Critical Care Nursing

CRITICAL
CARE
NURSING
CRITICAL
Crucial
Crisis
Emergency
Serious
Requiring immediate action
Thorough and constant observation
Total dependent
(Oxford Dictionary)
Prof. Dr. R S Mehta, BPKIHS
CRITICAL CARE
NURSING
The care of seriously ill clients from point
of injury or illness until discharge from
intensive care
Deals with human responses to life
threatening problems -trauma /major
surgery
(Mary,L.S., Deborah, G.K. & Marthe, J.M. 2005)
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
CRITICALLY ILL CLIENT

At high risk for actual or potential lifethreatening health problems
More ill
Required more intensive and careful
nursing care
DEFINITIONS
CRITICAL CARE :
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.
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 Technology
ECG monitoring
Arterial Lines
Oxygen Saturation
Ventilation
Intracranial Pressure
Monitoring
Temperature
Pulmonary Artery
Catheter
IABP
Extensive use of
pharmaceuticals
10
The Critical Care Nurse

Specialty dealing with human responses
to life-threatening problems
Requires Extensive Knowledge and a
Continual Desire to Learn
11
Economic Impact of ICU

(1994)
* <10% of hospital beds
* 30% of acute care hospital cost
* >20% of hospital budget
* 1% of GNP expended for ICU care
With aging of the population
Demand for critical care service will
increase
12
Historical Background
13
World War II
Shock wards
established for
resuscitation
Transfusion practices
in early stages
After World war-II,
nursing shortage
forced grouping of
postoperative patients
in recovery areas
14
Polio epidemic
1950s: use of
mechanical ventilation
(iron lung) for treatment
of polio
Development of
respiratory intensive care
units
At the same time, general
ICUs developed for sick
and postoperative
patients
15
History Continued
Collaboration between nurses and
physicians
1950s & 1960s CV Disease most
common diagnosis
1960s 30-40% mortality rate for MI
1965 1st specialized ICU The
Coronary Care Unit
Emergence of Specialized ICUs
16
1957
17
ICUs also treat the

dying
Isaac Asimov:
Life is pleasant.
Death is peaceful.
It is the transition
that is difficult
Isaac Asimov: Professor of Biochemistry Boston
18
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
19
An Ideal ICU
20
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
21
Team Dynamics
A multidisciplinary team to effectively
attain specified objective
Physician team leader & critical care
nurse manager
22
Critical Care Practice Pattern

Open
Closed
transitional
23
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
24
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
25
Transitional Units
Definition:
intensives are locally present shared comanaged 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
26
ICU Model Care

Full-time intensivist model :
patient care is provided by an intensivist
Consultant intensivist model :

an intensivist consults for another physician to
coordinate or assist in critical care, but dose not
have primary responsibility for care
Multiple consultant model:

multiple specialists are involved in the patient care,
(esp. R/T doctors for ventilators), but none is
designated especially as the consultant intensivist
Single physician model :

primary physician provides all ICU care
27
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
28
A Good ICU
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
29
What are the conditions

considered as Critical?
1. ANY PERSON WITH LIFE
THREATENING CONDITION
2. PATIENTS WITH :
ARF
AMI
CARDIAC TAMPONATE
SEVERE SHOCK
30
HEART BLOCK
ACUTE RENAL FAILURE
POLY TRAUMA, MULTIPLE

