Ethics in Critical Care

 “Ethics” can be defined as a set of principles of

right conduct or a system of moral values.

 It helps us to differentiate between right and

wrong or what we have to do in specific
situations.
 Ethical Issues
 Critical care nurses face ethical issues every day
–Informed consent
–Withholding or withdrawal of treatment
–Organ and tissue transplantation
–Confidentiality
–Distribution of health care resources
–Advanced technology for life-sustaining
treatments.
 Bioethical Principles
Non maleficence:
Never harm anyone
Not to intentionally inflict harm
Beneficence:
Maximize benefit and minimum harm.
Duty to prevent harm, remove harm, and promote
the good of another person
Autonomy:
Respect and not to interfere the choice and action of
an individual.
Right of self-determination concerning medical care
Justice:
 Fair distribution of benefits.
Veracity:
 An obligation to tell truth .
Fidelity:
 To keep promise and fulfill commitments .
Confidentiality:
 Respect for right to control information
The Nurse’s Ethical Responsibilities

The Nursing profession is guided by the

American Nurses Association (ANA) Code of
Ethics for Nurses With Interpretive Statements
 Ethical Decision-Making Process
1-Assess 3-Develop plan
–Contextual factors -- with patient, surrogate,
–Physiological factors family, and team
–Personal factors 4-Act on plan
2-Consider options 5-Evaluate plan
–Patient wishes –Short-term outcomes
–Ethical principles –Long-term outcomes
–Potential outcomes
 Safe Guards in Nursing Practice

• Licensure
• Standards of care
• Consent
• Correct identification
• Documentation
• Drug maintenance
 Law in Critical Care
Three areas of law in CCN:
 Administrative law

 Civil law

 Criminal law
Administrative law:
The state agency develops regulations that dictate
how the nurse practice act is to be interpreted and
implemented. If a citizen feels that he or she has not
received reasonable nursing care, the citizen may
contact the state agency and file a complaint against
the nurse or nurses involved in the care.
Civil law:
In civil cases, one private party files a lawsuit against
another. One specific area of civil law, tort law, forms
the foundation of most civil cases involving nurses
.Examples of torts include negligence, malpractice,
assault, and battery.
Criminal law:
In criminal cases, the local, state, or federal
government files a lawsuit against an
individual. Criminal offenses, which are
extremely rare in nursing situation.
 Common Legal Issues in Critical Care

Negligence
Breach of a duty of care which results in
damage.
Types of Negligence:
 Ordinary
 Gross
Ordinary:
Ordinary negligence implies professional
carelessness.
Gross:
Gross negligence suggests that the nurse will
fully and consciously ignored a known risk for
harm to the patient.e.g. providing patient care
while under the influence of drugs or alcohol.
 Legal Risk Areas
Assault:
Act not performed but develop a fear related to
touch and gives threat verbally or nonverbally.
Battery:
Is the use of force against another, resulting in
harmful, offensive or sexual contact.
Fraud :
Unlawful gain, or to deprive a victim of a legal right.
Invasion of privacy:
Intrusion into an individual's private and
confidential matters.
False imprisonment:
Is the unlawful restraint of a person against her
will by someone without legal authority.
Defamation :
The action of damaging the good reputation of
someone.
Its two types are :
1.Slander; damaging reputation verbally
2.Libel ; damaging reputation in written form .
 Legal Issues Related To Consents

• These are the legal documents which indicates

clients permission to perform surgery,
treatment or give information to third party .

• The competent client must be over 18 years of

age , emotionally and mentally competent and
non sedated .
 Types of consents
 Admission agreement
 Blood transfusion consent
 Surgical consent
 Research consent
 special consents ( broncoscopy , ventilation ,
general anesthesia )
INTRA-AORTIC BALLOON PUMP (IABP)
by
Shahla Arshad
Lecturer
INS-KMU
 OBJECTIVES

At the end of this presentation the learners will be able to:

 Discuss Hemodynamic of IABP.
 Describe the hemodynamic benefits of properly
timed balloon pumping.
 List indications, contraindications and complications
of IABP.
 Discuss Nursing responsibilities associated with
IABP .
 INTRA AORTIC BALLOON PUMP
• The intra-aortic balloon pump (IABP) is a
mechanical device that
increases myocardial oxygen perfusion and
indirectly increases cardiac output through after
load reduction. It consists of a cylindrical
polyethylene balloon that sits in the aorta,
approximately 2 centimeters (0.79 in) from the
left subclavian artery. The balloon inflates and
deflates via counter pulsation.
 INTRA AORTIC BALLOON PUMP COUNTER
PULSATION

