NCMB418 LECTURE:
06
BSN 4TH YEAR 1ST SEMESTER PRELIM 2023
Bachelor of Science in Nursing 4Y1
Professor: Michael Joseph Diño, PhD, MAN, RN, LPT
Prelim Topics:
• Introduction to Critical Care Nursing
• Quality & Safety in Critical Care
• American Heart Association Standards
• Electrocardiogram
• Basic Life Support (BLS)
• Advanced Cardiovascular Life Support (ACLS)
*kung ano lng tinuro ni sir sa f2f/ video lectures this prelim
INTRODUCTION TO CRITICAL CARE NURSING
Critical Care Nursing (CCrN)
- The delivery of specialized care to critically ill clients (with
life-threatening illness or injuries). Such patients may be
unstable, have complex needs, and require intensive and
vigilant nursing care.
- Examples of Critical ill clients:
• Who needs immediate surgery
• Post surgical
• With Comorbidities
• Diagnosed with diseases that affects multiple parts of
the body
• Emergency conditions
• Post accident
• Post-operative clients with major surgery
• Illness involving vital organs
• Stable clients with signs of impending doom
- Classification of Critical Care Clients:
• Level 0: normal ward care
• Level I: at risk of deteriorating
• Level II: needs more observation or intervention
• Level III: multisystem failure
- Critical care nurses are responsible for making sure that
critically ill patients and members of their families receive
close attention and the best care possible. (not only we
focus to the patient, we should also focus to their families/
significant others)
- In most instances, the critical ill clients are unconscious,
to check their consciousness, we need to ask questions to
the client, so that we can identify if the patient is conscious
or semiconscious.
- According to the AACCN (2019), the assessment of
critically ill patients and their families is an essential
competency for critical care practitioners. Information
obtained from assessment identifies the immediate and
future needs of the patient and family so a plan of care can
be initiated to address or resolve these problems.
• Critical: Crucial – Crisis – Emergency – Serious
• Critical Care Nursing – care of the seriously-ill clients
from point of injury/ illness until discharge from
intensive care
- Deals with human responses to life-threatening
problems
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Exam Week
- Comprehensive, specialized, and individualized
nursing services which are rendered to patients with
life-threatening conditions.
• Goals
- Survival of the critically ill patients and restoring
QUALITY of LIFE
- Helping families of critically ill patients in coping
with stress
- Some terms:
• ECC (Emergency Cardiovascular Care
• CPR (Cardiopulmonary resuscitation)
• ACLS (Advanced Cardiac Life Support)
Characteristics of a Critical Care Nurse
Attributes of critical care nurse = quality and behavior
Critical care nurses need to ACT
1) Advocate – a person who works on another person’s
behalf (protect his/her rights, assist with family decisions,
negotiate with other members of the healthcare team,
keeping patient and family informed)
2) Critical Thinker – a person with a complex mixture of
knowledge, intuition, logic, common sense, and
experience. (outstanding qualities)
3) Team Player – collaborates with other members of the
healthcare team to optimize patient outcomes.
4) Educator – facilitator of patient, family, and staff education.
Responsibilities of Critical Care Nurse
1) Assessment – constant assessment of patient and
equipment.
2) Planning – considerations: physiological and psychological.
(Prioritize physiological over psychological)
3) Implementation – interventions to existing and potential
problems. (Prioritize existing over potential problems,
current problem muna unahin)
4) Evaluation – patients response to interventions.
Multidisciplinary Teams in Critical Care
- Nurses working with critically ill patients commonly
collaborate with a multidisciplinary team of health care
professionals. The team approach enables caregivers to
better meet the diverse needs of individual patients.
- Members commonly include:
• Registered nurses,
• Doctors,
• Physician assistants,
• Advanced practice nurses such as clinical nurse
specialists and nurse practitioners,
• Patient care technicians,
• Respiratory therapists and others.
- Definitions:
 CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023
• Wound-ostomy-continence Nurse – skin integrity,
bowel and bladder
• Occupational Therapist – assess activities of daily
living
• Patient-care Technician – Direct patient care: bathes
the patient, vital signs and transportation
• Physical Therapist – Mobility and functional ability
• The Doctor – cardiologist, neurologist, pulmonologist
Rapid Response Teams (RRTs)
- The use of RRTs was identified as an evidence-based,
lifesaving strategy that would improve patient outcomes by
preventing avoidable patient deaths outside the critical
care areas.
- Most RRTs consist of a structured group and usually
include a critical care nurse, a respiratory therapist and,
possibly, a doctor who collaborate with the patient’s nurse
and intervene appropriately.
- The RRT may be called upon at any time (24/7) that a staff
member becomes concerned about a patient’s condition.
- Kapag nagka emergency or nag arrest un patient sa kahit
anong ward or part ng hospital, tatawagan ang RRTs. CODE
BLUE
Communication in Healthcare
- Because communication failures in health care can lead to
errors and serious adverse events, health care
professionals must pay close attention to communicating
effectively. Consistent use of a structured communication
tool, such as SBAR, improves the effectiveness of
communications, provides a safer environment for patients,
and pro- motes collegial relationships among health care
team members.
- SBAR is a communication tool for ensuring that the right
information gets to the right person in the most clear,
concise, and effective way.
- Initially, it was used in military. It is a structured
communication tool used as a framework for improving
interprofessional communication and patient safety. As a
tool, it meets the quality requirements for safe and
effective clinical documentation of care.
- SBAR also improves the effectiveness of communications,
provides a safer environment for patients, and promotes
collegial relationships among healthcare team members.
S Situation What is going on at the present time?
B Background What has happened in the past and is
relevant to this situation?
A Assessment What do you think is happening?
R Recommendation What do you think needs to be done?
- SBAR Example: Nurse Calling a Physician: "Dr. Garci, this
is Nurse Gloria, I am calling from Fatima University Medical
Center about your patient Renato. (S) Here’s the situation:
Renato is having increasing dyspnea and is complaining of
chest pain. (B) The supporting background information is
that he had a total knee replacement two days ago. About
two hours ago he began complaining of chest pain. His
pulse is 120 and his blood pressure is 128 over 54. He is
restless and short of breath. (A) My assessment of the
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situation is that he may be having a cardiac event or a
pulmonary embolism. (R) I recommend that you see him
immediately and that we start his on O2 stat. Do you
agree?”
Critical Assessment Process
Phase 1: Pre-arrival Assessment
- Begins at the moment the information is received about the
upcoming admission of the patient. (Otw plng si patient sa
hospital)
- It provides baseline perspectives of the patient and helps
nurses to predict the patient’s health needs and the
possible resources and setup that will be needed.
- Determines the possible picture of the client and his or her
needs. (anticipate possible resources needed by the
patient)
- Starts as soon as the nurse becomes aware of a patient
coming in the ICU, whether from the ward, operating room
or emergency room
- Usual documentation – abbreviated report on patient
• Patient: Age, Gender, Chief Complaint, Diagnosis,
Pertinent history, Physiologic status, Invasive devices,
Equipment, Laboratory/ diagnostic tests.
• Environment: Setup, Equipment Functioning: ECG and
electrodes Sphygmomanometer Pulse oxymeter
Suction machine ad catheters Bag valve mask device
Oxygenation equipment IV poles and infusion pumps
Bedside supply cart Admission kit Forms and care
documentations
- Critical care nurse responsibilities:
1) Patient (Client)
- U need to gather as much of information that u can
get from the patient while he/she is prearrival
(before the patient arrives)
2) Environment (Hospital Equipment)
- U need to prepare the hospi equiments na pwede
gamitin sa patient. Ang pinaka importante na dapat
iprepare ay FRC
- Hospital Equipment: FRC
1) Fluid – IV Pole, IV Fluids, Infusion pump, Syringe pump
2) Respi – Suction machine, Catheters, Bag valve, Oxygen,
Pulse oximeter, Ventilator
3) Cardio – ECG, electrodes, Sphygmo, Defibrillator, AED
 CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023

