PRESENTATION ON

CARE OF
CRITICALLY ILL
PATIENT
COLLEGE OF NURSIING REGIONAL INSTITUTE OF MEDICAL SCIENCES

SUBMITTED TO SUBMITTED BY

Mrs. H. MAMATA DEVI Miss ANAMIKA SHARMA

TUTOR 2nd YEAR M.Sc. NURSING

CON, RIMS CON, RIMS

 INTRODUCTION
Critical care medicine specializes in caring for the most seriously ill patients. These
patients are best treated in an intensive care unit (ICU) staffed by experienced personnel.
Some hospitals maintain separate units for special populations (eg, cardiac, trauma, surgical,
neurologic, pediatric, or neonatal patients). ICUs have a high nurse:patient ratio to provide
the necessary high intensity of service, including treatment and monitoring of physiologic
parameters.

Supportive care for the ICU patient includes provision of adequate nutrition and
treatment and prevention of infection, stress ulcers and gastritis, and pulmonary embolism.
Because 15 to 25% of patients admitted to ICUs die there, Doctors and Nurses should know
how to minimize suffering and help dying patients maintain dignity.

MEANING
 CRITICALLY ILL PATIENTS: critically ill patients are those who are at risk for
actual (or) potential life threatening health problems or unstable patients.
 CRITICAL CARE NURSING: It is the field of nursing with a focus on the utmost care
of the critically ill (or) unstable patients
 CRITICAL CARE UNITS: CCUs or Intensive care units (ICUs) are designed to meet
the special needs of acutely and critically ill patients.

CLASSIFICATION OF CRITICAL CARE PATIENTS

Level 0: Normal acute ward care

Level 1: (General at risk ward patients)

a) Acute ward care, with additional advice and support from the critical care team e.g.
patients who are at risk of deterioration, or

b) Who are recovering after higher levels of care and still have great nursing needs

Level 2: (High Dependency)

a) Detailed observation or intervention e.g. patients with a single failing organ

system, or post-operative patients, or patients stepping down from higher levels
of care

Level 3: (Intensive Care)

a) Advanced respiratory support alone, or basic respiratory support together with

support of at least two organ systems
CONDITIONS REQUIRING CRITICAL CARE
Critical care is needed for patients having life-threatening illness or injury, such as:
a. Severe burns
b. COVID-19
c. Heart attack
d. Heart failure
e. Kidney failure
f. People recovering from certain major surgeries
g. Respiratory failure
h. Sepsis
i. Severe bleeding
j. Serious infections
k. Serious injuries, such as from car crashes, falls, and shootings
l. Shock
m. Stroke

GUIDING PRINCIPLES FOR PROVIDING CARE TO CRITICALLY

ILL PATIENT
 Delivery of optimal and appropriate care
 Relief of distress
 Compassion and support
 Dignity
 Information
 Care and support of relatives and caregivers

NURSING MANAGEMENT OF CRITICALLY ILL PATIENT

I) Admission and orientation of the patient and family members to CCU\ICU.
II) Patient Assessment: Upon receiving responsibility for the care of a patient the nurse
should assess the patient.
 The assessment includes becoming familiar with the patient's history, and
performing a physical examination.
  The history may be obtained from the client or may be passed on during rounds.
Rounds are an excellent forum for communication. Information should be
provided as to the significant changes in the patient's status.
 The nurse should be skilled at performing physical examinations; it defines the
patient's responses to the disease process. The physical exam helps establish a
baseline for comparison in evaluating ongoing nursing or medical interventions.
 At minimum, a temperature, pulse, and respiration should be checked; in
addition mentation should be noted, chest auscultated and the bladder should be
palpated.
 The patient's hydration status should be determined.
 A quick assessment should be made of all indwelling catheters.
 Following the nursing assessment and a review of the doctor's orders, plans
should be formulated for the nursing care of the patient.
III) Planning patient care : Planning patient care involves developing plans to
meet the needs identified in the assessment phase.
 Planning helps the nurses become organized, set priorities, and contemplate
actual and potential problems or risk factors.
 The nurse should be capable of recognizing those risks and have a plan for
dealing with them.
 A part of the planning process includes the development of nursing care plans.
 Nursing care plans should include monitoring intake and output, nutritional
support, meeting comfort needs including assessing for pain. Measures should
be taken to minimize the risk of nosocomial infections. Bandage and wound
care should be performed. Non-ambulatory patients will require recumbent
patient care. Catheter care will need to be performed.
 Essential nursing care includes:
A. Continuous monitoring
B. Respiratory care
C. Cardio vascular care
D. Gastrointestinal
E. Nutritional care
F. Neuromuscular care
G. Comfort and reassurance
H. Communication with the patient
 I. Infection control, skin care ,general hygiene and mouth care
J. Fluid, electrolyte and glucose balance
K. Bowel and Bladder care
L. Dressing and wound care
M. Communication with patient and relatives

