameter and length, easily Smaller airway in diameter and length, easily occludeocclude

• Nurse must avoid over extending or over Nurse must avoid over extending or over flexing of neck because airway can easily flexing of neck because airway can easily occlude.occlude.

• Small roll should be kept behind the Small roll should be kept behind the shoulders to prevent obstruction.shoulders to prevent obstruction.

CONT.CONT.• Nurse should also look for nasal Nurse should also look for nasal

obstruction which can be caused by obstruction which can be caused by obstruction, secretions, edema, obstruction, secretions, edema, inflammation or poor NG taping. inflammation or poor NG taping.

• Watch for retractions Watch for retractions Abdominal breathing as their accessory Abdominal breathing as their accessory

muscles are not yet developed.muscles are not yet developed.

• Listen breath sounds, look for chest rise Listen breath sounds, look for chest rise and fall.and fall.

Stridor Stridor Wheezing for soundsWheezing for sounds If unequal then suspect Pnuemothorax or If unequal then suspect Pnuemothorax or

atelactasis or ETT obstruction or dislodgement. atelactasis or ETT obstruction or dislodgement.

CONT.CONT.

GASTROINTESTINAL SYSTEM:GASTROINTESTINAL SYSTEM:• Protuberant abdomen but different causes of Protuberant abdomen but different causes of

abdominal distention. abdominal distention. • Abdominal girth is measured every shift Abdominal girth is measured every shift • Stomach capacity varies with the age of the Stomach capacity varies with the age of the

child therefore feeding should be of an child therefore feeding should be of an appropriate amount.appropriate amount.

• Newborn stomach capacity is 90 ml, 1 month Newborn stomach capacity is 90 ml, 1 month old is 150 ml, 12 month old is 360 mlold is 150 ml, 12 month old is 360 ml

• If child is receiving chest physiotherapy then If child is receiving chest physiotherapy then NG aspiration should be check to avoid NG aspiration should be check to avoid aspiration.aspiration.

CONT.CONT. RENAL SYSTEM:RENAL SYSTEM:

• Normal urine outputNormal urine output Infants: 2mL/kg/hourInfants: 2mL/kg/hour

• Decreased ability to concentrate urineDecreased ability to concentrate urine

ChildrenChildren: : 1mL/kg/hour1mL/kg/hour Adolescents: 0.5ml/kg/hourAdolescents: 0.5ml/kg/hour

• Increased risk of dehydration Increased risk of dehydration Dry mucous membranes Dry mucous membranes Poor skin turgor Poor skin turgor Sunken fontanelsSunken fontanels Decrease urine outputDecrease urine output Increase urine concentrationIncrease urine concentration

CONT.CONT.

ENDOCRINE SYSTEM:ENDOCRINE SYSTEM:• Increase glucose demand because Increase glucose demand because

of large brain to body size ratio.of large brain to body size ratio.• Smaller glycogen stores.Smaller glycogen stores.• Children are more prone to develop Children are more prone to develop

hypoglycemia.hypoglycemia.• Blood glucose levels should be Blood glucose levels should be

closely monitored.closely monitored.

CONT.CONT. IMMUNE SYSTEM:IMMUNE SYSTEM:

• Children and infants are more prone to Children and infants are more prone to get infections.get infections.

• Skin is thinner so provide less barrier to Skin is thinner so provide less barrier to pathogens.pathogens.

• Children may not demonstrate fever and Children may not demonstrate fever and leukocytosis in response to infection leukocytosis in response to infection (fewer stored neutrophils)(fewer stored neutrophils)

• Signs should observe like altered Signs should observe like altered feeding behavior, hypothermia, altered feeding behavior, hypothermia, altered glucose metabolism etc.glucose metabolism etc.

CONT.CONT.

INTEGUMENTARY SYSTEM:INTEGUMENTARY SYSTEM:• Skin, hair, nails and glands of children Skin, hair, nails and glands of children

depends upon the age of children.depends upon the age of children.• They have less adipose tissues therefore They have less adipose tissues therefore

they are more prone to get they are more prone to get hypothermia.hypothermia.

• Sweat gland not functional until 1 month Sweat gland not functional until 1 month of ageof age

• Bruises should be noticed deeply for Bruises should be noticed deeply for location and color changes as it can be location and color changes as it can be associated with abuse.associated with abuse.

OTHER CHALLANGESOTHER CHALLANGES

Ventilatory issuesVentilatory issues• Respiratory distress, bag mask Respiratory distress, bag mask

ventilation and ETT intubationventilation and ETT intubation Medication administrationMedication administration

• According to body weightAccording to body weight Pain managementPain management

• Pain assessment scalesPain assessment scales Interaction with children and familyInteraction with children and family

PREGNANT WOMANPREGNANT WOMAN

PHYSIOLOGICAL CHANGESPHYSIOLOGICAL CHANGES

CARDIOVASCULAR CHANGES:CARDIOVASCULAR CHANGES:• Maternal blood volume increases 40% to Maternal blood volume increases 40% to

50% above baseline.50% above baseline.• Increase in cardiac output of 30% to Increase in cardiac output of 30% to

50%.50%.• Blood pressure during pregnancy is Blood pressure during pregnancy is

affected by maternal position. affected by maternal position. • Side lying position is usually Side lying position is usually

recommended.recommended.