- Defines the status of the patient prior to the illness

- Assessment data includes:
• P – Past Medical Hx Medical conditions, Laboratory
procedures, Hospitalizations, Medications, Allergies,
Review of Body Systems
• S – Social Hx Age, Gender, Ethnic origin, Height, Weight,
Education, Occupation, Marital Status, Religion,
Significant others, Substance abuse, Domestic abuse
• P – Psychological Communication, Coping Styles,
Anxiety, Stress, Family needs
• S – Spirituality Faith/preference, Spiritual practices
• PA – Physical Assessment
o Nervous – GCS scoring, pupil assessment, LOC,
trauma
o Cardiovascular – check for pulses, check perfusion
o Respiratory – breathing pattern, arterial blood gas
result, auscultation, secretions
o Urinary – amount, color, odor, Dx: BUN/ Crea/ UA
o Gastrointestinal – nutrition, hydration status,
contour and symmetry of abdomen
o Integumentary – check the integrity, ulcer
Phase 2: Admission Quick Check
Phase 4: Ongoing Assessment
- Starts immediately upon arrival of the patient.
-
- General appearance of the client is checked (i.e.
- An abbreviated version of the comprehensive admission
consciousness or responsiveness, allergies, etc.)
assessment performed by the nurse at varying intervals.
- It is a quick overview of ventilation (respiratory), circulation
(short version ng comprehensive admission, to check if ur
(cardiac), and chief complaint (diagnostic tests and
client is responding well to the interventions)
equipment).
- Performed as long as the client is in the hospital,
- Common diagnostic tests include: (a) serum electrolytes,
- Continuous assessment is necessary to determine
(b) glucose, (c) CBC with platelets, (d) coagulation studies,
outcome of the client’s disease
(e) arterial blood gases, (f) chest x-ray, and (g) ECG.
- It is based on how frequent the patient should be assessed.
- Based on the parameters represented by ABCDE:
• For unstable patients: every 15 minutes
• A – Airway
• For stable patients: every 2-4 hours.
o Patency Position of artificial airway
- Assessment frequency:
• B – Breathing
• Stability – Ability to maintain equilibrium.
o Quantity and quality of respirations
• Complexity – Entanglement of 2 or more systems (mas
o Breath sounds
frequent ang assessment mo sa patient na maraming
o Spontaneous breathing (presence)
systems ang affected)
• C – Circulation, Cerebral Perfusion, Chief Complaint
• Predictability – Expectations on a certain course or
o ECG
events. (if u r expecting that the client will experience an
o Blood pressure
event, u need to frequently assess the patient. Yung
o Peripheral pulses, capillary refill
feeling mo, nagchicheat na sayo ung jowa mo, so
o Skin color, temperature, moisture
kailangan mo sya icheck lagi, or kaya sundan mo kung
o Bleeding (presence)
saan sya pupunta HAHA charot)
o Level of consciousness, responsiveness
• Vulnerability – Susceptibility to actual or potential
• D – Drugs, Diagnostic Tests
stressors
o Drugs prior to admission
• Resiliency – Capacity to return to a restorative level of
o Current medication
functioning (Ex: 35 y/o or 84 y/o patient, mas frequent
o Diagnostic test results
mo iassess ung 84 y/o patient kasi mas resilient ung
• Equipment
younger kaysa sa older)
o Patency of vascular and drainage system
o Equipment functioning and labeling
American Heart Association Standards
Phase 3: Comprehensive Admission Assessment
The BLS Survey (Arrest)
- An in-depth assessment of the past medical and social
- The BLS Survey is a systematic approach to basic life
history and a complete physical examination of each body
support that any trained healthcare provider can perform.
system.
- This approach stresses early CPR and early defibrillation. It
- Physical assessment is usually by system approach
does not include advanced interventions such as advanced
- Psychosocial assessment is performed, too, as this could
airway technique or drug administration.
determine prognosis
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 CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023

