Essentials of

Critical Care Nursing

 Essentials of
Critical Care Nursing

Jaya Kuruvilla MSc (N)

PD Hinduja National Hospital and MRC
College of Nursing
Mumbai

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Essentials of Critical Care Nursing
© 2007, Jaya Kuruvilla
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First Edition: 2007

ISBN 81-8061-920-6
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 Reviewers
Kasturi Ramesh Adiga
BSc (N) DNEA MA (Sociology)
Acting Dean, Ibri Nursing Institute
Ministry of health
Sultanate of Oman
(Former Principal, School of Nursing, Manipal,
India)

Nandini Korula
MD (Anesthesia)
Professor in Anesthesiology
CMC hospital, Vellore, India.
(Former consultant in Anesthesia, Royal Hospital,
Muscat, Sultanate of Oman)

John Idikula MS
Senior Specialist (Surgery) and Medical
Superintendent In charge of Ibri Hospital, Sultanate
of Oman. (Former Professor in surgery, CMC
Hospital, Vellore India)
 Dedicated (Professionally)
to
My former colleagues of Surgical Intensive Care Unit,
CMC Hospital, Vellore and students of the past and present

(Personally)
to
My inspiring father, (Late) T B John and loving and
supportive children, Sheba, Shubha and Vinod
 Preface
Critical Care Nursing has reached an all time height in its advances in technology and in
caring based on scientific basis during the last two decades. The focus of Critical Care Nursing
is to provide care for patients who are experiencing acute physical, physiological and
psychological alteration which occur as a result of the disease process, hospitalization and
diagnostic and therapeutic interventions.
In this book CCU refers to critical care unit, which may be synonymous to Intensive Care
Unit. Critical care unit is defined as a specially designed and equipped facility staffed by
skilled personnel to provide effective and safe care for patients with life threatening or
potentially life threatening problems.
Critical care nurses provide care to restore health, alleviate pain and suffering, preserve
and uphold the rights and dignity of the individuals and assist those patients in whom the
salvageability is impossible, to a humane and dignified death.
While working in critical care unit a nurse keeps the unit always ready, receives the patient
to the unit, monitors the alterations, plans and carries out interventions that compensate for
altered body functioning and participates in all diagnostic and therapeutic interventions.
Nursing is aimed at diagnosis and treatment of human responses to actual and potential
health problems. Maslow’s hierarchy of needs provides for a route to holistic care. It allows
the client to be placed on health-illness continuum and to incorporate the health models in
meeting the needs of the patient in critical care unit. Sister Callista Roy’s Adaptation model is
incorporated into the care of patients. According to her each person is a unified biopsychosocial
system which is in constant interaction with the changing environment. The nurse in the critical
care unit assists the client to reach a balance in the biopsychosocial system or to a peaceful
death. This book focuses on total aspects of care of an adult patient with selected critical illnesses.
Some of the common conditions are discussed in detail.
Advances in medical science and biomedical technology have brought about considerable
impact on the practice of critical care nursing. A critical care nurse needs to understand the
physiology and pathophysiology of organ system so that she can quickly and intelligently
identify the responses in the client based on which she would plan and implement and evaluate
care. So I believe that a nurse has to have knowledge in medicine and nursing to provide
scientific nursing care. Therefore, this book is organized according to different body systems
with necessary medical knowledge as the background, while emphasizing the human responses
such as fear, pain, sensory deprivation and sensory overload and their management through
application of Nursing process.
I also believe that success of any critical care unit depends on the cooperative and
collaborative effort of the nurses, physicians, technicians and other health team members. The
nurse has to communicate effectively with all team members and coordinate the activities of
x ESSENTIALS OF CRITICAL CARE NURSING
the critical care unit to achieve high quality of care. While working in the highly charged high
tech environment, she also needs to incorporate the human touch into the care.
The family of critically ill needs support during the illness and assistance in grieving process
when they become bereaved. It is a challenge for critical care nurses to extend their empathetic
support and communication skills to the outside walls of the critical care unit and reach them,
who are in need and being drained off their physical and mental energy, time and financial
resources.
While giving attention to holistic care of individual with critical illness, other general aspects
of management of a critical care unit also is touched upon which would help nurses who
would be called upon to take up additional responsibilities of planning and managing the
critical care unit. Chapter on Pharmacology has touched upon briefly the drugs used in CCU.
As these drugs undergo rapid revolutions, reader is expected to check on the latest information
by the Manufacturer or detailed and latest work on pharmacology. As for procedure carried
out in CCU, the institution’s policy, standing orders, protocol and the technical facility available
are to be taken into consideration.
This book is intended for the students of basic and posts basic programs, nurse practitioners
in CCU and educators to serve as a reference on essential aspects of critical care nursing.
Nursing care plan is incorporated into most of the conditions. Different formats of care plan
are used to give an opportunity for the reader to be familiar with them.
Finally, critical care nurses at all time must strive for updating their knowledge continuously
through all the resources available to make themselves capable of meeting diversified challenges
which they come across in their day-to-day practice.

