CRITICAL CARE NURSING PPT

CRITICAL CARE NURSING

Prepared By:

Nurhayati Mohamad Nor

CRITICAL 1. Crucial
CARE 2. Crisis
NURSING : 3. Emergency
CRITICAL 4. Serious
5. Requiring immediate action
6. Thorough and constant observation
7. Total dependent

(Oxford Dictionary)

Summary

CRITICAL • The care of seriously ill
CARE clients from point of injury or illness
NURSING until discharge from intensive care
• Deals with human
responses to life threatening
problems -trauma /major surgery

(Mary,L.S., Deborah, G.K. & Marthe, J.M. 2005)

CRITICAL CARE NURSE

1. Care for clients who are very ill
2. Provide direct one to one care
3. Responsible for making life-and death decision
4. At high risk of injury or illness from possible exposure to

infections
5. Communication skill is of optimal importance

CRITICALLY ILL
CLIENT

• At high risk for actual or
potential life- threatening
health problems

• More ill
• Required more intensive and

careful nursing care

DEFINITIONS

CRITICAL CARE :
• CRITICAL CARE IS A TERM USED

TO DESCRIBE AS THE CARE OF
PATIENTS WHO ARE EXTREMELY
ILL AND WHOSE CLINICAL
CONDITION IS UNSTABLE OR
POTENTIALLY UNSTABLE.

DEFINITIONS CRITICAL CARE UNIT :
IT IS DEFINED AS THE UNIT IN WHICH
COMPREHENSIVE CARE OF A CRITICALLY

ILL PATIENT WHICH IS DEEMED TO
RECOVERABLE STAGE IS CARRIED OUT.

DEFINITIONS

CRITICAL CARE NURSING : IT REFERS TO THOSE
COMPREHENSIVE, SPECIALIZED
AND INDIVIDUALIZED NURSING

CARE SERVICES WHICH ARE
RENDERED TO PATIENTS WITH
LIFE THREATENING CONDITIONS

AND THEIR FAMILIES.

Critical Care Technology

• ECG monitoring • Arterial Lines
• Oxygen Saturation • Ventilation
• Intracranial Pressure • Temperature

Monitoring • Extensive use of
• IABP
• Pulmonary Artery pharmaceuticals

Catheter

The Critical “Specialty dealing with
Care Nurse human responses to life-
threatening problems”
Requires Extensive
Knowledge and a
Continual Desire to Learn

Economic * <10% of hospital beds
Impact of ICU * 30% of acute care hospital cost
* >20% of hospital budget
(1994) * 1% of GNP expended for ICU care
With aging of the population

• Demand for critical care
service will increase

Historical Background

• World War II
• Shock wards established for

resuscitation
• Transfusion practices in

early stages
• After World war-II, nursing

shortage forced grouping of
postoperative patients in
recovery areas

Polio epidemic

• 1950’s: use of mechanical ventilation
(“iron lung”) for treatment of polio

• Development of respiratory intensive
care units

• At the same time, general ICU’s
developed for sick and postoperative
patients

History Continued

• Collaboration between nurses and
physicians

• 1950’s & 1960’s – CV Disease most
common diagnosis

• 1960’s – 30-40% mortality rate for
MI

• 1965 – 1st specialized ICU – The
Coronary Care Unit

• Emergence of Specialized ICU’s

Multidisciplinary
&

Collaborative approach to
ICU care

MEDICAL & NURSING DIRECTORS :

co-responsibility for ICU management
• a team approach : doctors, nurses, R/T, pharmacist
• use of standard, protocol, guideline consistent approach to all
issues
• dedication to coordination and communication for all aspects
of ICU management
• emphasis on research, education, ethical issues, patient
advocacy

Team • A multidisciplinary team
Dynamics to effectively attain
specified objective

• Physician team leader &
critical care nurse
manager

Critical Care Practice Pattern

• OPEN • CLOSED • TRANSITIONAL

Open Units Definition :

any attending physician with hospital
admitting privileges can be the
physician of record and direct ICU
care. (All other physicians are
consultants)

Disadvantage :

• lack of a cohesive plan
• Inconsistent night coverage
• Duplication of services

Closed Units Definition:
An intensivist is the physician of record for
ICU patients. (other physicians are
consultants), All orders & procedures
carried out by ICU staff
Advantage:

• improved efficiency
• standardized protocol for care
Disadvantage:
• potential to lock out private physician
• increase physician conflict

Transitional Definition:
Units intensives are locally present shared co-
managed care between ICU staff and private
physician ICU staff is a final common pathway for
orders and procedures
Advantage:
• reduce physician conflict, standard policies and

procedures usually present
Disadvantage:
• confusion and conflict regarding final authority

& responsibilities for patient care decision

ICU Model 1. Full-time intensivist model :
Care • - patient care is provided by an intensivist

2. Consultant intensivist model :

• - an intensivist consults for another physician to
coordinate or assist in critical care, but dose not
have primary responsibility for care

3. Multiple consultant model:

• - multiple specialists are involved in the patient
care, (esp. R/T doctors for ventilators), but none is
designated especially as the consultant intensivist

4. Single physician model :

• - primary physician provides all ICU care

A Good ICU 1. Well organized

2. Trust

3. Coordinated care
• Full-time intensivist: daily round
• protocol & policies (eg: how to
DC elective operation when bed
not available)
• bedside nurses ( master
degree)↑
• no intern

A Good ICU A team: doctors, nurses, R/T,
pharmacists

• led by full time intensivists
critical care trained available in
a timely fashion (24hr/day) no
competing clinical
responsibilities during duty

• closed units, if resources allow

What are the conditions considered as Critical?

