Critical Care Nursing

Definition
• Critical care nursing is the field
of nursing with a focus on the utmost care
of the critically ill or unstable patients
following extensive injury, surgery or life
threatening diseases.
• Critical care nursing is a specialty within
nursing that deals specifically with very
sick, complex patients facing life-
threatening problems.
 Critical care nursing
• Critical care nursing is a specialty within
nursing that deals specifically with very sick,
complex patients facing life-threatening
problems.
• Nurses practicing in a critical care setting must
possess advanced nursing skills and expert
knowledge of specialized electronic equipment
used for the monitoring and treatment of
acutely ill patients
 Types of care provided
• Basic Patient Care : In many other areas of
nursing, basic patient care such as cleaning
and bandaging a patient’s wounds, taking
vitals, turning, moving, or bathing patients
would be delegated to a patient care
technician or nurse’s aide. Critical care nurses,
however, must provide all of a patient’s care
because a critically ill or injured patient’s
condition can decline quickly.
 Ctd…
• Advanced Nursing Care :
In addition to basic patient care, a critical care nurse is
responsible for highly technical patient assessments,
implementing complex patient care plans, and the
administration of extensive medication protocols.
Duties such as tracking life support equipment,
providing supplemental oxygen, administering IV
medications, monitoring cardiac and renal status,
catheter care, and dressing changes are a common
part of a critical care nurse’s job description.
 Responsibilities of CCN
• Coordinate with health care team members to evaluate, plan,
and implement patient care plans
• Prepare and administer (orally, subcutaneously, through an IV)
prescribed medications
• Provide basic bedside care including dressing changes, catheter
care, assisting the patient with moving, and taking vital signs
• Monitor patients for subtle or sudden changes in ventilation,
renal, and cardiac status
• Report adverse reactions to treatments or medication
• Order, interpret and evaluate diagnostic tests to assess a
patient’s condition
 Ctd….
• Quickly identify when a patient decompensates and alert the
rest of the critical care team
• Initiate corrective action when a patient displays adverse
symptoms
• Monitor and adjust specialized electronic equipment such as
cardiac monitors, respirators, ventilators, and oxygen pumps
• Act as a patient advocate, by respecting the basic rights,
beliefs, and values of the patient
• Communicate essential and appropriate information about a
patients’ condition to family members and significant others
Provide comfort and end-of-life care
 Definition of a Critically ill Patient
• Critically ill patients are defined as those
patients who are having actual or potential
life-threatening health problems.
 Critical care
• It is a multidisciplinary health care speciality
that is meant for patients with acute life
threatening illness or injury.
 Critical Thinking
Critical thinking is a multidimensional skill, a cognitive
or mental process or set of procedures. It involves
reasoning and purposeful, systematic, reflective,
rational, outcome-directed thinking based on a body
of knowledge, as well as examination and analysis of
all available information and ideas. Critical thinking
leads to the formulation of conclusions and the most
appropriate, often creative, decisions, options, or
alternatives (Ignatavicius, 2001; Prideaux, 2000).
 CRITICAL THINKING
IN NURSING PRACTICE
Using critical thinking to develop a plan of nursing care requires
considering the human factors that might influence the plan. The
nurse interacts with the patient, family, and other health care
providers in the process of providing appropriate, individualized
nursing care. The culture, attitude, and thought processes of the
nurse, the patient, and others will affect the critical thinking
process
from the data-gathering stage through the decision-making stage;
therefore, aspects of the nurse-patient interaction must be
considered
(Wilkinson, 2001).
 Critical thinking Continue…
Nurses must use critical thinking skills in all practice settings—
acute care, ambulatory care, extended care, and in the home
and community. Regardless of the setting, each patient situation
is viewed as unique and dynamic.

The unique factors that the patient and nurse bring to the health
care situation are considered, studied, analyzed, and
interpreted. Interpretation of the information presented then
allows the nurse to focus on those factors that are most relevant
and most significant to the clinical situation. Decisions about
what to do and how to do it are then developed into a plan of
action.
The critically ill patient is highly
• Vulnerable
• unstable
• And complex thereby requiring vigilant
monitoring and intense nursing care.
Who is in Critical Care Team?
Common Problems of a Critically ill Patient