ORGAN FAILURE AND ORGAN
DYSFUNCTION
SEVERE BURNS
31
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 PATIENTS NEEDS,
REGARDLESS OF THE REASON FOR
THE ENCOUNTER.
32
COMPONENTS OF
NURSING ASSESSMENT
1. 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 familys medical history
33
Social history
Perception of illness
2. Psychological and Social Examination. Clients perception
. Emotional health
. Physical health
. Spiritual health
. Intellectual health
. 3. 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.
34
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 patients
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.
35
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.
36
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.
37
LEVEL - III :
PROVIDES ALL ASPECTS OF
INTENSIVE CARE INCLUDING
INVASIVE HAEMODYNAMIC
MONITORING AND DIALYSIS.
NURSE PATIENT RATIO IS 1:1
38
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
39
failure
HIGH DEPENDENCY
CARE
Coronary care units (CCU)
Renal high dependency unit (HDU)
Post-operative recovery room
Accident and emergency departments
(A&E)
Intensive care units (ICU)
40
TYPES OF CRITICAL
CARE UNIT
NEONATAL INTENSIVE UNIT
(NICU)
SPECIAL CARE NURSERY (SCN)
PAEDIATRIC INTENSIVE CARE
UNIT (PICU)
PSYCHIATRIC INTENSIVE UNIT
(PICU)
41
CORONARY CARE UNIT (CCU)

CARDIAC SURGERY INTENSIVE
CARE UNIT (CSICU)
CARDIOVASCULAR INTENSIVE
CARE UNIT (CVICU)
MEDICAL INTENSIVE CARE UNIT
(MICU)
MEDICAL SURGICAL INTENSIVE
CARE UNIT (MSICU)
42
OVERNIGHT INTENSIVE
RECOVERY (OIR)
NEUROSCIENCE /
NEUROTRAUMA INTENSIVE
CARE UNIT (NICU)
NEURO INTENSIVE CARE UNIT
(NICU)
BURN INTENSIVE CARE UNIT
(BNICU)
43
SURGICAL INTENSIVE CARE UNIT

(SICU)
TRAUMA INTENSIVE CARE UNIT
(TICU)
SHOCK TRAUMA INTENSIVE
CARE UNIT (STICU)
TRAUMA NEURO CRITICAL
CARE INTENSIVE CARE UNIT
(TNCC)
44
RESPIRATORY INTENSIVE CARE

UNIT (RICU)
GERIATRIC INTENSIVE CARE
UNIT (GICU)
45
Types of ICU
General
Medical Intensive Care Unit(MICU)
Surgical Intensive Care Unit
Medical Surgical Intensive Care Unit(MSICU)
Specialized
Neonatal Intensive Care Unit(NICU)
Special Care Nursery(SCN)
Paediatric Intensive Care Unit(PICU)
Coronary Care Unit(CCU)
Cardiac Surgery Intensive Care Unit(CSICU)
Neuro Surgery Intensive Care Unit(NSICU)
Burn Intensive Care Unit(BICU)
Trauma Intensive Care Unit
46
PRINCIPLES OF
CRITICAL CARE
NURSING
ANTICIPATION : The first
principle in critical care is Anticipation.

One has to recognize the high risk
patients and anticipate the requirements,
complications and be prepared to meet
any emergency. Unit is properly
organized in which all necessary
equipments and supplies are mandatory
for smooth running of the unit.
47
EARLY DETECTION AND

PROMPT ACTION :
The prognosis of the patient depends on
the early detection of variation, prompt
and appropriate action to prevent or
combat complication. Monitoring of
cardiac respiratory function is of prime
importance in assessment.
48
COLLABORATIVE PRACTICE :
Critical Care, which has originated as technical
sub-specialized body of knowledge has evolved
into a comprehensive discipline requiring a very
specialized body of knowledge for the physicians
and nurses working in the critical care unit fosters
a partnerships for decision making and ensures
quality and compassionate patient care.
Collaborate practice is more and more warranted
for critical care more than in any other field.
49
COMMUNICATION :
Intra professional, inter departmental and
inter personal communication has a
significant importance in the smooth
running of unit. Collaborative practice of
communication model
50
Prevention of Infection : Nosocomial

infection cost a lot in the health care services.
Critically ill patients requiring intensive care are at
a greater risk than other patients due to the
immunocompromised state with the antibiotic
usage and stress, invasive lines, mechanical
ventilators, prolonged stay and severity of illness
and environment of the critical unit itself.
51
Crisis Intervention and Stress

