Intro to Critical Care Nursing

Critical care areas are filled with stressors

● ​Loss of privacy
● Artificial lighting & Noise
● Lack of meaningful stimuli
● Pain

Types of Units
● ICU = Intensive Care Unit
○ Monitoring Needed
■ Continuous ECG
■ BP
■ O2 sat
■ Cardiac Output (Co)
■ Intracranial Pressure
■ Temperature
■ Cardiac Index (CI)
■ Stroke Volume (SV)
■ Stroke Volume Variation (SVV)
■ Ejection fraction
■ End-Tidal C02
■ Tissue O2 consumption
○ On going support by
■ Mechanical ventilators
■ Intra-Aortic balloon Pumps (IABPs)
■ Circulatory Assist Devices (CAD)
■ Dialysis Machines
● SICU = Surgical
● MICU= Medical
● CCU = Coronary Care Unit
● PACU = Post Anesthesia Care Unit
● IMCU = Intermediate Care Unit
● PCU = Progressive Care Unit ​(aka intermediate care or step-down units)
○ Transition b/t ICU and general care or discharge.
○ Are at risk for serious complications, but risk is lower than ICU patients
■ Cardiac Procedures
● Stent placement
■ Awaiting heart transplant
■ Rec’ing stable doses of vasoactive drugs
● Diltiazem ( Cardizem)
■ Weaned from prolonged Mechanical Ventilations
○ Monitoring in these units
■ Continuous ECG
■ Arterial BP
■ O2 sat
■ End-Tidal CO2

Rapid Response Teams (RRTs)

● Provides for the delivery of advanced care by an interprofessional team
○ critical care nurse, respiratory therapist, critical care physician or an advanced practice
RN
● RRTs bring rapid and immediate care to unstable patients in noncritical care settings
American Association of Critical-Care Nurses (AACN)
● Founded in 1969
● Largest specialty organization in world
● Influences critical care standards of practice
● Number one priority is education of critical care nurses.
● The AACN definition: “that specialty dealing with human responses to life-threatening problems.”
The AACN Standards of Professional Practice include:
I - Quality of care
II - Individual Practice Evaluation
III - Education
IV - Collegiality
V - Ethics
VI - Collaboration
VII - Research
VIII - Resource Utilization

Critical Care Patient

● Patients often exhibit early and subtle signs of deterioration (e.g., mild confusion, tachypnea) 6 to
8 hours before cardiac or respiratory arrest.
● A patient is generally admitted to the ICU for one of three reasons
○ FIRST​: Patient may be physiologically unstable, requiring advanced clinical judgments by
nurse and HCP
○ SECOND:​ Patient may be at risk for serious complication and need frequent
assessments and often invasive interventions
○ THIRD:​ Patient may need intensive and complicated nursing support related to the use of
IV polypharmacy and advanced technology
■ sedation, thrombolytics, drugs requiring titration [vasopressor]
■ mechanical ventilation, intracranial pressure monitoring, continuous renal
replacement therapy, hemodynamic monitoring
● Patients can be clustered by
○ Disease condition
■ Neurology, Pulmonary
○ Age group
■ Neonate, Pediatrics
○ Acuity
■ acute and unstable ​vs​. chronic but technology dependent
● Commonly treated patients in ICU:
○ Respiratory distress
○ Acute neurologic impairment
○ Myocardial infarction
○ Post-op heart surgery
○ Major surgical procedure
■ Organ transplant
○ Trauma
○ Burns
○ Medical emergencies
■ sepsis, DKA, drug overdose, thyroid crisis
● Those not expected to recover are not admitted
○ pt in a persistent, vegetative state or to prolong the natural process if death
● Nonsurvivors in ICU are older, have comorbidities and experience longer ICU stays.
○ liver disease, obesity

Common Problems of Critically ill Patients

● Often intubated and mechanically ventilated
● Prolonged immobility
 ● High risk for skin problems and venous thromboembolism
● Health care-associated infections ​(HAIs)
○ Predisposed/t use of multiple invasive devices
● Sepsis and multiple organ dysfunction syndrome may follow
● Special problems
○ anxiety, pain, impaired communication, sensory-perceptual problems, sleep and nutrition
can occur