- By using the BLS Survey, healthcare providers may achieve Survey Code Action
their goal of supporting or restoring effective oxygenation, V Visualize
ventilation and circulation until the Return of Spontaneous Verbalize Vital Signs (HR, BP, RR, O2,
Circulation (ROSC) or initiation of ACLS interventions. T)
O Supplementary oxygen (below 94%):
Airway Nasal cannula (2-4 L/min)
Face Mask (2-10 L/min)
M Monitor (Pads on Chest) “White on
the right, Smoke over Fire”
Breathing Provide HRQCPR as needed Rhythm
Circulation intervention (slow, fast)

I Establish IV/IO
T Treat reversible causes (5 Hs and 5
Ts): 5Hs: Hypovolemia, Hypoxia,
Hydrogen Ion, Hyper/pokalemia,
Differential
Hypothermia 5Ts: Tension
Diagnosis
pneumothorax, Tamponade
(cardiac), Toxins, Thrombosis
(pulmonary/ coronary)

Return of Spontaneous Circulation (ROSC: Post Arrest)

- Return of spontaneous circulation (ROSC) is resumption of
sustained perfusing cardiac activity associated with
significant respiratory effort after cardiac arrest.
1) Check Responsiveness - Signs of ROSC include breathing, coughing, or movement
o Verbalization: Tap and shout “Are you alright?”; and a palpable pulse or a measurable blood pressure
o Check for absent or abnormal breathing (or only [PETCO 35-45]. Attachments:
gasping) by looking or scanning the chest movement (5-
10 seconds)
2) Activate Emergency Response
o Activate emergency response system and get an AED;
send someone to get an AED
3) Circulation
o Check carotid pulse for 5-10 seconds;
o If no pulse, start HQCPR (30:2) beginning with chest
compressions
o If there is pulse, start rescue breathing at 1 breath every
5-6 seconds (10-12 breaths per minute); - ROSC Assessment/ Interventions
o Check pulse every 2 minutes
• C – Circulation Fluids (PNSS/ PLRS) 1-2 L Perform 4
4) Defibrillation
point auscultation
o If no pulse, check for shockable rhythm with AED as
• AB – Airway Breathing Advanced airway Perform 5 point
soon as it arrives;
auscultation
o Follow each shock immediately with CPR, beginning
• D – Disability Therapeutic hypothermia: PNSS/PLRS,
with compressions
30cc/kg, 4 degrees Celsius 12-24 hours Core body
The ACLS Survey (Pre-Arrest)
temperature should be 32-34 degrees Celsius
- In the ACLS survey, the healthcare provider continue to
assess and perform an action appropriate until transfer to
the next level of care. Many times, team members perform
assessment and actions in ACLS simultaneously.
- An important component of this survey is the differential
diagnosis, where identification and treatment of the
underlying causes may be critical to patient outcome.
- REMEMBER! For unconscious patients, healthcare
providers should conduct the BLS Survey followed by ACLS
Survey. For conscious patients, providers should conduct
ACLS Survey first.

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 CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023
ETHICAL AND LEGAL CONSIDERATIONS IN CRITICAL CARE
NURSING
Foundations for Ethical Decision Making
1) Professional codes and standards
2) Institutional policies
3) Legal standards
4) Principles of ethics
a) Beneficence – best interest of the patient remains more
important than self-interest
b) Nonmaleficence – not only the will to do good but the
equal commitment to do no harm
c) Autonomy – freedom from external control;
acknowledge and protect a patient’s independence
d) Privacy – right of the patient to be free from unjustified
access by others
e) Confidentiality – protection of information; patient
information should be shared within the healthcare
team directly involved in patient care
f) Fidelity – agreement to keep promises
g) Veracity – being truthful or honest.
Contemporary Issues
1) Informed consent
- patients must make decisions based on accurate and
appropriate information; voluntary
- The client understands the nature of the treatment and
its advantages and disadvantages
- To indicate that NO COERCION was made before
signing
- To PROTECT the client against unauthorized procedure
- To PROTECT the surgeon and the hospital against legal
actions
a) Emancipated minor
• a college student living away from home
• in military service
• Pregnant
• Anybody who has given birth
b) Authorized representatives for:
• Minors
• Unconscious patients
• Psychologically incapacitated
EXEMPTIONS: if experts agreed that the care is an
EMERGENCY, has life-threatening conditions, or patient is
unconscious and authorized representative cannot be
reached
2) Determining capacity – reflects a medical decision on
patient’s functional ability to participate in the decision-
making process; patients are presumed to have the
determining capacity
3) Advance directives – statements made by a patient with
decision-making capacity describing the care of treatment
he/she wishes to receive when no longer competent
a) Treatment directives (“living will”) – specify in advance
his/her treatment choices and which interventions are
desired
b) Proxy directives – durable power of attorney for health
care
4) End of life care issues
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- end-of-life care includes physical, emotional, social,
and spiritual support for patients and their families
- Goal: to control pain and other symptoms to make the
patient as comfortable as possible; quality of life
a) Decisions to forego life-sustaining treatments
b) Nutrition and hydration
c) Pain management
d) Resuscitation decisions – DNR, DNI
5) Paternalism – deliberate restriction of autonomy by health
care professionals based on the idea that they know what
is best for the client
Forms of Advanced Directive
Determining Capacity
- Reflects a medical decision on patient’s functional ability to
participate in the decision-making process
- Patients are presumed to have the determining capacity
End-Of-Life-Issues
- Care given to patients who are near death and/or stopped
treatment to cure or control his/her disease.
- End-of life care includes physical, emotional, social, and
spiritual support for patients and their families
GOAL: To control pain and other symptoms to make the
patient as comfortable as possible: quality of life.
• Nutrition and Hydration
- Given through NGT, IV, or duodenal feedings, or
gastrostomy
- Continue if the nutrition and hydration status
expedite the patient’s return to an acceptable level
of functioning
- Discontinue if not beneficial.
• Pain management
- One of the main components of palliative care
- Done if there is a decision to forego life-sustaining
treatment
- “Should provide interventions to relieve pain and
other symptoms in the dying patient even when
those interventions entails risks of hastening death.”
ANA (Code for Nurses)
• Do Not Resuscitate (DNR) Orders
- Aka “no code”
- Withhold CPR
- No other heroic act to be perform on the patient
- Nurse documents participation in the discussion
Laws on Critical care Nursing
1) Scope of Nursing Practice based on R.A. 9173
2) Nurses’ Code of Ethics
3) Patient’s Bill of Rights and Obligations
4) Dying Patient’s Bill of Rights
***Senate Bill 586 - AN ACT PROVIDING PALLIATIVE AND END-
OF-LIFE CARE, APPROPRIATING FUNDS THEREFOR AND FOR
OTHER PURPOSES
The Process of Ethical Analysis (AACCN, 2019)
1) Assessment
a) Identify the problem – clarify the competing ethical
claims, conflicting obligations, and personal and
 CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023