Reduction : partnerships are formulated
during crisis. Bonds between nurses,
patients and families are stronger during
hospitalization. As patient advocates,
nurses assist the patient to express fear
and identify their grieving patttern and
provide avenues for positive coping.
52
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.
53
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 or 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.
54
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.
55
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
56
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
57
ICU requires trained nurses in critical care.
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.
58
CRITICAL CARE NURSE

Factors to be considered in
recruiting Critical Care Nurses
are:
1.
2.
3.
4.
Intra and interpersonal factors

Technical Qualifications.
Educational background
Clinical Experience.
59
PRIME RESPONSIBILITIES OF A
CRITICAL CARE NURSE
Continuous monitoring
Keep ready emergency trolley /
crash
Cart
Efficient Individualized Care.
Counseling and information to

family.
Application of policies and

procedures
Proper records of all activities

60
Maintain infection control
QUICK REFERENCE PROTOCOL

FOR MANAGING EMERGENCY IN
ICU
Quickly review the patient Identity,
History , Physical Exam.
Be with the patient, ask for help.
Place the patient in a suitable

position.
Attach the cardiac monitor and

call for
crash cart.
Maintain Prof.
ABC
Along
with61 expert
Dr. R S Mehta,
BPKIHS
Administer medication as needed.

Carry on Investigations - ABG, ECG,
Urea, Creatinine, Blood Sugar,
Cardiac enzymes.
Maintain Fluid and Electrolytes .
Record right things at right time
rightly.
62
Core Competencies
Patient Care
Medical Knowledge
Professionalism & Ethics
Interpersonal Communication Skills
Practice-based Learning and
Improvement
Systems-based Practice
63
Evaluation of ACCP Board

Review Lectures
Medical Knowledge
Practice Based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
Systems-Based Practice
X
X
64
QI PROJECTS
THCI
FCCS
In Training Exams
Tauma MAn
Procedure Log Books
Error Reporting
Monthly Evaluations
Patient Care
Family Need of the

Critical Care Patient
Information major source of anxiety
and litigation (legal issues)
Reassurance can reassure care is
being given
Convenience access to the patient
65
Job description
Patient care
Multidisciplinary rounds
Bed allocation/triage
Infection control
Protocol development
Quality control/assurance
Education
Residents, fellows, med students, nurses, respiratory therapists,
nurse practitioners
Research
Quality assurance projects
Clinical trials
Database-driven projects
66
General Concept, Setting and

Principle of Critical Care Nursing
67
Who are critically ill patient?
68
Critical illness are grouped by the system of

the body;
A. Cardiac System
1. Acute myocardial infarction with complications
2. Cardiogenic shock
3. Complex arrhythmias requiring close monitoring and intervention
4. Acute congestive heart failure with respiratory failure and/or
requiring hemodynamic support
5. Hypertensive emergencies
6. Unstable angina, particularly with dysrhythmias, hemodynamic
instability, or persistent chest pain
8. Cardiac tamponade or constriction with hemodynamic instability
9. Dissecting aortic aneurysms
10. Complete heart block
69
B. Pulmonary System .
1. Acute respiratory failure requiring ventilatory support
2. Pulmonary emboli with hemodynamic instability
3. Massive hemoptysis
C. Neurologic disorder
4. Intracranial hemorrhage
5. Meningitis with altered mental status or respiratory
compromise
6. Central nervous system or neuromuscular disorders with
deteriorating neurologic or pulmonary function
7. Status epilepticus
8. Severe head injured patients
70
D. Drug Ingestion and Drug Overdose

