CRITICAL CARE NURSING

MEANING

CRITICAL
• Crucial
• Crisis
• Emergency
• Serious
• Requiring immediate action
• Thorough and constant observation
• Total dependent (Oxford Dictionary)
 DEFINITION
CRITICAL CARE:

Is a term used to describe as the care of patients who are

extremely ill and whose clinical condition is unstable or
potentially unstable.

CRITICAL CARE UNIT :

It is defined as the unit in which comprehensive care of a

critically ill patient which is deemed to recoverable stage is
carried out.
 DEFINITION

CRITICAL CARE NURSE :

 Care for clients who are very ill
 Provide direct one to one care
 Responsible for making life-and death decision
 At high risk of injury or illness from possible
Exposure to infections
 Communication skill is of optimal importance

CRITICAL CARE NURSING :

It refers to those comprehensive, specialized and individualized
nursing care services which are rendered to patients with life
threatening conditions and their families.
CRITICAL CARE NURSING :
It refers to those comprehensive, specialized and
individualized nursing care services which are rendered to
patients with life threatening conditions and their families.
 CRITICALLY ILL CLIENT

CRITICALLY ILL CLIENT:

 At high risk for actual or
potential life- threatening
health problems
 More ill
 Required more intensive
and careful nursing care
 What are the conditions considered as
Critical?

1. Any person with life threatening condition

2. Patients with : ARF, AMI, cardiac tamponate, severe shock,

heart block, acute renal failure, poly trauma, multiple organ
failure and organ dysfunction, severe burns
 CRITICAL CARE TECHNOLOGY

 ECG monitoring
 Arterial Lines
 Oxygen Saturation
 Ventilation
 Intracranial Pressure
 Monitoring Temperature
 Pulmonary Artery Catheter
 IABP
 Extensive use of pharmaceuticals
HISTORICAL BACKGROUND
 HISTORY- CONTD

 Collaboration between nurses and physicians

 1950’s & 1960’s – CV Disease most common diagnosis
 1960’s – 30-40% mortality rate for MI
 1965 – 1st specialized ICU – The Coronary Care Unit
 Emergence of specialized ICU’S
American Association of Critical-Care Nurses - AACN

• 1969

• Educational support

• Certification

• Largest professional

• Specialty nursing organization

• Scholarships

• Research

• Publishes 2 journals

• Local chapters

• Political awareness

• Provides standards of practice

 CONCEPTS OF CRITICAL CARE NURSING

• Critical care nurses must work in environments where patients

are constantly monitored.
• Critical care nurses work with patients who are gravely ill and
need constant monitoring.
• They are often found in intensive care units (as well as cardiac,
neonatal and paediatric ICUs) as well as emergency rooms,
cardiac cath labs, burn units, telemetry and progressive care
units.
 PRINCIPLES OF CRITICAL CARE

• Anticipation
• Early detection
• Collaborative practice
• Communication

• Prevention of infection
ANTICIPATION:
• Recognize the high-risk patients and anticipate the requirements
• complications and be prepared to meet any emergency.
• Organizing the unit with necessary equipment and supplies are
mandatory for smooth running of the unit.

EARLY DETECTION & PROMPT ACTION:

• Prognosis of the patient depends on the early detection of
changes, prompt and appropriate action to prevent or combat
complications.
 COLLABORATIVE PRACTICE

Critical care is requiring a very specialized body of

knowledge for the physicians and nurses working in the unit.
Collaborative practice between the physicians and the nurses
working in the critical care unit fosters a partnership for
decision-making and ensures quality and compassionate
patient care. Collaborative practice is more and more
warranted for critical care more than in any other field.
COMMUNICATION

Intra-professional, interdepartmental and interpersonal communication has a significant

importance in the smooth running of unit.

PREVENTION OF INFECTION

Critically ill patients requiring intensive care are at a greater risk of nosocomial infection than

other patients due to the following:

• Immuno compromised state with the antibiotic

• Physical & psychological stressors

• Invasive lines

• Mechanical ventilators

• Prolonged stay and severity of illness

• Nutritional depletion

• Environment of the critical care unit itself

 AN IDEAL ICU

Multidisciplinary & Collaborative approach to ICU care

Medical& nursing directors :

co-responsibility for ICU management

A team approach :

Doctors, nurses, R/T, pharmacist

Use of standard, protocol, guideline:

Consistent approach to all issues

Dedication to coordination and communication for all aspects of ICU

management

Emphasis on research, education, ethical issues, patient advocacy

 TEAM DYNAMICS

 A multidisciplinary team to effectively attain specified

objective
 Physician team leader & critical care nurse manager
CRITICAL CARE PRACTICE PATTERN

 Open

 Closed
 Transitional
 OPEN UNITS
Definition :

Any attending physician with hospital admitting privileges can be

the physician of record and direct ICU care. (All other physicians are
consultants).

Disadvantage :

 Lack of a cohesive plan

 Inconsistent night coverage

 Duplication of services
 CLOSED UNITS
Definition:
An intensivist is the physician of record for ICU patients. (other
physicians are consultants), All orders & procedures carried out by ICU
staff.
Advantage:
improved efficiency
standardized protocol for care
Disadvantage:
potential to lock out private physician
increase physician conflict
 TRANSITIONAL UNITS
Definition:
Intensives are locally present shared co- managed care between ICU
staff and private physician ICU staff is a final common pathway for
orders and procedures .
Advantage:
Reduce physician conflict, standard policies and procedures usually
present.
Disadvantage:
Confusion and conflict regarding final authority & responsibilities
for patient care decision.
 A GOOD ICU
• Well organized
• Trust
• Coordinated care
• Full-time intensivist:
• Daily round
• Protocol & policies (eg: how to DC elective operation when bed not
available)
• Bedside nurses (master degree)
• no intern
• A team: doctors, nurses, R/T, pharmacists
• Led by full time intensivists
• Critical care trained available in a timely fashion (24hr/day)
• No competiting clinical responsibilities during duty
• Closed units, if resources allow
 ASSESMENT

NURSING ASSESSMENT :
It is the first stage of nursing process in which the nurse
should carry out a complete and holistic nursing assessment of
every patient’s needs, regardless of the reason for the
admission.
 COMPONENTS OF NURSING
ASSESSMENT
NURSING HISTORY:

Taking a nursing history prior to the physical examination allows a nurse to establish
a rapport with the patient and family.