professional values; acknowledge the emotional and Steps of Evidence-Based Nursing

communication issues
b) Gather data – distinguish the morally relevant facts,
including medical, nursing, legal, social, and
psychological facts; clarify patient’s religious and
philosophical beliefs and values
c) Identify the individuals involved in the problem’s
development and who should be involved in the
decision making; discern factors that may impede the
patient’s ability to make the decision
2) Plan
a) Consider all options and avoid restricting choices to the
most obvious
b) Identify the pros and cons (“harms and goods’)
c) Analyze if plan is in accordance with ethical theories
and principles
d) Look into institutional policies and/or procedures that
address the issue
3) Implementation – choose a plan and act (anticipate
objections)
4) Evaluation
a) Outline the results
b) Identify what harm or good occurred as a result
c) Identify necessary changes in the institutional
policy(ies) or other strategies to avoid similar issues in
the future
QUALITY & SAFETY IN CRITICAL CARE
Knowledge Translation
- Applying research in nursing practice
- Effective and timely exchange, synthesis and application of
knowledge among researchers and users to capture the
benefits of research
Step 1 – Ask Clinical Questions
PICOT Format – framing a clinical question in EBP
1) Population
- What are the characteristics and/or condition of the
group?
- Patient/ population of interest/ problem (start with the
patient, or group of patients, or problem)
2) Intervention
- What is the screening, assessment, treatment, or
service delivery model that you are considering.
- What is the proposed intervention?
3) Comparison
- What is the main alternative to the intervention,
assessment, or screening approach.
- (What is the main alternative, to compare with the
intervention? This might be no intervention.)
4) Outcome
- What do you want to accomplish, measure, or improve
- What is the anticipated or hoped-for outcome?
5) Time frame
- How long will it take to reach the desired outcome?
Example 1:
"I work in MICU where ventilator-related infections are a
common problem. I've heard that oral care of ventilated
patients even with water can help prevent this. I wonder if
there's any evidence for that and whether it might help our
patients?"
P – patients in MICU
I – water
C – oral care with water only
O – Prevention of ventilator-related infections
T - (will depend on the time frame set)

The SPIDER tool – can be used when dealing attitudes and

experiences rather than scientifically measurable data since it
focuses less on the intervention and more on the design.
Deals with "samples" rather than a "patient" or "populations".
1) S – ample (group of participants)
2) PI – phenomenon of interest (how and why of behaviors
and experiences)
Evidence-Based Nursing (EBN) 3) D – esign (how the study was devised and conducted)
- Under the umbrella of Evidence Based Practice 4) E – valuation (measurement of outcome; might be
- Definitions of evidence-based nursing have varied in subjective and not necessarily empirical)
scholarly literature 5) R – esearch Type (qualitative, or quantitative, or mixed)
- Application of the best available evidence often from Research questions framed using the SPIDER tool tend to
research findings into the clinical setting to ensure best begin with "What are the experiences of ...?"
practice Example: "What are the experiences of fourth year university
- Scott & McSherry’s extensive literature review looked at students in using their critical care units related learning
commonalities between EBN definitions and synthesized experience?"
them to come up with the following definition: “An ongoing S Fourth year university students
process by which evidence, nursing theory, and the PI CCUs RLE
practitioners’ clinical expertise are critically evaluated and D Survey
considered, in conjunction with patient involvement, to E Experiences (of having the RLE in CCUs)
provide delivery of optimum nursing care for the individual.” R Qualitative
(Melnyk, B, Fineout-Overholt, E., Stillwell, S., and
Williamson, K., 2010).