1. Hemodynamically unstable drug ingestion
2. Drug ingestion with significantly altered mental
status with inadequate airway protection
3. Seizures following drug ingestion
E. Gastrointestinal Disorders
4. Life threatening gastrointestinal bleeding including
hypotension, angina, continued bleeding, or with
comorbid conditions
5. Hepatic failure
6. Severe pancreatitis
71
F. Endocrine
1. Diabetic ketoacidosis complicated by hemodynamic
instability, altered mental status, respiratory insufficiency,
or severe acidosis
2. Severe hypercalcemia with altered mental status,
requiring hemodynamic monitoring
3. Hypo or hypernatremia with seizures, altered mental
status
4.
Hypo or hypermagnesemia with hemodynamic
compromise or dysrhythmias
5. Hypo or hyperkalemia with dysrhythmias or muscular
weakness
6. Hypophosphatemia with muscular weakness
72
G. Surgical
1. Post-operative
patients
requiring
hemodynamic
monitoring/ventilatory
support or extensive nursing care
H. Miscellaneous
2. Septic shock with hemodynamic instability
3. Hemodynamic monitoring
4. Environmental injuries (lightning, near
drowning, hypo/hyperthermia)
73
Admission Criteria in ICU

The ICU admission decision may be based on
several models utilizing prioritization, diagnosis,
and objective parameters models.
A.
Prioritization Model
This system defines those that will benefit most
from the ICU (Priority 1) to those that will not
benefit at all (Priority 4) from ICU admission.
74
Priority 1:
These are critically ill, unstable patients in need of
intensive treatment and monitoring that cannot be
provided outside of the ICU. Usually, these
treatments include ventilator support, continuous
vasoactive drug infusions. Examples of these patients
may include post-operative or acute respiratory
failure patients requiring mechanical ventilatory
support and shock or hemodynamically unstable
patients receiving invasive monitoring and/or
vasoactive drugs.
75
Priority 2:
These patients require intensive monitoring
and may potentially need immediate
intervention. Examples include patients with
chronic comorbid conditions who develop
acute severe medical or surgical illness.
76
Priority 3: These unstable patients are critically ill

but have a reduced likelihood of recovery because of
underlying disease or nature of their acute illness.
Examples include patients with metastatic
malignancy complicated by infection, cardiac
tamponade, or airway obstruction.
Priority 4: These are patients who are generally not

appropriate for ICU admission. Admission of these
patients should be on an individual basis, under
unusual circumstances and at the discretion of the
ICU Director. These patients can be placed in the
following categories:
77
B. Diagnosis Model
This model uses specific conditions or
diseases to determine appropriateness
of ICU admission.
(described above in critically ill patient)
78
C. Objective Parameters Model

Vital Signs
Pulse < 40 or > 150 beats/minute
Systolic arterial pressure < 80 mm Hg or 20 mm Hg below the patient's
usual pressure
Mean arterial pressure < 60 mm Hg
Diastolic arterial pressure > 120 mm Hg
Respiratory rate > 35 breaths/minute
Laboratory Values (newly discovered)
Serum sodium < 110 mEq/L or > 170 mEq/L

Serum potassium < 2.0 mEq/L or > 7.0 mEq/L
PaO2 < 50 mm Hg pH < 7.1 or > 7.7
Serum glucose > 800 mg/dl
Serum calcium > 15 mg/dl
Toxic level of drug or other chemical substance in a hemodynamically or
neurologically compromised patient
79
Radiography/Ultrasonography/Tomography
(newly discovered)
Cerebral vascular hemorrhage, contusion or subarachnoid
hemorrhage with altered mental status or focal neurological
signs
Ruptured viscera, bladder, liver, esophageal varices or
uterus with hemodynamic instability
Dissecting aortic aneurysm
Electrocardiogram
Myocardial infarction with complex arrhythmias,
hemodynamic instability or congestive heart failure
Sustained ventricular tachycardia or ventricular fibrillation
Complete heart block with hemodynamic instability
80
Physical Findings (acute onset)

Unequal pupils in an unconscious patient
Burns covering > 10% BSA
Anuria
Airway obstruction
Coma
Continuous seizures
Cyanosis
Cardiac tamponade
81
Team of Critical Care