• Look for Manifestations of the Disease

• Haemodynamic Insufficiency
• Respiratory Insufficiency
• Deterioration in LOC
• Fluid imbalance
• Electrolyte imbalance
• Acid Base imbalance
• Nutritional problems
• Infections
• Effects of Drugs
• Dysfunction of vital organs
• Complications of Immobility
• Complications of the Disease
• Self Care deficit
• Psychological distress
• Altered family process
• Financial Burden
 Psychological Stressors in ICU Patient
• Fear of death
• Fear of Residual deficits /Complications
• Pain, Insomnia, Discomfort
• Lack of Autonomy
• Lack of privacy
• Noise, Light
• Separation from Family
• Boredom
• Role change
• Ineffective Communication
 Nurses Responsibility in Critical Care
• Comprehensive Nursing Care
• Initial Assessment
• Maintain ABC
• Early Identification of Deterioration
• Prompt Intervention in case of emergencies
• Ongoing Monitoring
• Watch for & Prevent complication
• Management of complications
• Management of the disease and its Causes
• Meeting the Basic needs of the Patient
• Sending & Receiving results of diagnostic test
• supportive care: diet, exercise, spiritual needs
• Relaxation/Diversion for the patient
• Documentation
• Reporting
• Supporting the relatives
• Coordination of the teamwork
• The staff nurse will report any changes in
his/her patients condition directly to the
physician and the charge nurse.
• Ensure a physician is aware of all lab reports.
• Rationale: The staff nurse is the one person
who has current and detailed information on
the patients condition.
• All critical care patients must have continuous
monitoring -BP,ECG,Pulse,Oxygen saturation.
Rationale: A critically ill patients’ vital
parameters changes rapidly which may
indicate deterioration of condition.
• Alarms must be left on at all times.
Appropriate limits will be selected at the
nurse’s discretion according to institutional
policy.
• Rationale: To ensure rapid detection of heart
rate or BP changes.
• All patients admitted for neurological
problems will have hourly neurological
assessments performed , using the Glasgow
Coma Scale.
• Rationale: To quickly reference previous
function, if deterioration occurs, to provide a
clear understanding of the patients
neurological status.
• The turning of all critically ill patients every two
hours is done unless contraindicated, with skin
assessment recorded.
• Rationale: This is to relieve pressure points and
allow for skin perfusion.
• All intensive care patients will have chest PT q4h
and as needed, unless contraindicated.
• Rationale: Immobility increases the risk for the
retention of secretions and reduced ventilation.
• All Critical Care patients will have mouth care
done every four hours with inspection for oral
sores. Teeth will be brushed every shift and as
needed.
• Rationale: Intubation increases risk for
developing mouth ulcers and/or infections.
• Routine daily baths will be done on night shift.
This will include total skin care, fingernails and
hair washing & dress changes.
• Rationale: The night shift is quieter and less
hectic
• Ventilatory changes will only be done upon written
order.
• Rationale: To maintain optimal and consistent
respiratory management.
• All orders written other than by the Critical Care
physicians will be brought to the attention of the
Critical Care physician by the nurse prior to being
carried out.
• Rationale: To ensure all therapy is consistent with
goals for the patients management
• All change of shift reports will include a review of all
physician orders, lab results, medication
administration record, and joint review of
systemwise status.
• Rationale: To ensure communication between shifts
and reduce potential for medication or treatment
errors. Health status is jointly reviewed to ensure
that both incoming and out going shifts are clear on
interpretation of findings to be able to promptly
detect a change in patient condition
 Skill in Procedures
• Monitoring- BP,CVP,Pulse,Oxygenation,GCS
• Endotracheal Suctioning
• CPR- ALS
• Administration of Drugs, IV fluids
• Wound Care, Care of Drain
• Prepare for Diagnostic Procedures
• Feeding-Nasogastric feeding
• Meeting Elimination need- Catheterise
• Exercise:Chest Physio,Passive Exercise
• Hygienic Care. Monitoring in Critical Care
• ECG, Heart rate,
• Blood Pressure:ABP,CVP,PAP,NIBP
• SpO2
• Temprature
 End-of-Life Issues
• Dilemmas that center on death and dying are prevalent in
nursing practice and frequently initiate moral discussion.
• The dilemmas are compounded by the fact that the idea of
curing is paramount in health care. With advanced
technology, it may be difficult to accept the fact that
nothing more can be done, or that technology may
prolong life but at the expense of comfort and quality of
life.
• Focusing on the caring as well as the curing role may assist
nurses in dealing with these difficult moral situations.
 DO-NOT-RESUSCITATE ORDERS
• The “do not resuscitate” (DNR) order is a controversial
issue. When a patient is competent to make decisions, his
or her choice for a DNR order should be honored,
according to the principles of autonomy or respect for the
individual (Trammelleo, 2000).
• However, a DNR order is at times interpreted to mean that
the patient requires less nursing care, when actually these
patients may have significant medical and nursing needs,
all of which demand attention. Ethically, all patients
deserve and should receive appropriate nursing
interventions, regardless of their resuscitation status.
 LIFE SUPPORT
In contrast to the previous situations are those in which a
DNR decision has not been made by or for a dying
patient. The nurse may be put in the uncomfortable
position of initiating life-support measures when,
because of the patient’s physical condition, they appear
futile. This frequently occurs when the patient is not
competent to make the decision and the family (or
surrogate decision maker) refuses to consider a DNR
order as an option. The nurse may be told to perform a
“slow code” (i.e, not to rush to resuscitate the patient)
or may be given a verbal order not to resuscitate the
patient; both are unacceptable medical orders
The best recourse for nurses in these situations is to be aware
of hospital policy related to the Patient Self-Determination
Act (discussed later) and execution of advance directives.
The nurse should communicate with the physician.
Discussing the matter with the physician may lead to further
communication with the family and to a reconsideration of
their decision, especially if they are afraid to let a loved one
die with no further efforts to resuscitate (Trammelleo, 2000).
Finally, when working with colleagues who are confronting
such difficult situations, it helps to talk and listen to their
concerns as a way of providing support.
 Ethical Decision Making
As noted in the preceding discussions, ethical
dilemmas are common and diverse in nursing
practice. Although the situations vary and
experience indicates that there are no clear
solutions to these dilemmas, the fundamental
philosophical principles are the same, and the
process of moral reflection will help nurses to justify
their actions. The approach to ethical decision
making can follow the steps of the nursing process.
 STRESS AND ADAPTATION
Stress is a state produced by a change in the
environment that is perceived as challenging,
threatening, or damaging to the person’s
dynamic balance or equilibrium. The person is,
or feels, unable to meet the demands of the
new situation. The change or stimulus that
evokes this state is the stressor.
• The desired goal is adaptation, or adjustment
to the change so that the person is again in
equilibrium and has the energy and ability to
meet new demands.