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 CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023

Step 2 – Gather Evidence

To describe if clinical practice is streamlined when questions
are asked
1) Internal Evidence
- Direct from client or institutions
2) External Evidence
- Scientific literatures; research database
- Kapag maghahanap ng research = Meta-analysis papers
3) Database
Step 3 – Assess the Evidence
- Once articles are selected for review, these must be rapidly
appraised to determine those most relevant, valid, reliable,
and applicable to the clinical question. (Guide: Are the
results of the study valid? What are the results and are they
important? Will the results help me care for my patients?)
- Iassess kung quality sya or hindi, kung applicable ba sya sa
setting mo
1) Internal Evidence – Does this study investigate a
population similar to my client?
2) External Evidence – Is your client demonstrating a
response to the intervention?
Step 4 – Make your Clinical Decision
- Synthesize the studies to determine if they come to similar
conclusions, thus supporting an EBP decision or change
- Research evidence alone is not sufficient to justify a
change in practice. Clinical expertise, based on patient
assessments, laboratory data, and data from outcomes
management programs, as well as patients' preferences
and values are important components of EBP
1) Define – Your clinical question
2) Extrapolate – Applicable information from external
evidence
3) Consider – Clinical expertise
4) Incorporate – Needs and perspectives of clients
5) Develop – Assessment & treatment plan
6) Evaluate – Your clinical decision

Forest plot
- An essential tool to summarize information on previously
published study findings.
- Research figure
- Invented by Richard Peto (Statistician and Epidemiologist, Pag nagcross ng line ung diamond = parehas lng, walang
University of Oxford) difference ang intervention
Pag hindi sya nag cross ng line = meron syang pagkakaiba

Salient Points to consider in the use of EBN Practice:

• Promotes use of EBP among advanced practice nurses and
direct care nurses
• Identifies a network of stakeholders who are supportive of
the EBP project
• Cognitive behavioral theory underpinnings
• Emphasis on healthcare organizational readiness and
identification of facilities and barriers
• Encompasses research, patient values, and clinical
expertise as evidence.

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 CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023
Quality and Safety Monitoring
1) Care bundles
- A group of 3-5 evidence-based interventions, when
performed together, have a better outcome than if
performed individually
- can be used to ensure the delivery of the minimum
standards of care
- can be used as an audit tool to assess the delivery of
interventions
- NOTE: cannot be used to assess how well individual
interventions are performed
- encourage the review of evidence and modification of
clinical care guidelines, engendering staff education in
best practice
- key principle = high level of adherence to all
components
- Example: The sepsis care bundle, part of the
international Surviving Sepsis campaign, is the most
widely utilized bundle.
2) Checklists
3) Continuous quality improvement
4) PDCA - Plan-Do-Check-Act (PDCA) cycle (Deming Cycle,
Shewhart Cycle)
- a management tool for continuous improvement of a
business's products or processes. It can be applied to
standardize nursing management and thus improve the
nursing quality and increase the survival rate of patients
- Uses: implementation of change, solve problems, and
continuously improve nursing management processes
- cyclical nature; allows it to be utilized in a continuous
manner for ongoing improvement
P - PLAN the change or improvement
D – DO = conduct a pilot test of the change
C – CHECK = gather data about the pilot change to
ensure the change was successful
A – ACT = implement the change on a broader scale;
continue to monitor the change and repeat as
necessary by repeating the cycle
- Expertise Required: easy to use and requires little or no
training.
- Advantages:
• Makes sure that all appropriate steps are followed.
• Offers a systematic improvement method.
• Is an effective process improvement guide.
• Informs future improvement by providing feedback.
• Maintains order during problem solving.
- Disadvantage: Requires significant commitment over
time.
Multidisciplinary plans of care
- benefits to both patients and the hospital system:
1) Improve patient’s outcome
2) Increased quality and continuity of care
3) Improve communications and collaboration
4) Identification of hospital system problems
5) Coordination of necessary services and reduced
duplication
6) Prioritization of activities
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7) Reduce length of stay and health care costs.
Format for the multidisciplinary approach categories:
1) Discharge outcomes
2) Patient goals
3) Assessment and evaluation
4) Consultations
5) Tests
6) Medications
7) Nutrition
8) Activity
9) Education
10) Discharge planning
NOTE: Primary consideration = patient’s safety
Information and communication technologies in CCU
1) Clinical Information System
2) Computerized provider order entry (CPOE)
3) Hand-held Technologies
4) Tele-health Initiatives (Tele-ICU)
Advocacy: Access to social care services
• PhilHealth
• DOH
• DSWD
• PAGCOR
• PCSO
AMERICAN HEART ASSOCIATION STANDARDS AND
ELECTROCARDIOGRAM
American Heart Association
- International organization based on the US.
- Organization that studies and give some best practices
when it comes to Cardiopulmonary Resuscitation (CPR)
and emergency cardiovascular care (ECC)
BLS SURVEY (ARREST)
- It is being done when the patient is unconscious.
- BLS survey means Basic Life Support Survey
- systematic approach to basic life support that any trained
healthcare provider can perform.
- This approach stresses early CPR and early defibrillation.
- It does not include advanced interventions such as
advanced airway technique or drug administration.
- By using the BLS Survey, healthcare providers may achieve
their goal of supporting or restoring effective oxygenation,
ventilation and circulation until the Return of Spontaneous
Circulation (ROSC) or initiation of ACLS interventions.
- NOTE: The first thing to do is to check alertness
1) Unresponsive/No normal breathing/ No breathing (only
gasping)
2) Check responsiveness (Hey, Hey, Hey are you okay?
Hey, hey, hey are you alright?)
3) Check if the scene is safe (NOTE: If outside the hospital)
4) Active emergency response (OUTSIDE: Ask someone to
get an AED or call 911)
5) Breathing and circulation (Check for carotid pulse for 6-
10 seconds while checking the rise and fall of the
chest.)
• Assess for 2 normal breaths w/in 10 seconds
• Depth of Compression: 5-6 cm deep
 CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023