 RESPIRATORY CARE
Patients may have airway obstruction, altered ventilation, poor secretion clearance,
atelectasis (lung collapse) , impaired muscle function etc.
Respiratory care includes
• Improving Oxygenation
• Appropriate use of medication
• Monitoring of treatment efficacy
• Recognition of early warning signs of an exacerbation with rapid access to appropriate
services (Ventilator, Crash trolley, Emergency drugs)
• Positioning (Fowlers position)
• Suctioning if necessary
• Tracheostomy care.
 CARDIO VASCULAR CARE
Prolonged immobility impairs autonomic vasomotor responses to sitting and standing
causing profound postural hypotension.
Cardiovascular care includes
• Continuous Cardiac Monitoring (dysrhythmia)
• Appropriate use of medication
• Monitoring of treatment efficacy
• Recognition of early warning signs of an exacerbation with rapid access to appropriate
services (Defibrillator , ECG, Emergency drugs)
• Positioning
 GASTRO-INTESTINAL/ NUTRITIONAL CARE
The supine position predisposes to gastro oesophageal reflux and aspiration

pneumonia.
Gastrointestinal care includes
  A patient with 30 degree head elevation prevents reflux.
• Early enteral feeding reduces infection, stress ulceration and GI bleeding.
• Immobility is associated with gastric stasis and constipation. Hence, gastric stimulants and
laxatives should be provided.
 NEUROMUSCULAR CARE
Immobility, prolonged neuromuscular blockage and sedation promote atropy, joint
contractures and foot drops may occur.
Neuromuscular care includes
 Physiotherapy and splints may be required.
 Glasgow coma scale to assess the patients’ consciousness. The Glasgow coma scale
or GCS is a neurological scale that aims to give a reliable, objective way of recording
the conscious state of a person for initial as well as subsequent assessment. GCS was
initially used to assess level of consciousness after head injury. In hospitals it is also
used in monitoring chronic patients in intensive care.
 COMFORT AND REASSURANCE
• Anxiety, discomfort and pain must be recognized and relieved with reassurance,
Physical measures, analgesics and sedatives.
• In particular, endotracheal or nasogastric tubes, bladder or bowel distension, should be
examined.
• Line sites, painful joints and urinary catheters often cause discomfort, and are often
overlooked.
• Comfort needs includes keeping the patient clean and dry, seeing to the patients mental
well-being, assessing the patient for pain

