Critical Care Nursing

 By

 Mfitumukiza Valence

(MNS, DHSM, BNS, RN)

Learning Objectives

 By the end of the lesson learners should be able to;

 Define Critical Care
 Explain the use of critical thinking in caring for critically ill pateints
 Understand pateints’ experience of having critical illness and nursing roles to
manage their anxieties
 Understand the role played by family members in management of critically ill
patients.
Critical care
 Speciality within nursing that deals specifically with human responses to life threatening
problems’ (American Association of Critical Care Nurses, 2009)
 Brilli et al. (2001) translate this contemporary view of critical care as being the appropriate medical
care given to any physiologically compromised patient.
Critical Thinking in care of critically ill
patients
 Critical thinking is “The ability to focus your thinking to get the results you
need” (AlfaroLeFevre, 2009).
 The term “Critical Thinking” is used in many different ways.
 The definition above provides you with two key factors in critical thinking:
 • Focus
 • Results If you focus on getting the results you need, you are successfully using
critical thinking.
 Critical thinking in nursing is outcome-focused thinking that:
• Is guided by standards, policies and procedures, ethics, and laws.
• Is based on principles of nursing process, problem solving, and the scientific
method.
• Carefully identifies the key problems, issues, and risks involved.
• Applies logic, intuition, and creativity.
• Is driven by patient, family, and community needs.
• Calls for strategies that make the most of human potential.
• Is constantly re-evaluating, self-correcting, and striving to improve.
 Critical Thinking Indicators (CTIs) Alfaro-LeFevre recognizes three categories of nursing
competencies:
 1. Knowledge/intellectual skills
 2. Interpersonal skills
 3. Technical skills
 Critical Thinking Skills and Attitudes
 Scheffer and Rubenfeld (2000) identify seven Critical Thinking Skills and nine Critical Thinking Attitudes:
 In nursing practice, you continually use critical thinking.
 Thinking Ahead
 Anticipate
 You anticipate that equipment and supplies you need to take with you to care for a patient.
 You anticipate how long each activity will take to complete.
 Based on previous experience, you anticipate that a patient will respond in a particular way, such as relief of
angina pain following a dose of nitroglycerin.

 Thinking in Action
 Act
 Because you know what patient responses are expected and what signs and symptoms
 indicate a problem, you evaluate patient responses and act accordingly.
 When your plan for the shift is derailed by an emergency, a change in patient status, patient admissions, or other
factors, you reprioritize and adjust your plans.
 When patient care equipment is not functioning as expected, or is alarming, you troubleshoot.
 Thinking About Your Actions

 Reflect
 After a shift that has gone particularly well, in which you actually found time to do
some “extras” for your patients, you think back on how the shift unfolded to identify
any actions you or others took that could make for such a satisfying shift again.
 The nursing assistant helped you get a heavy patient out of bed more effectively
than previous times with others assisting you.
 You review mentally how the two of you worked together.
 You make a note on the patient’s plan of care and communicate the approach during
report.
 You compliment the nursing assistant for her part in the effective transfer.
 You were in charge today and it was a nightmare. One particular physician was
extremely demanding and uncooperative.
 You reflect on your communications with this physician and vow that you will not
have the same experience again.
 You decide to tell her that you need to find a more effective way of communicating
and ask for her perception of the situation and any suggestions she may have.
 This model of critical thinking requires reflection to learn from past experiences
Patients experience with critical illness

 Admission to a critical care unit (CCU) may signal a threat to the life and
well-being of the patient who is admitted.
 A number of authors have sought to study and describe patients’ experiences
related to their ICU stay
 Although many of the patients recalled feelings that were negative, they also
recalled neutral and positive experiences.
 Negative experiences were related to;
 fear, anxiety, sleep disturbance, cognitive impairment, and pain or discomfort.
 Positive experiences were related to feelings of being safe and secure.
Nursing Interventions to relieve anxiety

 Creating a healing environment

 Fostering trust
 Providing information
 Allowing control
 Cultural sensitivity
 Cognitive techniques
 Internal dialogue
 External dialogue
 Cognitive reappraisal
 Guided imagery and relaxation technique
 Deep Breathing Exercises
 Music therapy
 Humor
 Massage and therapeutic touch
 Meridian therapy eg acupuncture
 Animal –human therapy
Family’s experience with
critical illness
 Definition of family
 “Family” refers to two or more persons who are related in any way – biologically, legally, or
emotionally. Patients and families define their families. (Institute for Patient and Family – Centered
Care, 2010) “Significant others” may also be used.
 If the patient is awake and able to answer – the family is whoever the patient designates
 If the patient is unable to answer – how do we know?
 Health Care Proxy
 Documented in a previous admission
 Who accompanied with the patient?
 Why is this important? This will determine who is going to support and/or assist in decision making.
 Family needs
 Families experience stress and anxiety when a loved one is admitted to the ICU.
 Many studies have identified the needs of families of critically ill patients and nurse interventions that
may decrease this stress.
 In 1979 Molter conducted a study to identify specific needs of significant others. The top five needs
were to:
 have hope
 feel that the hospital staff cares for the patient
 be near the patient
 be informed of any change in the patient status
 know the staff (Molter, 1979)
 Family needs
Critical Care Family Needs Inventory (CCFNI) identified five concept areas:
 Proximity
 Assurance
 Information
 Support

 Comfort (Leske, 1992)

 Consequences of unmet needs
 Anxiety and Fear (Simon, Phillip, Badalamenti, and Ohlert, Krumberger , 1997)
 Depression
 Post traumatic stress syndrome

 Concerns that not everything possible was being done (Meyers, Eichhorn, Guzzetta, 2000)
 Clinical practice guidelines for
support of the family
 A shared decision-making model

 Early and repeated care conferences

 Honoring cultural requests

 Spiritual support

 Family presence at rounds and during resuscitation

 Clinical practice guidelines for
support of the family
 Open visitation

 Family-friendly signage

 Family support before, during, and after a death

 Staff education and debriefing (ACCM Task Force of the SCCM, 2007)
 AACN Practice Alerts
 AACN Practice Alert: Family presence during resuscitation and
procedures. (2010) aacn.org

 AACN Practice Alert: Visitation in the adult ICU. (2011) aacn.org

 How to add family (F) into
ABCDE bundle
Questions:
 How can we engage families in activities that benefit the patient?
 What effect does engaging families in patient activities have on the
family?
 Advantages to family engagement
For patients:
 Decreases anxiety, confusion and agitation (Hupcey, 1999)
 Reduces cardiovascular complications (Fumigalli, Boncinelli, Lo Nostro, et al., 2006)
 Decreases the ICU LOS (Davidson, Powers, Hedayat, et al. 2007)
 Makes the patient feel more secure
 Increases patient satisfaction
 Promotes quality and safety
 Family contributions
 “Active presence” to facilitate communication and what is known about the patient’s condition

 “Protector” creates sense of safety by having a family member at the bedside to watch over and
advocate for them

 “Historian” provides information about patient’s medical history and personal preferences
 Family contributions (cont)

 Facilitators” to maintain meaningful relationships

 “Coaches” to provide encourage and inner strength

 “Voluntary caregiver” assists in providing actual care

(McAdam, Arai, and Puntillo, 2008)
 Family contributions to
patient recovery
As part of the care team, families can assist with:

 Being present during SATs (spontaneous awakening Trials)

 Delirium assessment and interventions

 Early mobilization

 Your thoughts?
 Engaging the family
 Provide education
 What to expect
 Family roles
 Model caring behaviors
 Support
 Encouragement

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