• Allow for full chest recoil Electrocardiogram

• Chest compression should be steady and fast Cardiac Monitoring
• RATE: 100-120 bpm - provides continuous observation of the patient’s heart rate
• When giving chest compression, one hand and rhythm and is a routine nursing procedure in critical
(nondominant) is on the top of the other and care patients.
interlace it. Keep the arms straight with locking - It is common in (a) emergency units, post-anesthesia
elbows and place it on the center of the chest, lower recovery units and operating rooms.
side of the breastbone - Cardiac Monitor – A device that shows the electrical and
• When performing ventilation, tilt the head back, pressure waveforms of the cardiovascular system for
pinch the nose, and blow the victim’s mouth. Check measurement and treatment. Parameters specific to
the chest if there’s a return of its normal position respiratory function can also be measured.
while taking another breath. Repeat the cycle.
Minimize interruptions and chest compression to
last no more than 5 seconds.
• Alternate the 30 chest compressions and 2
ventilations until help arrives.
• If there’s 1 rescuer, switch position every 2-3
minutes
Scenario Pulse Breathing Response
Secondary
1 Yes Yes
Assessment
Rescue Breaths 1:5-6
2 Yes No
secs
3 No No CPR C: 30 B: 2
Reassess (impossible Electrocardiograph (ECG)
4 No Yes
to happen) - a graphic record or representation of the electrical activity
• Defibrillation (Use of Automated External of the heart muscles.
Defibrillator) When seeing signs regaining
consciousness, STOP CPR and put the victim into
recovery position
ACLS SURVEY (PRE-ARREST)
- It is being done with conscious patient.
- In the ACLS survey, the healthcare provider continues to
assess and perform an action appropriate until transfer to
the next level of care.
- Many times, team members perform assessment and
actions in ACLS simultaneously.
- An important component of this survey is the differential
diagnosis, where identification and treatment of the
underlying causes may be critical to patient outcome.
- REMEMBER: For unconscious patients, healthcare
(Namemeasure ‘yung O2 sat kapag may nakaattach sa patient
providers should conduct the BLS Survey followed by ACLS
na pulse oximeter. Nareread yung capnography ng patient
Survey. For conscious patients, providers should conduct
kapag may nakaattach na capnography device. Same with the
ACLS Survey first.
blood pressure, may nakaattach na sphygmomanometer sa
client to read the BP. ECG tracing may mga nakaattach ng
electrodes)
Electrode Placement
- Electrodes detect the tiny electrical changes on the skin
that arise from the heart muscle depolarizing during each
heartbeat.
- Electrodes are optimally placed directly on dry skin.
- To prevent unclear ECG tracing, the following preparations
are suggested:
a) Shaving the skin if necessary,
b) Removing dead skin cells by rubbing the area with a
rough paper or cloth,
c) Removing oil, grease and dirt using alcohol, and

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d) Using electrodes from airtight packages. Position Box size Equivalence

- In emergency situation, healthcare providers use 3 or 5 Horizontal Small 0.04 second
leads of electrodes because they have no plenty time to Large 0.20 second
attach those electrodes. Vertical Small 0.1 mV
Limb Leads Bipolar I, II, III Large 0.5 mV
Augmented aVR, aVL, aVF
Chest Leads Precordial V1, V2, V3, V4, V5, V6

• 3-Lead ECG System

- Attaching 3 electrodes on the patient’s chest.
- “White on the Right, Smoke over Fire”
• 5-Lead ECG System
- Attaching 5 electrodes on the patient’s chest
- “Snow over Grass, Melt Chocolate”
- Add the green and brown electrodes for 5-lead
electrodes.

The Normal ECG

A normal ECG contains traces of waves, intervals, segments,
and one complex:
Component Description Types
Positive (above) and P-wave, Q-wave,
negative (below) Rwave,
Wave
deflection S-wave, Twave
from baseline
The time between two PR interval, QRS
specific ECG events. interval, QT
Interval
interval,
ST interval
The length between PR-segment,
two specific points on STsegment,
Segment the ECG which are TP-segment
supposed to be at the
baseline amplitude
The combination of QRS complex
Complex Multiple waves
grouped together

Conduction System of the Heart

- The contraction and relaxation of cardiac muscle results
• V1 Fourth intercostal space at the right sternal edge from the depolarisation and repolarisation of myocardial
• V2 Fourth intercostal space at the left sternal edge cells.
• V3 Midway between V2 and V4 - The sinoatrial node acts as a natural pacemaker and
• V4 Fifth intercostal space in the mid-clavicular line initiates atrial depolarisation.
- The impulse is propagated to the ventricles by the
• V5 Left anterior axillary line at same horizontal level as V4
atrioventricular node and spreads in a coordinated fashion
• V6 Left mid-axillary line at same horizontal level as V4 & V5
throughout the ventricles via the specialised conducting
tissue of the His-Purkinje system.
The ECG Grid Paper/Strip
- The ECG grid on the paper consists of a series of small and
large boxes.
- Horizontal boxes measure time, while vertical boxes
measure voltage:

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 CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023

His-Purkinje Conduction system

(Nagpupump ang heart because of electrical impulses ng

heart and of course dahil ang heart is made up of muscles and
yung muscles na yon ay nakakareceived ng electrical activity
na nanggagaling sa SA node which came from the food that a
person’s ate and a lot of factors that contributes to that)

(The picture above ay parang wiring system ng heart kaya yung

electricity nagdidisperse sa buong heart kaya nagfufunction
ang heart)

(In a normal person, ang electricity ay naproproduce sa Sinus

Node. Kapag nag fail ang sinus node, magbaback up ang
atrioventricular node. There’s something wrong with the client.
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 CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023