Nutrition problems when arriving or staying in ICU

● I​nadequate nutrition is linked to increase morbidity
○ I.E. enteral feeding interruptions d/t need to give meds or for test & procedures.
● Hypermetabolic states
○ characterized by increased blood pressure and heart rate, peripheral insulin resistance,
and increased protein and lipid catabolism, which lead to increased resting energy
expenditure, increased body temperature, total body protein loss, muscle wasting, and
stimulated synthesis
○ burns, sepsis
● Catabolic states
○ Characterized by fatigue, low energy levels, exercise intolerance, and a reduction in your
ability to handle any kind of stress leading to the breakdown or losing overall mass, both
fat and muscle.
○ acute kidney injury
● Severely malnourished states
○ chronic heart, pulmonary, or liver disease
● Determining whom to feed, what to feed, when to feed, and how to feed (route) is crucial when
caring of a critically ill patients
● Primary goal of nutritional support:
○ Prevent or correct nutritional deficiencies
■ Early provision of enteral nutrition or parenteral nutrition
● Enteral nutrition
○ Delivery of calories via GI tract
○ ​Preserves the structure and function of the gut mucosa and stop
the movement of gut bacteria across the intestinal wall and into
the bloodstream
○ associated with fewer complications and shorter hospital stay
○ Less invasive than parenteral nutrition
● Parenteral nutrition
○ IV delivery of calories
○ Used when enteral route cannot provide adequate nutrition or is
contraindicated
■ paralytic ileus, diffuse peritonitis, intestinal obstruction,
pancreatitis, GI ischemia, abdominal trauma or surgery,
and severe diarrhea
Anxiety
● Primary source:
○ Perceived or anticipated threat to health or life, loss of control of body functions, and an
environment that is foreign
● Pain, impaired communication, sleeplessness, immobilization and loss of control all enhance
anxiety
● Reduce anxiety:
○ Express concerns, ask questions, and state their needs.
○ Include pt and caregiver in all conversations and explain the purpose of equipment and
procedures.
○ ​Encourage caregivers to bring photographs and personal items.
 ○ Appropriate use of antianxiety meds​ (lorazepam [Ativan])​ and relaxation techniques
(music therapy) may reduce stress response
Pain
● Inadequate pain control is often linked with agitation and anxiety = adds to stress
● Patients who are at high risk for pain:
○ Medical conditions that include ischemic, infectious, or inflammatory process
○ Immobilized
○ Have invasive monitoring device (endotracheal tubes)
○ Require invasive or noninvasive procedures
● Critically ill patients (those intubated) → ​continuous IV sedation → ​Propofol [Diprivan] ​or for pain
and sedation → Analgesic agent ​fentanyl [Sublimaze]
■
Be alert that this prevents full neuro status assessment
● Guidelines should include a ​daily,​ scheduled interruption of sedation ​→
“Sedation Holiday”​ t​o allow a neuro exam
Impaired Communication
● Especially patients with an ET tube, those who can not speak because of sedative and paralyzing
drugs
● Explore other methods of communication
○ Picture board, Notepads, Magic slates, Computer keyboards
● When speaking w/ pt à look directly at the patient and use hand gestures when appropriate
● Use approved interpreter if pt or caregiver does not speak english
● Nonverbal communication is important
● High levels of procedure-related touch and lower level of comfort-related touch
○ If appropriate, use comforting touch with ongoing evaluation of the patient’s response
○ Encourage caregivers to touch and talk with the patient even if the patient is
unresponsive
Sleep problems
● Nearly all patients in ICU have sleep disturbance
○ associated with delirium and delayed recover
● Arrange the environment to promote the patient’s sleep-wake cycle
·​ ​ ​Strategies include:
○​ ​Scheduling rest periods
○ Dimming lights at nighttime
○ Providing eye masks and or ear plugs
○ Opening curtains during daytime
○ Getting physiologic measurements w/o disturbing the pt
○ Limiting noise
○ Providing comfort measures → massage
○ Benzodiazepines
Temazepam[Restoril]
benzo-like drugs zolpidem [Ambien]
Sensory/Perceptual problems
● Acute and Reversible
● Alterations in consciousness
Delirium aka ICU psychosis
● NOT​ dementia
● Alterations in mentation
○ delusions, short attention span, loss of recent memory
● Psychomotor behaviors
○ restlessness, lethargy
● Sleep-wake cycle
○ daytime sleeping, nighttime agitation
Risk Factors:
● Pre Existing dementia, history of baseline hypertension or alcohol abuse, and severe illness on
admission
 ● Environmental factors
○ sleep deprivation, anxiety, sensory overload, and immobilization
● Physical conditions
○ hemodynamic instability, hypoxemia, hypercarbia, electrolyte disturbances, and severe
infections
● Certain drugs
○ Sedatives (benzo), analgesics (opioids), and antimicrobials (aminoglycosides)
Nursing Interventions
● Monitor all patients for delirium
● Address/Correct physiologic factors
○ Oxygenation, Perfusion, and electrolyte problems.
● Help orient patient
○ Use of clocks and calendars
● If experiencing hyperactivity, insomnia or delusions → tx with sedative drugs with anxiolytic
effects
○ Dexmedetomidine ( Precedex)
● Presence of Caregiver can help orient and reduce agitation
● Last → Introduction of early mobility protocols can help reduce agitation
● For Sensory overload
○ Limit noise and assist the patient in understanding noises that cannot be prevented
○ Find a suitable place for patient-related discussions
■ Adds stress if pt is being talked about in front of pt but pt doesn't have input
○ Muting phones, setting alarms based on the patient’s condition, and reducing
unnecessary alarms.
■ Silencing BP alarm when handling invasive lines and then reset the alarm when
done
■ Silence ventilator alarms when suctioning
○ Last → limit overhead paging

Psychosocial Suppor
● Involving the family increases the patient’s outcome
● Caregivers play a valuable role in the patient’s recovery and are members of the interprofessional
care team
● Identify a spokesperson for the family to help coordinate information exchange between the
interprofessional care team and family
● Evaluate the appropriateness of including caregivers in rounds and patient care conferences.
○ It helps with acceptance and coping with problems when they see that the team is caring
and competent
● Limiting visitation does NOT protect the patient from adverse physiologic consequences.
○ AACN strongly recommends less restrictive, individualized visiting policies

Ethical Considerations
​4 Ethics Principles​:
● Respect for autonomy ​→ right to make decisions
● Nonmaleficence​ → not harming a patient
● Beneficence​ → helping a patient
● Justice​ → treating patients equally
Cultural Competence
● Ensures individual differences r/t culture are incorporated into the plan of care
● Often meeting the patient’s physiologic needs is a priority and overshadows the influence of the
patient’s culture on the illness experience
● Telling some pt’s that they are dying as a way of letting them prepare for death may impose on
the family’s role.