 In intra aortic balloon pump (IABP) counter

pulsation, inflation and deflation of a balloon in
the thoracic aorta is matched with systole and
diastole. It is used to increase oxygen supply to
the myocardium, decrease left ventricular work,
and improve cardiac output
 INDICATIONS FOR IABP

 Acute ventricular failure

 Cardiogenic shock
 Myocardial infarction
 Cardiac Surgery
 Intractable angina
 High risk surgery
 CONTRAINDICATION

 Aortic insufficiency
 Aortic aneurysm
 Aortic dissection
 Limb ischemia
 Thromboembolism
 IABP Kit Contents
• Introducer needle
• Guide wire
• Vessel dilators
• Sheath
• IABP (34 or 40cc)
• Gas tubing
• 60-mL syringe
• Three-way stopcock
• Arterial pressure tubing (not in kit)
 INSERTION AND OPERATION

 The balloon used in IABP counter pulsation is positioned in

the thoracic aorta via the femoral artery. It is positioned
just distal to the great vessel and proximal to the renal
artery.
 Once in place the balloon catheter is attached to a console
that displays the patient’s ECG and an arterial waveform for
timing of the balloon inflation and deflation.
 The console also displays a balloon waveform that illustrate
the inflation and deflation of the balloon itself. The balloon
is inflated and deflated in accordance with the cardiac
cycle.
 Inflation occurs during diastole, increasing aortic
pressure and retrograde blood flow back towards
the aortic valve. This increases coronary artery
perfusion pressure and blood flow, thus improving
oxygen supply to coronary arteries.
 Deflation occurs just before systole (i.e. ,just before
blood is ejected from the left ventricle). This
decreases the resistance to ejection, the ventricular
workload and myocardial oxygen demand.
 Timing of inflation and deflation must match with
the cardiac cycle to ensure the effectiveness of IABP
therapy.
CONVENTIONAL TIMING OR TRIGGERING

Conventional timing uses the arterial

waveform as the triggering mechanism to
determine both inflation and deflation of the
balloon. Balloon inflation occurs at the dicrotic
notch(which signals the closure of the aortic
valve and the beginning of diastole on the
arterial waveform). Deflation is timed to occur
at end diastole, just before the next sharp
systolic up stroke on the arterial waveform
 PATIENT MANAGEMENT DURING IABP SUPPORT

 IABP counter pulsation is usually an unplanned, emergent

intervention for a deteriorating condition.
 Preparing family members prior to their first visit with the
patient following device insertion and providing ongoing
explanations of the patient status and care can help to
alleviate anxiety.
 Honest communication helps family members recognize
changes in the patient’s condition and make informed,
realistic decisions regarding the patient’s care.
 Attach pulse oximeter
 Tip should be in 2nd intercostal space anteriorly on Chest
CXR.
 Nurse must be able to recognize and correct
problems in balloon pump timing.
 Cardiovascular monitoring is also important in
determining the effectiveness of IABP therapy.
 Effective IABP therapy causes a decrease in
heart rate and MAP.
 Heart rhythm and regularity must also be
considered. Irregular dysrhythmias may inhibit
efficient IABP .
• Following insertion, the nurse assesses and
documents the quality of pulses, skin perfusion,
and neurological status per protocol, and notifies
the physician of any changes.
• Avoid hip flexion, which may obstruct flow to the
affected extremity, by keeping the cannulated leg
straight and the head of the bed at an angle less
than 30 degrees.
• Monitor for bleeding problems because heparine
is administered through out the therapy.
 CXR daily
 Prophylactic antibiotics
 Daily
–Haemoglobin (risk of bleeding or haemolysis)
–Platelet count (risk of thrombocytopenia)
–Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
 Wean off the IABP as early as possible as longer duration is
associated with higher incidence of limb complications.
 Check lower limb pulses -2 hourly.
-If not palpable -vascular obstruction , thrombus or
embolus(urgent surgical consultation)
 COMPLICATION

 Mechanical problems
 Impaired circulation –obstruction (Thrombosis)
 Bleeding-groin heamatomas
 Infection
 Thromboembolism
 Aortic perforation or dissection
 Heparine induced thrombocytopenia
 WEANING FROM IABP

Weaning patients from balloon assistance usually

can begin 24 to 72 hours after insertion ,some
patients require longer periods of support because
of hemodynamic instability. The nurse assesses
the patient for any change in hemodynamic status.