Kapag nag failed ang atrioventricular node, UPPER WAVES P-wave, R-wave, T-wave
magcocompensate ang heart kaya kung ano ang natitirang LOWER WAVES Q-wave, S-wave
electricity sa purkinje fibers ayon lang ang gagamitin ng heart. Between P and R waves PR Interval
Malaking problema ito kasi puwedeng mag expire na ang Between Q, R, and S waves QRS Interval
patient) Between Q (lower) and T
QT Interval
(upper) waves
Between S and T waves ST Interval
At the end of P-wave and
PR Segment
before the start of R-wave
After S-wave and the start of
ST Segment
T-wave
After T-wave and towards to
TP Segment
the P-wave of the next cycle

Interpreting the ECG Strip: The 8-step Approach

(Ang flow ng electricity ay mayroong direction. SA node----
Atrioventricular Node----- Purkinje Fibers. Therefore, kapag
nagplace ng leads sa chest ng client at nagfunction ang heart
ay mayroong connection)
STEP 1: Determine Rate
- Multiply the number of QRS complexes found over six
seconds by a factor of 10 to get the heart rate in a minute.
For example:
- Normal rate is 60-100 for adults. Rate of less than 60bpm
is bradycardia, while more than 100bmp is tachycardia.

STEP 2: Determine the Rhythm

(Ang waves ay parang spaghetti, mayroong pataas at pababa.
Yung pataas ay tinatawag na positive deflection meaning yung
pinakalocation ng electrodes ay papunta roon sa positive pole.
‘Yung negative deflection naman ay pababa wherein ang
direction naman nito ay papuntang negative pole.)
J.A.K.E 12 of 16
- Check the P-P interval (atrial) of R-R interval (ventricular).
Rhythm may be regular or irregular.
STEP 3: Determine Presence of P-wave
- This can be done by locating an evident p-wave before the
QRS complex; and if each P-wave is related to a QRS with
1:1 conduction.
STEP 4: Check PR Interval
- Count the number of small squares between the start of
the P- wave and the start of the QRS complex; then
multiply the number of squares by 0.04 second; normal
duration is 0.12 to 0.20 second.
STEP 5: Check QRS Complex
- Check is QRS complex is evident and similar in size and
shape. Normal duration is 0.06 to 0.10 second
STEP 6: Determine Presence of T-wave
- This can be done by locating an evident T-wave after the
QRS complex; and if each t-wave has normal shape and
size.
STEP 7: Check QT Interval
- Count the number of small squares between the beginning
of the QRS complex and the end of the T wave, where the T
wave returns to the baseline; normal duration is 0.36 to
0.44 second
STEP 8: Evaluate other components
- Check for rhythm abnormalities (for example, flutter,
fibrillation, heart block, escape rhythm, or other
arrhythmias).
 CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023

Sinus Rhythm Normal Sinus Rhythm

- refers to any cardiac rhythm where the sinoatrial node is - It is imperative for critical care nurses to recognize the
generating impulses within the cardiac muscle. The normal sinus rhythm to ascertain deviations and
presence of sinus rhythm is necessary, but not sufficient, abnormalities.
for normal electrical activity within the heart. Normal Sinus Rhythm (NSR)
- If there is sinus rhythm and the heart rate is greater than Characteristics Description
100, then “sinus tachycardia” is present. If the there is Rate 60-100 bpm
sinus rhythm and the heart rate is less than 60, then “sinus Rhythm regular
bradycardia” is present. If there are no P waves present or P-wave precede QRS, consistent shape
the P wave morphology is not normal, then the exact PR Interval 0.12 to 0.20 second
rhythm must be determined. QRS Complex 0.04 to 0.10 second
Normal Sinus Rhythm Conduction normal flow

Rhythms Originating in the Sinus Node

Sinus Bradycardia

Sinus Tachycardia

• Sinus Bradycardia - can be normal findings in athletes

Cardiac Arrhythmia during sleep; may be a response to vagal simulation and
- a problem with the rate or rhythm of the heartbeat. During certain medications (digitalis, beta-blockers, calcium
an arrhythmia, the heart can beat too fast, too slow, or with channel blockers); seen in patients with increased ICP,
an irregular rhythm. uremia, myxedema and obstructive jaundice.
- Arrhythmias are any cardiac rhythm that is not normal
sinus rhythm. It may result from altered impulse formation
or conduction. Arrhythmias are named by the place where
they originate and by their rate. The typologies of
arrhythmias are as follows: (a) rhythms originating in the
sinus node, (b) rhythms originating in the atria, (c) rhythms
originating in the ventricle, and (e) AV blocks.
• Sinus Tachycardia - a normal response to exercise and
emotion; and can be caused by some medications (e.g.
ephinephrine, dopamine, caffein)

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• Sinus Arrhythmia - occurs when sinus node discharges Rhythms Originating in the Ventricles
irregularly, and is a normal phenomenon during respiration; [NOTE: ventricular arrhythmias are considered to be more
may be caused by digitalis toxicity. dangerous than other arrhythmias due to their potential to
decrease cardiac output]

• Sinus Arrest - occurs when impulses from the sinus node

are not formed as expected (p-wave absent at some point);
also known as sinus pause; causes include vagal
simulation and drugs (digitalis, beta-blockers, calcium
channel blockers)

• Ventricular Asystole - absence of any ventricular rhythm.

Rhythms Originating in the Atria

• Ventricular Fibrillation - rapid, ineffective quivering of the

ventricles; no cardiac output or palpable pulse (fatal
without immediate treatment)

• Supraventricular Tachycardia - rapid rhythm of the heart

that begins in the upper chambers.

• Atrial Flutter - caused by fixed re-entry circuit in the right

atrium on patients with health concerns (e.g. rheumatic
heart disease, atherosclerotic heart disease, heart failure,
myocardial infraction)
• Ventricular Tachycardia - rapid ventricular rhythm;
commonly caused by coronary artery diseases.