Unit
Physicians.
The Most Responsible Physician (MRP) is the physician in charge of the patients
care during the current hospitalization. He or she communicates with other members
of the team on a daily basis.
Nurses
Intensive Care nurses are the minute-to-minute critical care providers. They not only
help to provide, but also coordinate most aspects of care delivery. They have
received specialized training in caring for critically ill patients.
Respiratory Therapists
Respiratory therapists have special training and experience in caring for patients with
breathing problems. They work closely with the physician to develop a plan to
support a patients breathing. They set up, monitor and maintain the breathing
machines (mechanical ventilators), and they adjust these machines minute by minute
and hour by hour to best meet the patient's needs.
82
Pharmacists
Pharmacists consult with the physician in selecting the right medicines at
the correct dose for patients and also in monitoring drug levels in the
body. Pharmacists also help to decrease medication side effects and
provide valuable information to the team members.
Physical Therapist
They help prevent disabilities and facilitate rehabilitation as soon as
possible.
Dieticians
Dieticians calculate the nutritional needs of the critically ill patient and
consult with the physician to provide the patient with the best possible
diet, whether orally or through a feeding tube.
Medical Radiation Technologist

Medical Laboratory Technologist
83
Trauma Coordinator
The Trauma Coordinator reviews the plan of care for each trauma patient and in
consultation with the ICU Care Team, makes suggestions regarding patient needs.
She also works closely with the patient and family, and provides teaching and
information to the patient and family about the patients progress and expected
outcomes.
Social Worker
Social workers provide professional assistance with the needs of patients and
families. They can help to assess and determine what resources patients and families
might be lacking, providing them with information on agencies to assist with various
needs and generally assisting with other family difficulties.
Clinical Educator
Clinical Educators are nurses who provide ongoing education for ICU nurses on new
practices, protocols and on new equipment. They are up-to-date with the best
practices in ICU and communicate with the Manager and with ICU nurses about all
aspects of nursing practice and education. As an important part of their role, they
provide a comprehensive orientation to nurses new to the ICU Care Team as well as
providing continuing advice, support and education for all nurses in ICU.
84
Ward Clerk
ICU Ward Clerks help with communication by answering the phones, processing
physician orders and coordinating some of the patient activities in the ICU.
Pastoral Care
Chaplains are available to minister to the spiritual needs of patients and
families.
Manager
Nurse Managers are nurses with additional experience and education, who are
responsible for the day to day operations of the ICU. In addition to managing the
ICU nursing staff, the ICU Nurse Manager is responsible for the ICU budget and
nursing practices. Nurse Managers are responsible for ensuring that the care in
the ICU is safe. She/he hires ICU nurses and ensures that all nursing staff
members meet the standards established for their performance. She is also there
to assist family members with their needs.
85
Thank you
86
ICU & CCU Service

of BPKIHS
Nursing Care and Protocols
87
Critical Care
Considerations
F=Feeding/fluid
A=Analgesics
S=Sedation
T=Thrombolytic agents
H=Head elevation
U=Ulcer bed sore
G=Glucose monitoring
88
Feeding and Fluids

It includes
Enteral feeding
o Oro - gastric and Naso - gastric feeding
o Churn diet
o Dairy and poultry
products (Milk, egg,
youghort)
o High protein liquid diet
o Medications
89
Oral feeding
o Hospital diet
o Bland diet
o Normal diet
o Liquid intake
90
Transparenteral diet
o Oliclinomel
Includes: Amino acid solution with electrolyte (5.5%) volume
800 ml
Amino acid 44 gram
Na acetate
Na glycerophosphate
KCl
91
MgCl2
Sodium
Magnesium
PO4
Acetate
Chloride
Glucose 20% solution with CaCl2
92
Overall volume of TPN = 2000 ml