1. ANY PERSON WITH LIFE THREATENING CONDITION

2. PATIENTS WITH :

• ARF
• AMI
• CARDIAC TAMPONATE
• SEVERE SHOCK
• HEART BLOCK
• ACUTE RENAL FAILURE
• POLY TRAUMA, MULTIPLE ORGAN FAILURE AND ORGAN DYSFUNCTION
• SEVERE BURNS

NURSING IT IS THE FIRST STAGE OF NURSING
ASSESSMENT PROCESS IN WHICH THE NURSE
SHOULD CARRY OUT A COMPLETE
AND HOLISTIC NURSING ASSESS-
MENT OF EVERY PATIENT’S NEEDS,
REGARDLESS OF THE REASON FOR
THE ENCOUNTER

COMPONENTS OF NURSING ASSESSMENT

Nursing history
Psychological and Social Examination
Physical Examination
Documentation of Assessment

COMPONENTS Taking a nursing history prior to the physical
OF NURSING examination allows a nurse to establish a
ASSESSMENT : rapport with the patient and family.
Elements of the history include –
NURSING 1. Health Status
HISTORY 2. Cause of present illness including symptoms
3. Current management of illness
4. Past medical history including family’s

medical history
5. Social history
6. Perception of illness

COMPONENTS OF NURSING ASSESSMENT:
Psychological and Social Examination

Client’s Emotional Physical
perception health health

Spiritual Intellectual
health health

COMPONENTS OF NURSING ASSESSMENT:
Physical Examination

A nursing assessment includes physical examination, where the
observation or measurement of signs, which can be observed or
measured, or symptoms such as nausea or vertigo, which can be felt
by the patient.

The techniques used may include Inspection, Palpation, auscultation
and Percussion in addition to the vital signs like temperature, pulse,
respiration , BP and further examination of the body systems such as
the cardiovascular or musculoskeletal systems.

COMPONENTS The Assessment is
OF NURSING documented in the patient’s
ASSESSMENT : medical or nursing records,
Documentation which may be on paper or as
of Assessment part of the electronic
medical record which can be
assessed by all members of
the health care team.

CLASSIFICATION
OF

CRITICAL CARE
UNITS

CLASSIFICATION
OF CRITICAL
CARE UNITS

CLASSIFICATION OF CRITICAL
CARE PATIENTS

Level O : normal ward care
Level 1 : at risk of deteriorating , support from critical

care team
Level 2 : more observation or intervention, single

failing organ or post operative care
Level 3 : advanced respiratory support or basic

respiratory support ,multiorgan failure

HIGH Ø Coronary care units (CCU)
DEPENDENCY Ø Renal high dependency unit (HDU)
Ø Post-operative recovery room
CARE Ø Accident and emergency departments (A&E)
Ø Intensive care units (ICU)

• NEONATAL INTENSIVE UNIT (NICU) • SPECIAL CARE NURSERY (SCN)

• PAEDIATRIC INTENSIVE CARE UNIT (PICU) • PSYCHIATRIC INTENSIVE UNIT (PICU)

• CORONARY CARE UNIT (CCU) • CARDIAC SURGERY INTENSIVE CARE UNIT
(CSICU)
• CARDIOVASCULAR INTENSIVE CARE UNIT
(CVICU) • MEDICAL INTENSIVE CARE UNIT (MICU)

TYPES OF • MEDICAL SURGICAL INTENSIVE CARE UNIT • OVERNIGHT INTENSIVE RECOVERY (OIR)
CRITICAL (MSICU)
CARE UNIT
• NEUROSCIENCE / NEUROTRAUMA INTENSIVE • NEURO INTENSIVE CARE UNIT (NICU)
CARE UNIT (NICU)

• BURN INTENSIVE CARE UNIT (BNICU) • SURGICAL INTENSIVE CARE UNIT (SICU)

• TRAUMA INTENSIVE CARE UNIT (TICU) • SHOCK TRAUMA INTENSIVE CARE UNIT (STICU)

• TRAUMA – NEURO CRITICAL CARE INTENSIVE • RESPIRATORY INTENSIVE CARE UNIT (RICU
CARE UNIT (TNCC)

• GERIATRIC INTENSIVE CARE UNIT (GICU)

Types of ICU

General Medical Surgical Medical Surgical Specialized
Neonatal Intensive Care Intensive Care Intensive Care
Intensive Care Unit(MSICU)
Unit(NICU) Unit(MICU) Unit

Special Care Paediatric Coronary Care Cardiac Surgery
Nursery(SCN) Intensive Care Unit(CCU) Intensive Care
Unit(CSICU)
Unit(PICU)

Neuro Surgery Burn Intensive Trauma
Intensive Care Care Unit(BICU) Intensive Care
Unit(NSICU)
Unit

PRINCIPLES OF CRITICAL CARE NURSING

ANTICIPATION :
•The first principle in critical care is Anticipation.