CONT.CONT. RESPIRATORY CHANGES:RESPIRATORY CHANGES:

• Respiratory changes occur to Respiratory changes occur to accommodate the enlarged uterus and accommodate the enlarged uterus and the increased oxygen demands of the the increased oxygen demands of the mother and fetus.mother and fetus.

• Oxygen consumption increases by 15% Oxygen consumption increases by 15% to 20% during pregnancy to 20% during pregnancy

• Respiratory rate remains unchanged, Respiratory rate remains unchanged, although some women experience although some women experience tachypnea or shortness of breath at tachypnea or shortness of breath at some time during their pregnancy some time during their pregnancy

CONT.CONT.

RENAL SYSTEM:RENAL SYSTEM:• Renal blood flow increases by 30% Renal blood flow increases by 30% • Glomerular filtration rate (GFR) Glomerular filtration rate (GFR)

increases by 50% to increases by 50% to accommodate the increase in metabolic and circulatory requirements of pregnancy.

• These increases allow elevations in the These increases allow elevations in the clearance of many substances, such as clearance of many substances, such as creatinine and urea, and are reflected in creatinine and urea, and are reflected in lower serum levels lower serum levels

CONT.CONT.

GASTROINTESTINAL & METABOLIC GASTROINTESTINAL & METABOLIC CHANGES:CHANGES:• The pregnant woman is prone to passive The pregnant woman is prone to passive

regurgitation and aspirationregurgitation and aspiration• Smooth muscle relaxation contributes to Smooth muscle relaxation contributes to

nausea, heartburn, and constipation. nausea, heartburn, and constipation. • Hepatic and maternal fasting blood Hepatic and maternal fasting blood

glucose levels decrease owing to the glucose levels decrease owing to the constant transfer of glucose to the fetus constant transfer of glucose to the fetus

CONT.CONT.

HEMATOLOGICAL CHANGES:HEMATOLOGICAL CHANGES:• Hematocrit values decreases because of Hematocrit values decreases because of

hemodilution effect of increase plasma.hemodilution effect of increase plasma.• White blood cell count is increased White blood cell count is increased from

the normal range of 5,000 to 10,000/mm3 to 6,000 to 16,000/mm3..

• Bleeding, clotting time and platelet counts Bleeding, clotting time and platelet counts remain same throughout the pregnancy.remain same throughout the pregnancy.

CONT.CONT.

FETAL AND PLACENTAL FETAL AND PLACENTAL DEVELOPMENTAL CONSIDERATION:DEVELOPMENTAL CONSIDERATION:• Treatment decisions should be carefully Treatment decisions should be carefully

taken.taken.• Teratogens and teratogenic effect.Teratogens and teratogenic effect.• Placental functions depends on maternal Placental functions depends on maternal

blood flow.blood flow.• Hypertension, cocaine, smoking, Hypertension, cocaine, smoking,

alcoholism can cause vasoconstrictionalcoholism can cause vasoconstriction

CRITICAL CARE COMPLICATIONCRITICAL CARE COMPLICATION Severe pre - eclampsia (hypertension, Severe pre - eclampsia (hypertension,

edema and proteinuria)edema and proteinuria)**hypertension greater than 140 / 90 and severe hypertension greater than 140 / 90 and severe

greater than 160 / 110greater than 160 / 110 HELLP syndrome– Hemolysis, elevated HELLP syndrome– Hemolysis, elevated

liver enzymes and low plateletsliver enzymes and low platelets DIC – Disseminated intravascular DIC – Disseminated intravascular

coagulation coagulation Amniotic fluid embolus Amniotic fluid embolus ARDS – Acute respiratory distress ARDS – Acute respiratory distress

syndromesyndrome TraumaTrauma

CRITICALLY ILL OLDER CRITICALLY ILL OLDER

The leading causes of death among The leading causes of death among older patients are heart disease, older patients are heart disease, malignant neoplasms, malignant neoplasms, cerebrovascular accidents, influenza, cerebrovascular accidents, influenza, and chronic obstructive pulmonary and chronic obstructive pulmonary disease. disease.

When older adults have acute When older adults have acute exacerbations of their diseases, they exacerbations of their diseases, they often require hospitalization in an often require hospitalization in an intensive care unit (ICU) intensive care unit (ICU)

CONT.CONT.

Critical care nurses need to Critical care nurses need to understand the many physiological understand the many physiological changes that occur normally with changes that occur normally with aging. aging.

These age-related changes put the These age-related changes put the critically ill older adult at increased critically ill older adult at increased risk for complications. risk for complications.

CONT.CONT. BIOLOGICAL ISSUES:BIOLOGICAL ISSUES:

• Reduced resistance to stressReduced resistance to stress• Poor tolerance of extremes of heat and cold Poor tolerance of extremes of heat and cold

because of hypothalamic and skin changesbecause of hypothalamic and skin changes• Greater fluctuation in blood PhGreater fluctuation in blood Ph• The amount of connective and collagen tissue The amount of connective and collagen tissue

is increased.is increased.• Cellular elements in the nervous system, Cellular elements in the nervous system,

muscles, and other vital organs disappear.muscles, and other vital organs disappear.• The number of normally functioning cells is The number of normally functioning cells is

reduced.reduced.• The amount of fat is increased.The amount of fat is increased.