Jaya Kuruvilla
 Acknowledgements
Only when I ventured, I did realize that writing is highly demanding, taxing and time
consuming, especially when it has to be done along with regular job commitment and family
responsibilities. Writing of this book took unusually long time due to many unexpected
problems and course of events in my personal and professional life. But many supportive and
encouraging people sustained me throughout especially during the latter part of the completion
of the work. If not for them this would not have become a reality. These people along with my
clinical experience, patients and colleagues in Surgical Intensive Care Unit, CMC Hospital,
Vellore, my students of the past and present have influenced my thinking on critical care
nursing. Mrs Violet Jayachandran, MSc (N) (Wayne State University, Detroit) my professor
and retired Head of Surgical Nursing Department, CMC Hospital, Vellore, was instrumental
in creating an interest in critical care nursing in me, when I worked with her during the inception
of Surgical Intensive Care Unit, CMC Hospital, along with Dr Nandini Korula, then head of
the department of SICU who is also one of the reviewers of this book. I owe a lot to them and
other colleagues of SICU, nurses, doctors and paramedical staff for influencing my learning in
SICU.
I am indebted to many others to whom I would like to express my gratitude. First of all to
thank Mr Abraham Thomas medical coordinator and Mr Juma Ali the typist for their clerical
assistance, M/s Jaypee Brothers Medical Publishers Pvt. Ltd., New Delhi for taking up the
publishing of this book.
All my reviewers whose names are listed elsewhere have taken pain and time to review the
material and offer valuable guidance. Their knowledge, rich experience and expertise has
helped to give shape to this maiden venture. Mrs Kasturi Ramesh Adiga in her busy schedule
found time to go through each and every chapter of the book meticulously. There is no word
to express my gratitude to her. Dr Nandini Korula and Dr John Idikula have reviewed the
medical and surgical parts of the contents in spite of the tight schedule of their work. My
thanks to them.
Dr John Idikula, MOIC and Dr Mercy John, Specialist (Microbiology) of Ibri Regional Referral
Hospital, who in their personal capacity sustained me throughout with innumerable resources.
My warmest gratitude to them.
There are many other friends and my former students who encouraged me throughout. I
conclude with lots of appreciation for all those who have directly and indirectly helped me to
make this book a reality.
 Contents

1 GENERAL ASPECTS OF CARE

1. Evolution of Critical Care: Historical Perspectives .............................................. 2

2. Concepts of Critical Care Nursing ......................................................................... 2
3. Principles of Critical Care Nursing ..................................................................... 3,5
4. Scope of Nursing Practice in Critical Care Units ................................................. 6
5. Legal Aspects in Critical Care Nursing ................................................................. 8
6. Role of the Nurse in Critical Care Unit ................................................................ 15
7. Planning of a Critical Care Unit ........................................................................... 16
8. Nosocomial Infections and their Control in Critical Care Units ....................... 23
9. Psychosocial Components of Critical Care Nursing ......................................... 30
10. Nursing Process in Critical Care Unit ................................................................. 39

2 CORONARY COMPONENTS OF CRITICAL CARE NURSING

1. Assessment of Cardiovascular System .............................................................. 56

a. Related Anatomy and Physiology .................................................................. 56
2. Assessment of Cardiovascular Function ............................................................ 59
a. Diseases of the Coronary Arteries ................................................................. 70
b. Arrhythmias ...................................................................................................... 94
c. Cardiogenic Shock ......................................................................................... 102
d. Pacemakers .................................................................................................... 106
e. Cardiovascular Surgery ................................................................................. 110
f . Cardiac Assist Devices .................................................................................. 124
g. Clinical Death and Cardiopulmonary Resuscitation ................................... 130

3 PULMONARY COMPONENTS OF CRITICAL CARE NURSING

1. Related Anatomy and Physiology ..................................................................... 161

2. Assessment of Respiratory System .................................................................. 166
3. Nursing Process Pertaining to Pulmonary Function ....................................... 172
a. Acute Respiratory Failure ............................................................................. 178
• ARDS ............................................................................................................ 187
xiv ESSENTIALS OF CRITICAL CARE NURSING

b. Chronic Obstructive Pulmonary Diseases .................................................. 193