•One has to recognize the high-risk patients and anticipate the requirements,
complications and be prepared to meet any emergency.

•Unit is properly organized in which all necessary equipment's and supplies are
mandatory for smooth running of the unit.

• The prognosis of the patient
depends on the early detection
EARLY of variation, prompt and
DETECTION appropriate action to prevent or
AND PROMPT combat complication.
Monitoring of cardiac respiratory
ACTION : function is of prime importance
in assessment.

COLLABORATIVE Critical Care, which has originated as
PRACTICE : technical sub-specialized body of
knowledge has evolved into a
comprehensive discipline requiring a very
specialized body of knowledge for the
physicians and nurses working in the
critical care unit fosters a partnerships for
decision making and ensures quality and
compassionate patient care. Collaborate
practice is more and more warranted for
critical care more than in any other field.

COMMUNICATION :

Intra professional, inter Collaborative practice of
departmental and inter communication model
personal communication

has a significant
importance in the smooth

running of unit.

Prevention of Infection :

Nosocomial infection cost a lot in the Critically ill patients requiring intensive
health care services. care are at a greater risk than other
patients due to the
immunocompromised state with the
antibiotic usage and stress, invasive

lines, mechanical ventilators, prolonged
stay and severity of illness and

environment of the critical unit itself.

Crisis Intervention and Stress Reduction :

partnerships are formulated during crisis.
Bonds between nurses, patients and families are stronger during
hospitalization.
As patient advocates, nurses assist the patient to express fear and
identify their grieving patttern and provide avenues for positive coping.

ORGANIZATION
OF
ICU

DESIGN OF Should be at a geographically distinct area within the hospital, with controlled
ICU : access.
There should be a single entry and exit. However, it is required to have emergency
exit points in case of emergency and disaster.
There should not be any through traffic of goods or hospital staff. Supply and
professional traffic should be separated from public/visitor traffic.
Safe, easy, fast transport of a critically sick pt should be a priority in planning its
location. Therefore, the ICU should be located in close proximity or ER, OT, trauma
ward etc.
Corridors, lifts and ramps should be spacious enough to provide easy movement of
bed/trolley of a critically sick patient.
Close, easy proximity is also desirable to diagnostic facilities, blood bank, pharmacy
etc.

BED It is recommended that total bed
STRENGTH: strength in ICU should be between
8-12 and not less than 6 or not
more than 24 in any case.
3-5 beds per 100 hospital beds for a
Level III ICU or 2 to 20% of the total
no of hospital beds.
1 isolation bed for every ICU beds.

BED AND ITS 150-200 sq.ft per open bed with 8
SPACE: ft in between beds.
225-250 sq.ft per bed if in a single
room.
Beds should be adjustable, no head
board, with side rails and wheels.

Keep bed 2 ft away from head wall.

ACCESSORIES:

3 O2 outlets, 3 suction outlets Storage by each bedside. Hand rinse solution by each Equipment shelf at the head end.
(gastric, tracheal and underwater bedside.

seal), 2 compressed air outlets
and 16 power outlets per bed.

Hooks and devices to hang Infusion pumps to be mounted Level II ICUs may require multi- ventilators, infusion pumps,
infusions/ blood bags, extended on stand or poles. channel invasive monitors. portable X ray unit, fluid and bed
from the ceiling with a sliding rail
warmers, portable light,
to position. defibrillators, anaesthesia
machines and difficult airway
management equipment's are

necessary.

1. Medical Staff – the best senior medical staff to be appointed as an
Intensive Care Director or Intensivist. Less preferred are other specialists
from anaesthesia / medicine who has clinical commitment elsewhere. Junior
staff are intensive care trainers and trainees on deputation from other
disciplines.
2. Nursing staff – The major teaching tertiary care ICU requires trained

STAFFING : nurses in critical care. The no of nurses ideally required for such unit is 1:1
ratio, however it might not be possible to have such members in our set up.
So 1 nurse for 2 patients is acceptable. The no of trained nurses should also
be worked out by the type of ICU, the workload and work statistics and type
of patient load.
3.Allied Services – Respiratory services, Nutritionist, Physiotherapist,
Biomedical engineer, technicians, computer programmer, clinical pharmacist,
social worker / counsellor and othersupport staff, guards and grade IV
workers.