Critical Care Concepts & critical care environment Part I

Slide 1:
Welcome to Nursing 2501 and the first presentation on critical care concepts and the critical care
environment. My name is Linda Komara and I am one of the nursing 2501 faculty presenting online
lectures throughout this semester. Before you begin this presentation, please read the course syllabus to
ensure you are familiar with the course description, course outcomes, required textbooks, procedures and
other important information related to nursing 2501. Once you have read the syllabus, you are ready to
begin Unit I: Critical Care Concepts & the critical care environment. Please print the accompanying
handout prior to listening to each presentation so you can take notes. The presentation can be paused if
needed for note taking.

Slide 2:
The specialty of intensive care medicine was first introduced in the 1950s as a result of the polio epidemic
and the need for mechanical ventilators. Since that time, the critical care environment has become
increasingly sophisticated and complex, with the use of highly technical equipment.

Slide 3:
Nurses working in critical are responsible for providing care to patients experiencing, or at risk of
experiencing, life-threatening conditions. The American Association of Critical Care Nurses defines critical
care nursing as the "specialty within nursing that deals specifically with human responses to
lifethreatening problems... (critical care nurses are licensed professionals) responsible for ensuring that
acutely and critically ill patients and their families receive optimal care." Critically ill patients are often
unstable, with complex healthcare needs that require intense nursing care. Nurses can work in variety of
intensive-care units (ICUs), including medical, surgical, pediatric, and neonatal ICUs, cardiac care units,
cardiac catheter labs, telemetry units, progressive care units, emergency departments, and post
anesthesia care units

Nurses working in critical care have a high degree of responsibility. They assess and monitor patients
closely in order to identify subtle changes in a patient’s condition that may warrant immediate
intervention. Patients admitted to critical care tend to be seriously ill, requiring constant cardiac and
respiratory monitoring, and continual adjustment of treatments, such as the titration and dosing of multiple
intravenous medications. Because of these demands, nurses in ICUs have a decreased patient load, but
greater responsibility and autonomy. Critical care nurses must be able to interpret, integrate and respond
to a wide array of clinical information.

Slide 4:
The American Association of Critical Care Nurses (AACN) developed Standards of Care for Acute &
Critical Care Nursing Practice. These standards, which follow the nursing process, describe expectations
of competent acute and critical care nursing practice.
The Standards for Acute and Critical Care Nursing Practice are summarized on this slide.

a) Describe a level of care or performance common to the profession of nursing

b) Judge the quality of nursing practice
c) Establish roles and responsibilities expected of the practitioner by the profession
d) Stipulates what a competent level of nursing practice is
e) Describe the roles and behaviors expected of nursing professionals

Let's look at some aspects of the critical care environment.

Slide 5:
In addition to using AACN standards, nurses in both acute and critical care hospital settings use a variety
of EBP tools to ensure best practices to support clinical protocols and standards of care.

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The Quality and Safety Education for Nurses (QSEN) project addresses the challenge of preparing future
nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and
safety of the healthcare systems in which they work. Using the Institute of Medicine 2003 competencies,
QSEN defined quality and safety competencies for nursing and proposed targets for the knowledge,
skills, and attitudes to be developed in nursing programs for each competency.
http://qsen.org/competencies/

The Joint Commission updates its NPSG each year. The purpose of the National Patient Safety Goals is
to improve patient safety, focusing on problems in health care safety and how to solve them.
https://www.jointcommission.org/standards_information/npsgs.aspx

The Institute for Healthcare Improvement developed the concept of “bundles” to help health care
providers deliver the best possible care for patients undergoing certain treatments or procedures that
have inherent risks, for example the use of central venous catheters and mechanical ventilation. A
bundle is a structured way of improving the processes of care and patient outcomes using EBP.
http://www.ihi.org/topics/bundles/Pages/default.aspx

Nurses use these and a variety of other evidence based resources to incorporate best practices, and
ensure safe, quality patient care

Slide 6:
Have you ever been in a critical care unit? What do you remember? Maybe you remember the array of
equipment, the noise from beeping monitors & alarms, or the rush of staff members as they provided
patient care. The ICU can be an exciting place to work, but at times, overwhelming. Because of the
critical nature of patients’ conditions, nurses working in critical care often deal with end-of-life issues and
sometimes other ethical dilemmas related to withholding or withdrawing treatment, or providing medically
futile care. This can lead to moral distress.

Slide 7:
Let's look at the physical environment and some of the equipment found in an intensive care unit.