• This is the process of coping with the stress, a

compensatory process with physiologic and
psychological components.
 Adaptation
• Adaptation is a constant, ongoing process that
requires a change in structure, function, or
behavior so that the person is better suited to
the environment; it involves an interaction
between the person and the environment. The
outcome depends on the degree of “fit”
between the skills and capacities of the person,
the type of social support available, and the
various challenges or stressors being confronted.
 Stressors
• Each person operates at a certain level of
adaptation and regularly encounters a certain
amount of change. Such change is expected; it
contributes to growth and enhances life.
Stressors, however, can upset this equilibrium.
A stressor may be defined as an internal or
external event or situation that creates the
potential for physiologic, emotional, cognitive,
or behavioral changes in an individual.
 TYPES OF STRESSORS
Stressors exist in many forms and categories. They
may be described as physical, physiologic, or
psychosocial. Physical stressors include cold, heat,
and chemical agents; physiologic stressors include
pain and fatigue. Examples of psychosocial stressors
are fear of failing an examination and losing a job.
Stressors can also occur as normal life transitions
that require some djustment, such as going from
childhood into puberty, getting married, or giving
birth.
 STRESS AS A STIMULUS FOR DISEASE

• Relating life events to illness (the theoretical

approach that defines stress as a stimulus) has
been a major focus of psychosocial studies.
This can be traced to Adolph Meyer, who in the
1930s observed in “life charts” of his patients a
linkage between illnesses and critical life
events. Subsequent research revealed that
people under constant stress have a high
incidence of psychosomatic disease.
 Coping With the Stressful Event
• Coping, according to Lazarus, consists of the
cognitive and behavioral efforts made to
manage the specific external or internal
demands that tax a person’s resources and
may be emotionfocused or problem-focused.
• Coping that is emotion focused seeks to make
the person feel better by lessening the
emotional distress felt. Problem-focused
coping aims to make direct changes in the
environment so that the situation can be
managed more effectively. Both types of
coping usually occur in a stressful situation
NURSING IMPLICATIONS
 NURSING IMPLICATIONS
• It is important for the nurse to realize that the
optimal point of intervention to promote
health is during the stage when the
individual’s own compensatory processes are
still functioning. Early identification of both
physiologic and psychological stressors
remains a major role of the nurse.
 NURSING IMPLICATIONS
The nurse should be able to relate the
presenting signs and symptoms of distress to
the physiology they represent and identify the
individual’s position on the continuum of
function, from health and compensation to
pathophysiology and disease.
For example, if an anxious middle-aged woman
presented for a checkup and was found to be
overweight, with a blood pressure of 130/85 mm
Hg, the nurse would counsel her with respect to
diet, stress management, and activity. The nurse
would also encourage weight loss and discuss the
woman’s intake of salt (which affects fluid balance)
and caffeine (which provides a stimulant effect). The
patient and the nurse would identify both individual
and environmental stressors and discuss strategies
to decrease the lifestyle stress, with the ultimate
goal being to create a healthy lifestyle and prevent
hypertension and