Elements of the history include :

 Health Status

 Cause of present illness including symptoms

 Current management of illness

 Past medical history including family’s medical history

 Social history

 Perception of illness
Psychological and Social Examination-
• Client’s perception
• Emotional health
• Physical health
• Spiritual health
• Intellectual health
Physical Examination :
A nursing assessment includes physical examination, where the
observation or measurement of signs, which can be observed or measured,
or symptoms such as nausea or vertigo, which can be felt by the patient.
• The techniques used may include Inspection, Palpation,
auscultation and Percussion in addition to the vital signs like
temperature, pulse, respiration , BP and further examination of
the body systems such as the cardiovascular or
musculoskeletal systems.
• Documentation of Assessment:

The Assessment is documented in the patient’s medical or

nursing records, which may be on paper or as part of the
electronic medical record which can be assessed by all
members of the health care team.
 CLASSIFICATION OF CRITICAL CARE UNITS
LEVEL - I :

Provides monitoring, observation and short term ventilation. nurse patient

ratio is 1:3 and the medical staff are not present in the unit all the time.

LEVEL - II :

Provides observation, monitoring and long term ventilation with resident

doctors. the nurse-patient ratio is 1:2 and junior medical staff is available
in the unit all the time and consultant medical staff is available if needed.

LEVEL - III :

Provides all aspects of intensive care including invasive haemodynamic

monitoring and dialysis. nurse patient ratio is 1:1
 CLASSIFICATION OF CRITICAL CARE
PATIENTS

• Level O : normal ward care

• Level 1: at risk of deteriorating , support from critical care
team
• Level 2 : more observation or intervention, single failing
organ or post operative care
• Level 3: advanced respiratory support or basic respiratory
support ,multiorgan failure
 HIGH DEPENDENCY CARE

• Coronary care units (CCU)

• Renal high dependency unit (HDU)
• Post-operative recovery room
• Accident and emergency departments (A&E)
 TYPES OF CRITICAL CARE UNIT

• Neonatal intensive unit (NICU)

• Special care nursery (SCN)
• Paediatric intensive care unit (PICU)
• Psychiatric intensive care unit
 ORGANIZATION OF ICU
DESIGN OF ICU :
1. Should be at a geographically distinct area within the hospital,
with controlled access.
2. There should be a single entry and exit. However, it is required
to have emergency exit points in case of emergency and
disaster.
3. There should not be any through traffic of goods or hospital
staff. Supply and professional traffic should be separated from
public/visitor traffic.
 DESIGN OF ICU - CONTD

4. Safe, easy, fast transport of a critically sick pt should be a

priority in planning its location. Therefore, the ICU should be
located in close proximity to ER, OT, trauma ward etc.
5. Corridors, lifts and ramps should be spacious enough to provide
easy movement of bed/trolley of a critically sick patient.
6. Close, easy proximity is also desirable to diagnostic facilities,
blood bank, pharmacy etc.
 BED STRENGTH
1. It is recommended that total bed strength in ICU should be between 8-12 and not

less than 6 or not more than 24 in any case.

2. 3-5 beds per 100 hospital beds for a Level III ICU or 2 to 20% of the total no of

hospital beds.

3. 1 isolation bed for every ICU beds.

BED AND ITS SPACE:

1. 150-200 sq.ft per open bed with 8 ft in between beds.

2. 225-250 sq.ft per bed if in a single room.

3. Beds should be adjustable, no head board, with side rails and wheels.

4. Keep bed 2 ft away from head wall.

 ACCESSORIES
1. 3 O2 outlets, 3 suction outlets (gastric, tracheal and underwater
seal), 2 compressed air outlets and 16 power outlets per bed.
2. Storage by each bedside.
3. Hand rinse solution by each bedside.
4. Equipment shelf at the head end.
5. Hooks and devices to hang infusions/ blood bags, extended from
the ceiling with a sliding rail to position.
6. Infusion pumps to be mounted on stand or poles.
7. Level II ICUs may require multi channel invasive monitors
8. ventilators, infusion pumps, portable X ray unit, fluid and bed warmers, portable
light, defibrillators, anaesthesia machines and difficult airway management
equipments are necessary.
STAFFING :
1. Medical Staff – the best senior medical staff to be appointed as an Intensive Care
Director or Intensivist. Less preferred are other specialists from anaesthesia /
medicine who has clinical commitment elsewhere. Junior staff are intensive care
trainers and trainees on deputation from other disciplines.
2. Nursing staff – The major teaching tertiary care ICU requires trained nurses in
critical care.
 STAFFING

• The no of nurses ideally required for such unit is 1:1 ratio, however
it might not be possible to have such members in our set up. So 1
nurse for 2 patients is acceptable. The no of trained nurses should
also be worked out by the type of ICU, the workload and work
statistics and type of patient load.
3.Allied Services – Respiratory services, Nutritionist, Physiotherapist,
Biomedical engineer, technicians, computer programmer, clinical
pharmacist, social worker / counsellor and other support staff,
guards and grade IV workers.