First, there are a variety of monitors, from heart monitors to intracranial pressure monitors. You are
probably most familiar with cardiac monitoring. Nurses learn how to read and interpret data obtained from
monitors and intervene as necessary. Nursing responsibilities when caring for patient's on monitors
include: 1) knowing the patient's baseline status, 2) knowing the normal values for the information being
monitored, and 3) knowing what to do if the patient's values fall out of acceptable range. Nurses in critical
care units have a high degree of autonomy, following evidence-based algorithms and protocols in
providing patient care. What are algorithms & protocols? An algorithm is an explicit set of rules to follow in
solving health care problems. For example, for a pt in cardiac arrest, there are algorithms to guide
treatment of the dysrhythmia causing the arrest, such as defibrillating a pt. in ventricular fibrillation. A
protocol is a written plan, which specifies the procedure to follow in providing care for a particular
situation. For example, when monitoring a patient's heart rate, the nurse would have specific orders to
follow if the patient developed a dysrhythmia, such as bradycardia. The critical care nurse can administer
medication based on the physician’s written protocol.

Slide 8:
There is other equipment unique to critical care: IV pumps with multiple channels for administering
several IVs at the same time, oxygen, ventilators, and other respiratory equipment, suction equipment,
hemodynamic monitoring devices, chest tubes, intra-aortic balloon pumps, dialysis equipment and so on.

Bedside equipment found in ICUs is similar to equipment found on medical-surgical floors, and includes
hygiene supplies, chuxs, linen, PAS or pneumatic compression stocking, PCA pumps, and feeding
pumps.

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Slide 9:
In addition to the wide variety of equipment, numerous support services assist the nurse in providing
patient care. Social workers, case managers, dieticians, physicians, physical therapist, respiratory
therapist, and clergy all play an important role in providing wholly compensatory patient care. In wholly
compensatory care, a patient's self-care agency is so limited, they depend entirely upon others for their
well-being.

Patient's in the ICU are very vulnerable and under a great deal of stress. The nurse's role, as a patient
advocate, is to collaborate with these disciplines in order to provide a safe, caring, healing environment in
which the patient and/or family feel secure and in control of their situation.

Slide 10:
Now let’s look at the Psychological Issues of an ICU.

Stress can negatively affect the patient's ability to respond and adapt to changes in the environment.
Patients and families experience stress for a variety of reasons: 1) They experience stress due to the
illness itself, and disruption of normal lifestyle, 2) loss of control over the situation, and 3) change in family
structure and roles. ICU nurses also experience stress in caring for patients who have multiple healthcare
needs. Additionally, nurses must deal with family issues, staffing concerns, and the daily task of working
with a multidisciplinary team of health care professionals.

Slide 11:
Locus of control refers to the degree of control people feel they have over events in their lives. It is a
personal belief about what controls our lives.

People who feel they have control of their environment, because of the decisions and actions they take,
have an "inner locus of control." They believe they have command of their lives.

People who believe fate, luck, or pure chance control their lives have an "external locus of control." They
may feel it is God's will or predestination that determines the events in their lives. For example, the Amish
culture has a strong belief that whatever happens is God's will.

Most people have a combination of both inner & external locus of control. Which type of person would the
nurse probably find harder to care for - a patient with inner or external locus of control? Most likely the
patient with internal locus of control. When hospitalized, the loss of decision-making, or lack of control,
increases their stress, making them feel out-of-control and more vulnerable. The nurse can help these
patients by keeping them well-informed, and by giving them opportunities to make as many decisions as
possible, even small ones.

Slide 12:
Now let's discuss restorative interventions for the critically ill patient. In order to provide wholly
compensatory care, the critical care nurse must have knowledge and skill related to respiratory care,
emergency medications, hemodynamic monitoring, and a variety of catheters and special lines. First we'll
look at respiratory care and related nursing responsibilities.

Airway is always the number one priority; think ABCs, "A" meaning airway. In critical care, patients may
have a variety of artificial airways including endotracheal tubes, tracheostomy tubes, or oral airways.

Intubation: The goal of endotracheal intubation is to secure and maintain a patent airway, supply
ventilation and oxygenation, and provide a way to suction and remove secretions.