Osmolarity = 75 mOsm/L
pH = 6
Amino acid = 44 gram
Total calorie = 1,215 Kcal
93
Fluids
IV fluids like NS, RL, 5% D, 10% D, DNS
94
Analgesics
Fentanyl
o It works 600 times more effectively than
Morphine and reduces the pain and
increases the pain threshold
o Used in moderate and severe pain
o In ICU 50 100 g per Kg
o Antidote Naloxone 0.05 mg/ Kg
95
Morphine
o Reduces pain
o Chiefly used in MI
o 2-4 mg dissolved in 10 ml NS
o Antidote: Naloxone
o Supplied by hospital.
96
Acetaminophen and NSAIDs

o Often more effective than opioids in reducing
pain from pleural or pericardial rubs, a pain that
responds poorly to opioids.
o particularly effective in reducing muscular and
skeletal pain
o Tab form: 500mg OD
97
Sedatives
Benzodiazepines
1. Midazolam
o Short acting sedatives and hypnotics
o In intubated patients
o Dose 0.01- 0.05 mg/Kg for several hours
98
Benzodiazepines
2. Diazepam
Adult dose = 0.2 0.5 mg/ Kg

Not given in MI patients
99
Dissociative Anaesthesia
Ketamine
Adult dose= 1 3 mg/kg IV
100
Propofol
o Arousal is rapid 10- 15 min
o Used in neuro cases and those with
increased
ICP,
during
tracheostomy
procedure
101
Inotropes
Dopamine
Dobutamine
Nor- adrenaline
102
Thrombolytic agents
TEDS compressive stocking

SCD (Systematic Compressive Device)
LMWX
Heparin flush
103
Head elevation
Head is elevated to 30 degree.
104
Ulcer
Two hourly position change

Back care in each shift
Oxygen therapy
Each shift dressing of pressure sore
Air mattresses
105
Glucose monitoring
RBS as prescribed
Insulin therapy
Careful monitoring of signs of
Hypoglycemia
(trembling, clammy skin, palpitations,
anxiety, sweating, hunger, and irritability)
106
Infection control
Hand washing before, during and after the procedure

Sterility maintenance during procedures
Use of disinfectants
Weekly high wash
Monthly culture test of health personnel, equipments
and infrastructures
Regular inspection by infection control team
Each shift CVP dressing
107
Specific equipments
used in ICU and CCU
Ventilators
Infusion pumps
Cardiac monitors
Defibrillator
ABG machine
ECG machine
108
Drugs used in CCU
Aspirin
Clopidogrel
Nitroglycerine
Atorvastatins
LMWX
Morphine
109
Sedation score in ICU is done

by RASS
(Richmond Agitation Sedation Scale = RASS)

110
RASS
(Richmond Agitation Sedation
Scale)
Number
Characteristics
Definition
Intervention
+4
Combative
Violent, immediate
danger to staff
Restrain and
sedate
+3
Very agitated
Aggressive, pull or
remove tubes
Restrain and
sedate
+2
Agitated
Frequent non
Restrain and
purposeful movement, sedate
fights ventilator
+1
Restless
Anxious movement
but not aggressive or
vigorous
Alert and calm
Sedate
111BPKIHS
Prof. Dr. R S Mehta,
Number
Characteristics Definition
Intervention
-1
Drowsy
Not fully alert but has Verbal

sustained awakening, stimulation
eye contact to voice
(>10 sec)
-2
Light sedation
Briefly awakens, eye

contact to voice
(<10sec)
Verbal
stimulation
-3
Moderate
sedation
Moderate or eye
opening to voice but
no eye contact
Verbal
stimulation
-4
Deep sedation
No response to voice
but movement or eye
opening to physical
stimuli
Physical
stimulation
-5
No response
No response to voice
or physical stimuli
Physical
stimulation
112
It may seem a
strange principle to
enunciate (articulate)
as the very first
requirement in a
Hospital that it should
do the sick no harm.
[1859]
113
Thank you!!!
114

Critical Care Nursing

Uploaded by

Copyright:

Available Formats

You might also like

Critical Care Nursing

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Critical Care Nursing

Uploaded by

Copyright:

Available Formats

CRITICAL

CRITICAL CARE NURSE

Prof. Dr. R S Mehta, BPKIHS

CRITICALLY ILL CLIENT

Prof. Dr. R S Mehta, BPKIHS

CRITICAL CARE UNIT :

Prof. Dr. R S Mehta, BPKIHS