• Chronic Bronchitis ...................................................................................... 195
• Pulmonary Emphysema.............................................................................. 195
• Bronchiectasis ............................................................................................. 196
• Bronchial Asthma ........................................................................................ 198
• Status Asthmaticus ..................................................................................... 198
c. Restrictive Diseases of Lung ........................................................................ 202
• Pulmonary Embolism ................................................................................. 203
• Pneumothorax ............................................................................................. 206
• Pulmonary Edema ....................................................................................... 206
• Pneumonia ................................................................................................... 208
d. Thoracic Surgery ............................................................................................ 210
e. Nursing Process Pertaining to Patients Requiring
Assistance with Mechanical Ventilation ....................................................... 215

4 MEDICAL COMPONENTS OF CRITICAL CARE NURSING

Nursing Process Pertaining to

1. Hepatic Failure .................................................................................................... 235
2. Diabetic Keto Acidosis ....................................................................................... 249
3. Hyperosmolar Hyperglycemic Nonketoacidotic Diabetes .............................. 261
4. Endocrine Changes in Critically Ill Patient. ...................................................... 267
5. Drug Overdosage ................................................................................................ 281
6. Tetanus ................................................................................................................. 288
7. Disseminated Intravascular Coagulation .......................................................... 289
8. Multiple Organ Failure ........................................................................................ 290
9. Acquired Immunodeficiency Syndrome ........................................................... 314

5 SURGICAL COMPONENTS OF CRITICAL CARE NURSING

1. Fluid and Electrolyte Imbalance ........................................................................ 329

2. Total Parenteral Nutrition ................................................................................... 334
3. Pain ...................................................................................................................... 342
4. Nursing Process Pertaining to Complex Surgical Conditions
• Acute Abdomen .............................................................................................. 350
• Transplantation ............................................................................................... 353
 CONTENTS xv

• Bleeding in Surgical Patient .......................................................................... 372

• Shock ............................................................................................................... 379
• Trauma ............................................................................................................. 386
• Septic Syndrome ............................................................................................ 401
• Burns ............................................................................................................... 403
• Pancreatic Disease ......................................................................................... 418
5. Postoperative Patient in Critical Care Unit ....................................................... 422
6. Preventing Postanaesthetic Complication. ...................................................... 434

6 NEUROLOGICAL COMPONENTS OF CRITICAL CARE NURSING

1. Neurological Assessment .................................................................................. 440

2. Nursing Process Pertaining to Specific Neurologic Conditions .................... 457
a. Space Occupying Lesions ............................................................................. 457
b. Head Injury ...................................................................................................... 469
c. Ischemic Brain Injury ..................................................................................... 497
d. Epilepsy........................................................................................................... 501
e. Acute Spinal Cord Injury ............................................................................... 511
f. Guillain-Barre Syndrome ............................................................................... 524
g. Cerebrovascular Accident ............................................................................. 530
h. Neurosurgery .................................................................................................. 551

7 PHARMACOLOGY

Drugs commonly Used in Critical Care Units

1. Antianginal Drugs ............................................................................................... 566
2. Antihypertensives ............................................................................................... 568
3. Antiarrhythmic Agents ....................................................................................... 572
4. Insulin ................................................................................................................... 578
5. Bronchodilators ................................................................................................... 583
6. Muscle Relaxants ................................................................................................ 587
7. Antibiotic Therapy ............................................................................................... 590
8. Anticerebral Edema Agents ............................................................................... 602
9. Narcotic Analgesics ............................................................................................ 602
10. Anticoagulants and Blood Formers .................................................................. 604
xvi ESSENTIALS OF CRITICAL CARE NURSING

8 TRENDS AND ISSUES

1. Critical Care Today .............................................................................................. 614

2. Clinical Practice .................................................................................................. 615
3. Education ............................................................................................................. 616
4. Research .............................................................................................................. 617
5. Information Technology and Critical Care ........................................................ 618
6. Quality Assurance in Critical Care Nursing ..................................................... 621

9 PROCEDURES

1. Electrocardiogram............................................................................................... 629
2. Airway Management ........................................................................................... 632
a. With Mask ....................................................................................................... 632
b. Endotracheal Intubation ................................................................................ 633
c. Tracheostomy ................................................................................................. 635
d. Cuff Inflation ................................................................................................... 638
3. Suctioning ............................................................................................................ 640
4. Chest Physiotherapy ........................................................................................... 645
5. Arterial Puncture and Arterial Blood Gas Estimation ..................................... 648
6. Measuring CSF Pressure .................................................................................... 651
7. Ventricular Catheterization................................................................................. 652
8. Hemodynamic Monitoring .................................................................................. 653
a. Pulmonary Artery Pressure ........................................................................... 654
b. Central Venous Pressure ............................................................................... 656
9. Oxygen Therapy .................................................................................................. 658
10. Chest Drainage ..................................................................................................... 662

Index ...................................................................................................................... 677