CONT.CONT.• Oxygen use is decreased.Oxygen use is decreased.• During rest, the amount of blood pumped is During rest, the amount of blood pumped is

decreased.decreased.• Less air is expired by the lungs.Less air is expired by the lungs.• Excretion of hormones is decreased.Excretion of hormones is decreased.• Sensory and perceptual activity is decreased.Sensory and perceptual activity is decreased.• Absorption of lipids, proteins, and Absorption of lipids, proteins, and

carbohydrates is decreased.carbohydrates is decreased.• The arterial lumen thickens.The arterial lumen thickens.• Decrease in quality of sleep.Decrease in quality of sleep.

CONT.CONT.

PSYCHOSOCIAL ISSUES:PSYCHOSOCIAL ISSUES:• Deciding where and how to live for his Deciding where and how to live for his

or her remaining yearsor her remaining years• Providing sufficient incomeProviding sufficient income• Maintaining a maximum level of healthMaintaining a maximum level of health• Recognizing and feeling that he or she is Recognizing and feeling that he or she is

needed needed • Maintaining an adequate and satisfying Maintaining an adequate and satisfying

home environment relative to health home environment relative to health and economic status and economic status

CONT.CONT. PHYSICAL CHALLENGES:PHYSICAL CHALLENGES:

• Auditory changesAuditory changes• Visual changesVisual changes• Other sensory changes (decrease taste buds, loss Other sensory changes (decrease taste buds, loss

of tactile sensation etc)of tactile sensation etc)• Sleep changesSleep changes• Skin changesSkin changes• Cardiovascular changesCardiovascular changes• Respiratory changesRespiratory changes• Gastrointestinal changesGastrointestinal changes• Musculoskeletal changesMusculoskeletal changes• Renal changesRenal changes• Endocrine changesEndocrine changes• Immunological changesImmunological changes

POST ANESTHESIA PATIENTPOST ANESTHESIA PATIENT

POST ANESTHESIA PATIENTPOST ANESTHESIA PATIENT

The time immediately after surgery The time immediately after surgery is most crucial period in the patient’s is most crucial period in the patient’s recovery from anesthesia.recovery from anesthesia.

The nurse should know what The nurse should know what happens in operating room as it can happens in operating room as it can affect the patient's immediate affect the patient's immediate postoperative care.postoperative care.

Cont.Cont. Sedation:Sedation: An induced state of quiet, An induced state of quiet,

calm, or sleep by means of a medication.calm, or sleep by means of a medication. Minimal sedation:Minimal sedation: A state in which the A state in which the

patient responds normally to verbal patient responds normally to verbal stimuli. stimuli.

Moderate sedation:Moderate sedation: A drug-induced A drug-induced depression of consciousness during which depression of consciousness during which the patient responds purposefully to the patient responds purposefully to verbal commands either alone or in verbal commands either alone or in conjunction with tactile stimulation. The conjunction with tactile stimulation. The patient's protective reflexes remain intact.patient's protective reflexes remain intact.

Cont.Cont.

Deep sedation:Deep sedation: • A state during which the patient cannot A state during which the patient cannot

be easily aroused.be easily aroused.• Patient responds purposefully after Patient responds purposefully after

repeated or painful stimulation. repeated or painful stimulation. • Spontaneous ventilation and the ability Spontaneous ventilation and the ability

to maintain a patent airway may be to maintain a patent airway may be impaired.impaired.

Cont.Cont.

General anesthesia:General anesthesia: • A state during which a patient cannot be A state during which a patient cannot be

aroused, even by painful stimulation.aroused, even by painful stimulation.• The ability to independently maintain The ability to independently maintain

ventilatory function is often impaired.ventilatory function is often impaired.• Cardiovascular function may be Cardiovascular function may be

impaired.impaired.

Cont.Cont.

The initial parameters assessed by The initial parameters assessed by nurse are:nurse are:• Vital signs ( every 15 min)Vital signs ( every 15 min)• Pulse oximetryPulse oximetry• Level of consciousnessLevel of consciousness• Cardiac rhythmCardiac rhythm• Hemodynamic monitoringHemodynamic monitoring• Urine outputUrine output• Estimated blood lossEstimated blood loss

POTENTIAL PROBLEMS IN PAPPOTENTIAL PROBLEMS IN PAP

AIRWAY! AIRWAY! AIRWAY! AIRWAY!AIRWAY! AIRWAY! AIRWAY! AIRWAY! HypoventilationHypoventilation HypoxemiaHypoxemia Hypotension Hypotension HypertensionHypertension Cardiac dysrhythmiasCardiac dysrhythmias HypothermiaHypothermia HyperthermiaHyperthermia Nausea and vomitingNausea and vomiting Pain Pain

GROUP ACTIVITYGROUP ACTIVITY