 COMMUNICATION WITH THE PATIENT

• Assist interaction with appropriate communication
• Tell the patient about the care prognosis.
• And if the patient is unconscious, communicate about their health status and care
prognosis to their family members
 INFECTION CONTROL
• Hand washing is vital to prevent transmission of organisms between patients.
• Disposable aprons are recommended, sterile technique (e.g. gloves, masks, gowns,
sterile field) is essential for all invasive procedures (e.g. line insertion)
 • Isolation for transmissible infections (e.g. tuberculosis)
• Thorough cleaning of bed spaces (e.g. routinely and after patient discharge)
 SKIN CARE, GENERAL HYGIENE AND MOUTH CARE
Cutaneous pressure sores are due to local pressure (e.g. bony prominences). Friction,
Malnutrition, edema, ischemia, and damage related to moist or soiled skin may be other
causes of cutaneous damage.
Care needed
 Provide sponge bath, mouth care and general hygiene to the patient.
 Turn patient every 2 hours and protect susceptible areas.
 Special bed relieves pressure and assist turning.
 Provide back care.
 Poor oral hygiene can cause halitosis and discomfort. It also increases the risk of
ventilator associated pneumonia. Absence of mastication decreases the amount of
saliva produced which decreases the amount of protective enzymes located in the
oral cavity.
 Specific oral care may be required in addition to basic oral care if conditions such
as thrush or oral pressure areas are present
 Assessment is required to determine the quantity and type of oral care required
 Note: a normal healthy mouth is pink, moist, has no coating or cracking, redness,
ulcers or bleeding. When providing oral care this is what we are aiming for.
 FLUID ELECTROLYTES AND GLUCOSE BALANCE
• Regularly assess fluid and electrolytes balance by maintaining I/O chart hourly.
• Insulin resistance and hyperglycemia are common but maintaining normo-glycemia
improves outcomes.
 BLADDER CARE
• Urinary catheters cause painful urethral ulcers and must be stabilized by providing
urinary catheter care.
• Early removal reduces urinary tract infections.
• Urinary catheter care is performed every 8 hours. The urinary catheter itself
should be kept clean especially in the female patient where the vulva is in close
proximity to the rectum.
 • The urinary catheter should be attached to a collection system. By maintaining a
closed collection system you decrease the chance of a urinary tract infection
(UTI). Do not disconnect the urinary catheter from the collection system.
• Drain the system every 2-4 hours rather than hourly.
 DRESSING AND WOUND CARE
• Replace wound dressings as necessary.
• Change arterial and central venous catheter dressings every 48- 72 hours.
• A patient's surgical incision should be evaluated several times a day.
• A surgical incision may be expected to produce mild redness and swelling with no
drainage from the incision site. Extensive surgical manipulation, infectious
contamination, cause swelling, redness, bruising, drainage and an area that is hot to
the touch.
• Localized swelling, which is fluid filled, may be due to a seroma (serum pocket) or
hematoma (hemorrhage) formation. Swelling that occurs several days postoperatively
and is hot to the touch, may be due to an abscess or cellulitis.
• All wound/incision checks should be documented in the medical record. Any
abnormal findings are brought to the attention of the clinician.
 COMMUNICATION WITH RELATIVES
• Family members receive information from many care givers with different perspectives
and knowledge.
• Critical care teams must aim to be consistent in their assessments and honest about
uncertainties.
• All conversation should be documented.
 PATIENT EVALUATION
• As part of nursing care, nurse should constantly evaluate the patient's condition.
• The nurses should see if the therapy is improving the patient's condition.
• In addition, evaluation of the nursing care plans should be considered. Evaluation may
be inherent in many of the nursing care procedures discussed such as catheter or
bandage care.
• The nurse should see if risk factors are turning into complications. It is important to
remember, "If you don't look, you won't see".
Reference

1) Bruner and Suddharth.Textbook of Medical Surgical Nursing. 12th ed. New Delhi: Wolter
Kluwer Publication(P) Ltd; 2011. P. 308-310

2) Henderson V. The Concept of Nursing (2006) Journal of Advanced Nursing 53(1), P.21–34.
3) Elliott, D, Aitken, L & Chaboyer, W (eds) 2007, ACCCN's critical care nursing, Elsevier, Marrickville,
NSW.
4) https://medlineplus.gov/criticalcare.html
5) https://www.msdmanuals.com/professional/critical-care-medicine/approach-to-the-critically-ill-
patient/introduction-to-the-approach-to-the-critically-ill-patient