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Intubation is required for patients with impaired gas exchange needing mechanical ventilation.
Mechanical ventilation is used in patients experiencing respiratory failure, or those with hypoxemia and
respiratory acidosis. Respiratory failure is defined as a PaO2 less than 60 mm Hg & PaCo2 greater
than 50 mm Hg.
Slide 13:
Although nurses do not intubate patients, they participate in the procedure and must know what supplies
to gather and how to assist. In most units, intubation supplies are kept together, in one location, for quick
access. Some nursing responsibilities include:

1) Obtaining the right size laryngoscope, attaching the correct blade, and ensuring the batteries and
bulb are functional.
2) Monitoring the patient during the procedure, assessing for signs of hypoxia, dysrhythmias, and
aspiration. Watch the time; intubation should take no longer than 30 seconds, ideally 15 seconds or less.
3) Once the tube is in place, the nurse checks placement by: a) Checking end-tidal carbon
dioxide levels
This involves attaching a CO2 detector between the ambu-bag & the endotracheal tube.
Presence of CO2, exhaled from the lungs, indicates tracheal intubation. Note the CO2 monitors
in the picture on the slide. These simple CO2 detectors attach directly to the Endotracheal
tube & responds quickly to exhaled CO2 with a simple change in color from purple to
yellow.
b) Auscultating for bilateral breath sounds and inspecting the chest for symmetrical
expansion
To verify endotracheal tube placement a
c) Chest Xray is obtained

Verifying proper tube placement is extremely important to ensure both lungs fields are being properly
ventilated. Occasionally, if the tube is inserted too far, only the right mainstem bronchus is intubated,
since it is more directly in line with the trachea. This complication prevents the left lung from being
ventilated. Verifying tube placement identifies this complication immediately. You will have the opportunity
to learn more about endotracheal intubation in lab.

Tracheostomy tubes are often seen in critical care units. Review, and practice in lab how to properly
suction a tracheostomy tube and provide tracheostomy care using aseptic technique.

Slide 14:
Whether the patient has an endotracheal or tracheostomy tube, nursing responsibilities are similar: The
nurse
Monitors cuff inflation pressures to prevent tracheal necrosis
Maintains correct tube placement
Ensures tube patency by suctioning prn
Provides frequent oral care to reduce the incidence of ventilator associated pneumonia (VAP)
Monitors skin integrity watching for breakdown on the lip or within the oral mucosa
Assesses oxygenation and ventilation
Provides alternate methods of communication
Promotes comfort, safety, and security for the patient

Slide 15:
Other types of airways include oral & nasal airways.

Oral airways are used to secure the airway and prevent the tongue from falling back and obstructing the
airway. Oral airways can be used in unconscious pts with adequate respiratory effort; for example in the
recovery room. Oral airways can also be used to prevent awake, or agitated intubated pts from biting on
the endotracheal tube.

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The image on the lower left of the screen is a nasal airway. Nasal airways can be inserted in pts requiring
frequent nasotracheal suctioning.

Slide 16:
Ventilators: Mechanical ventilators support and maintain gas exchange. The nurse coordinates care with
respiratory therapy to ensure proper gas exchange and prevent complications. There are different types
of ventilators and ventilator settings. During the respiratory unit, you will learn more about ventilators, and
basic settings, such a tidal volume, oxygen percentage, and respiratory rate. In addition, you will learn
what certain alarms mean and how to intervene.

Slide 17:
Another aspect of restorative care is medication administration. Nurses must have knowledge of
emergency medications used in life-threatening situations. Included in the week one folder is a list of
emergency medications you should know, and related readings in the pharmacology textbook. The
pictures in the slides show a few emergency medication in boxes that contains a bristojet. A bristojet is a
pre-filled syringe used to deliver medications intravenously during emergency situations such as a code
blue or cardiac arrest. From left to right, the first medication is epinephrine, a catecholamine with alpha &
beta adrenergic effects. Epinephrine has several uses in emergencies, but is used mostly as a
vasoconstrictor to improve cerebral & cardiac perfusion. The second med, in the purple box, is atropine.
Atropine inhibits vagus nerve action and increases the heart rate. Atropine is uses to treat symptomatic
bradycardia. The third med is Lidocaine, a sodium channel blocker, antiarrhythmic, used to treat
ventricular dysrhythmias such as frequent premature ventricular contractions, or PVCs, and Vtach & Vfib.
The last medication on this slide is Calcium chloride used for emergency treatment of hypocalcemia.
Make sure to read the chapter in the pharmacology text titled Adult & pediatric emergency drugs. You will
learn more about these medications in the upcoming acute cardiac unit

This concludes Part 1 of the critical care environment. Complete the required readings, then answer the
questions in your handout to ensure you understand the material. Before you close the presentation, let's
test your knowledge with a few questions.

Review questions:

1. What are standards of nursing practice?

2. Describe "locus of control." Inner & external.

3. List the goals of intubation. What defines respiratory failure?

4. Identify three nursing responsibilities during intubation; give rational for their purpose.

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5. List three methods to determine endotracheal tube placement. Why is this important?

6. Describe nursing care of a pt. with an endotracheal or tracheostomy tube.

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