Nursing management of the Critically ill

patient
 Critical Care nursing

Specialized Nursing Care of critically – ill patients who have

immediate life threatening or potentially life-threatening illness or
injury.

ACCCN’s Critical care Nursing

Critical Care nursing
Assisting, Supporting & Restoring patient towards health

Aims at easing patient’s pain and preparing them for a

dignified death

Establishing therapeutic relationship with patient & relatives

Empowering patient individual physical , psychological,

sociological , spiritual, cultural capabilities by preventive ,
curative & rehabilitative interventions
Conditions requiring Critical Care
Neurological Conditions

Head injury
Spinal cord injury
Cerebral hemorrhage
Stroke
Myasthenia gravis
LGBS
Conditions requiring Critical Care
Respiratory Conditions

Pulmonary Embolism
Acute Asthmatic Attack
ARDS
Atelectasis
Bronchiectasis
Patient with ventilatory support
Conditions requiring Critical Care

Cardio-vascular conditions

Coronary Artery Disease

Myocardial Infarction
Heart failure
Patient underwent Cardiac Surgery
Patient with cardiac support like pacemaker, IABP etc.
Conditions requiring Critical Care

Metabolic Conditions

DKA
Diabetes mellitus
Renal Failure
Hyperthyroidism
Thyroid crisis
Adrenal Crisis
 Neurological System
Assessment of Consciousness level
Glasgow Coma Scale

Assessment of Neurological signs

PERLA (Pupil size, reaction to light, Accommodation)

Assessment for Meningeal signs

Headache, Nuchal rigidity, Photophobia

Assessment for Visual fields, Nystagmus, & other reflexes

Monitoring of ICP if the ICP monitor is present and assess for the
signs & symptoms of raised ICP
Respiratory System
Assessment of Respiratory System
Respiratory rate & pattern
Breath sounds- Normal & abnormal
Arterial Blood Gas Analysis
Saturation of Oxygen through Pulse Oximetery
Chest X-Rays , Sputum culture studies
Blood studies
Presence of respiratory care modalities

Assessment of Oxygen therapy

Non-invasive Oxygen therapy
Invasive therapy
Respiratory System …………..
Respiratory Care Modalities

Oxygen delivery systems -----------

•Nasal cannula
•Face mask
•Face tent
•Oropharyngeal Intubation
•Nasopharyngeal intubation
•Endotracheal intubation
•Tracheostomy tubes
 Respiratory System …………..
Mechanical Ventilation

 Type of Ventilator – Volume-cycled, Pressure-cycled

 Controlling mode - CMV, SIMV, SPONT.
 Tidal volume & Rate settings –
 FiO₂ (Fraction of inspired oxygen)
 Inspiratory to Expiratory ratio ( I:E) – 1:2 to 1:3
Pressure support
Pressure-flow & Volume-flow waveforms
 Minute volume – Tidal volume x Respiratory rate
 Water in the Ventilatory tubings,Disconnection or kinking of the tube
 Humidification ( humidifier filled with water ) & Temperature
 Alarms
Respiratory System …………..
Alarms

Low Airway pressure

• Air leak
• Insufficient gas pressure
• Disconnection

 High airway pressure

• Kinked ventilator tubing
• Secretions obstructing endotracheal tube
• Coughing or gagging
• Bronchospasms
• Pneumothorax
Respiratory System …………..
Alarms

 Low tidal / Minute volume

• Leak
• Displaced endotracheal tube

 Pneumonic - DOPE
D - Displacement of tube
O - Obstruction due to secretions, kinking
P - Pneumothorax
E - Equipment failure – Mechanical , Electrical
Respiratory System …………..
Assessing for the complications –

Airway Complications
Disconnection
Cardio-vascular Complications
Pulmonary vascular resistance
Respiratory Complications
Atelectasis, Barotrauma
Gastro-intestinal Complications
Abdominal Distention
Fluid & Electrolyte Complications
Respiratory Care
Assessment
Chest Physiotherapy
Postural drainage
Percussion
Vibration
Hydration Status
Endotracheal Suctioning
Tracheostomy tube care
Care of water-sealed chest drainage system
Humidification of the oxygen delivery system
Monitoring for the oxygen flow rates
Recording color & amount of the pulmonary secretions
 Cardio-vascular System
Assessment

Vital signs
Skin temperature
Pulse- all the pulses- rate, quality , pattern, rhythm & volume
Blood pressure- Indirect and Direct measurements
Fluid & Electrolyte status
Juglar venous pressure
Central venous pressure
Urine output
Presence of Edema
Other Parameters
Cardiac output
Pulmonary artery pressure
Pulmonary artery wedge pressure
 Cardio-vascular System……..
Assessment

Cardiac Dysrhythmias
Deep Vein Thrombosis
Signs & symptoms of heart Failure

Monitoring

Electrocardiaography
Lab investigations for – electrolytes, Coagulogram studies,
cardiac enzymes etc.
Cardio-vascular Care……..

Assessment & Continuous Monitoring

Intake & Output Records
Drugs
Nutrition (Metabolic)
Assessment

Anthropometric Measurements
Height, Weight, Skin folds, Limb circumference

Laboratory Investigations
Hemoglobin & Hematocrit Index, Serum Albumin,
Transferin, TLC, Nitrogen balance, Creatinine excretion

Assess for special nutrition requirements

Nutrition (Metabolic)………….
Mode of nutrition
NPO
Oral feeds
Elemental feeds – Oro-gastric tube, Naso-gastric tube,
Gastrotomy tube, Jejunostomy tube
Parenteral Feeds

Special diets available

High protein diets, Burn ‘A’, Burn ‘B’, Khidri feed,
Jejunostomy feeds, Diabetic diet, Renal diet etc.

Administration of the feed to meet the nutritional requirements

of the individual patient.
Pain & Comfort
Assessment

Pain – Onset, duration, Intensity, Precipitating or

Aggravating factors,

Use of Pain rating Scales – Visual analogue,

Numerical pain rating scale, FACES Scale etc.

Pain management
Non – pharmacological measures
Pharmacological Measures
Pain & Comfort……..

Other Nursing Interventions

Environmental Controls – Noise, temperature etc.
Position Changes
Use of Comfort devices – Pillows, Doughnuts etc.
Preventing injury
Safety Needs
Environmental Safety
Temperature & Humidity
Lightening
Noise
Falls
Electrical faults
Managing tubing's & Drains

Infection Control
Safety during Seizures
Meeting Basic Needs
Preventing injury
Other Nursing Interventions

Maintaining Skin integrity

Assessment of the skin

Frequent Position changes

Care of pressure points

Use of pressure-relieving devices – Air / Water mattresses,

water gloves, Air cushions, Air Rings etc.

Maintaining nutrition & hydration status

Vital signs
Other Nursing Interventions…….
Urinary & Bowel Elimination Needs

Passive or Assisted Exercises

Psychological Needs of the client & Family members

Explanation of the patient condition, measures
taken, patient improvement, need for lab investigations
and drugs
Clarifying doubts & queries
Arranging meeting with the physician
Facilitating loss & grieving process
Discussing critical issues along with physician
like Brain death, organ donation etc.
Other Nursing Interventions…….

Spiritual needs
Economic Needs
Affordability
Involving of governmental & non-
governmental agencies
Complications

Aspiration
Pressure Ulcers
Sepsis
Deep vein thrombosis
Contractures
Renal stones
Wrist drop & Foot drop
THANKS