• Atrial Fibrillation - an extremely rapid and disorganised

pattern of depolarisation; most commonly seen in adults
post cardiac surgery and with conditions such as
rheumatic heart disease, pulmonary disease , MI, and
congenital heart disease
AV BLOCKS
• First Degree AV Block - prolonged AV conduction to the
ventricles; due to coronary artery disease, rheumatic heart
disease and administration of some drugs (e.g. digitalis,
beta- blockers or calcium channel blockers).

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 CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023
• Second Degree AV Block (Type 1) - occurs when one
atrial impulse at a time fails to be conducted to the
ventricles (occurs at AV node)
• Second Degree AV Block (Type 2) - occurs when one
atrial impulse at a time fails to be conducted to the
ventricles (occurs below AV node)
• Third Degree AV Block - complete failure of conduction of
all atrial impulses to the ventricles.
15 ECG Readings
4 - Sinus – Normal BUT… (Complete PQRST)
• Sinus Bradycardia – Hear rate is less than 60
• Sinus Arrhythmia – irregular
• Sinus Arrest – with pauses
• Sinus Tachycardia – heart rate is more than 100
2 – Atria – Piercing (Pins)
• Atrial FLUtter – piercing Up
• Atrial FIBrillation – piercing up/down
4 – Ventricles – The Grass (No Negative Deflection)
• Ventricular Asystole – no “grass”
• Ventricular Fibrillation – budding “grass”
• Supra Ventricular Tachycardia – Medium “grass”
• Ventricular Tachycardia – Wide “grass”
4 – AV Blocks – With Defects (Deficient PQRST)
Some notes are from Ate Geraldine*
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ADVANCED CARDIOVASCULAR LIFE SUPPORT
- Advanced cardiovascular life support is a very
comprehensive concept.
- Nurses are an integral part of what we call “the multi-
disciplinary team”.
- The hospital is not only composed of nurses alone, but we
are collaborating and coordinating with the doctors for
collaborating with the pharmacist, nutritionist, respiratory
therapist would care, ostomy nurse, etc.
- During emergency procedures, nurses are also part of what
we call the different roles as far as the advanced cardiac
life support is concerned. (Kapag nag arrest si patient,
hindi sya usually gnagawa magisa lng, may 5 roles tayo
here)
Roles in ACLS
1) Team Leader
- Every resuscitation team must have a defined leader
- Assign roles to team members
- Makes treatment decisions
- Provides feedback to the rest of the team as needed
- Assume responsibilities for roles not defined
- If you are a team leader, you should know when to ask
others to prepare the medications, know how to read
ECG readings, know what would be the intervention for
the next scenario
2) Compressor
- Assesses the patient
- Performs compressions according to the local
protocols
- Rotates every 2 minutes or earlier if fatigued
- Tandem with monitor defibrillator or CPR Coach. They
are interchanging their roles every now and then. (Kasi
nakakapagod mag compress all the time, palitan sila)
3) Monitor Defibrillator
- Brings and operates the AED monitor/defibrillator and
acts as the CPR Coach if designated.
- If the monitor is present, places it in position where it
can be seen by the team leader (and most of the team)
- Partner of compressor
- He or she is the one who checks the cardiac monitor
and provides shock if necessary.
 CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023

4) Airway • Dopamine Infusion

- Opens the airway - Pharmacological intervention
- Provides bag-mask ventilation - Renal Dose = 2 mcg/kg/min
- Inserts airway adjuncts as appropriate - Cardiac Dose = 5 mcg/kg/min
5) IV/ IO/ Medications - Vasopressin Dose = 10 mcg/kg/min
- An ACLS provider role • Epinephrine Infusion
- Initiates IV/IO access - Pharmacological intervention
- Prepares and administers the medications - Titrate to response (depende un dosage nya, doon
6) Timer/ Recorder sa response ng client)
- Records the time of interventions and medications (and - Initial: 2 mcg/ min
announces when these are next due) - Max: 10 mcg/min
- Records the frequency and duration of interruptions in - It can increase up to 4 mcg/min if the client does not
compressions response to the medication. Stop if there’s a
- Communicates these to the team leader (and the rest response.
of the team) Fast Rhythm (Tachycardia)
- Documents all the procedures - Above the normal limits (>100 bpm)\
- Management:
Managements in ACLS 1) Stable
• Physiologic (Natural)
- Vagal maneuver (massaging the carotid) Allow
the client to cough
• Pharmacologic
- Adenosine: Min = 6 mg; Max = 12 mg
2) Unstable
• Sedate
- Diazepam = 5 mg
- Medazolam = 5 mg
• Synchronized Cardioversion (this is painful
procedure that’s why we need to sedate the pt first)
- SVT = 50 J
- AF = 120 J

Slow Rhythm (Bradycardia)

- Below the normal limits (< 60 bpm)
- Examples: Sinus Bradycardia, AV Blocks
- Effective sya kapag bumibilis na ang heart rate WHO WILL PASS THE BOARD EXAM??
- Pharmacological intervention – ano ang dose, gaano ka YOU!! WILL PASS THE BOARD EXAM!!!
frequent binibigay. GOOO FUTURE RN!! <3
- Managements: A. T. D. E
• Atropine Sulfate
- Pharmacological intervention
- Dose: 0.5 mg
- Max: 3 mg
- Total: 6 doses
- Interval: 3-5 mins
• Transcutaneous Pacing
- Procedure
- Delivery of small electrical current to temporarily
restore electrical activity of the heart.
o Demand TCP – delivers electrical stimulus only
when needed.
o Fixed Rate TCP – delivers electrical stimuli at a
selected rate regardless of patient’s intrinsic
cardiac activity.
- Device used is same with the defibrillator but small
dosage only.

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