09 – 26 – 21
According to the Practice Standards for
This chapter provides the different responsibilities
of a nurse researcher. The topics covered by this chapter
includes the development of Critical Care Nursing
Practice, Education and Professional Activities in the
Philippines, as well as Critical Care Body of Knowledge,
Critical Care Competencies and Professional
Organizations in Critical Care Nursing
INTRODUCTION OF THE LESSON AND LEARNING OUTCOME
Critical care nurses provide specialized care to
patients experiencing a life threatening or potentially life-
threatening illness. A complex, intensive and continuous
type of care is significantly required through education
and certification.
A critical care nurse must have an adequate
understanding of the practice of critical care nursing that
is embodied in different standards of care competencies
as well as an affiliate and continuously adheres to
professional organizations in critical care nursing.
LEARNING INPUTS
is concerned with human
responses to life-threatening problems, such as
trauma, major surgery, or complications of illness.
The framework of critical care nursing is a
complex, challenging area of nursing practice.
It utilizes the nursing process applying
assessment, diagnosis, outcome identification,
planning, implementation, and evaluation.
The critical care nursing practice is based on a
scientific body of knowledge and incorporates
the professional competencies specific to
critical care nursing practice and is focused on
restorative, curative, rehabilitative,
maintainable, or palliative care, based on
identified patient’s need.
Critical care units were formally developed in
the United States in the years following World
War II. Common elements driving the origin of
critical care units remain important even today,
including close patient monitoring, application
of sophisticated equipment, and surveillance-
based interventions to prevent clinical
deterioration or health complications.
Critical Care Nursing in Ontario, Quality critical care
nursing practice requires the engagement and
interconnection of three elements, namely;
1) The HEALTH CARE FACILITY, creates the necessary
safety culture and quality environment that
provides the foundation for the nursing practice.
2) The CRITICAL CARE UNIT, incorporates the quality
care framework within its policies and processes
such as the use of high-performance check lists and
closely monitors the program score cards; thereby
providing oversight mechanisms to create
conditions for daily quality care supported by
evidence informed practices which supports the
clinical nurse in achieving best practice.
3) The CRITICAL CARE NURSE, by utilizing specific
knowledge and building on previous experience,
progresses along the continuum from novice to
expert critical care nurse. The critical care nurse
maintains professional competence through
ongoing learning and reflective practice. In
addition, the critical care nurse contributes
positively to the image of nursing and is committed
to the delivery of quality patient care. In order to
foster delivery of evidence-based and/or best
practices within critical care nursing, defining
competency is crucial.
The specialty of critical care has its roots in the
1950s, when patients with polio were cared for
in specialized units.
In the 1960s, recovery rooms were established
for the care of patients who had undergone
surgery, and coronary care units were instituted
for the care of patients with cardiac problems.
The patients who received care in these units
had improved outcomes.
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 The image on the left
depicts an early cardiac
surgical unit. Critical care
nursing evolved as a
specialty in the 1970s with
the development of
general intensive care
units. Since that time, critical care nursing has
become increasingly specialized. Examples of
specialized critical care units are cardiovascular,
surgical, neurological, trauma, transplantation,
burn, pediatric, and neonatal units.
Today, Critical care nursing has expanded
beyond the walls of traditional critical care units. For
example, critically ill patients are cared for in
emergency departments; post anesthesia units;
step-down, intermediate care, and progressive care
units; and interventional radiology and cardiology
units. Critical care is also delivered during transport
of critically ill patients from the field to the acute
care hospital and during interfacility transport.
With advances in technology, the electronic
Intensive Care Unit (eICU) has emerged as another
setting for critical care nursing. In an eICU, patients
are monitored remotely by critical care nurses and
physician.
For the Critical Care Nurses of the Philippines, Inc,
(CCNAPI), Critical Care Nursing reflects a holistic
approach in caring of patients. It places great
emphasis on the caring of the biopsycho-social-
spiritual nature of human beings and their responses
to illnesses rather than salary on the disease
process. It helps maintain the individual patient’s
identity and dignity. The focus of caring includes
preventive care, risk factor modification and
education to decrease future patient admissions to
acute care facilities.
They believed that each patient should be viewed
as a unique individual with dignity and worth. The
critically ill patient should receive comfort and
provided privacy in a highly technological
environment. In collaboration with other health
care team members, critical care nurses provide
high level of patient care which includes patient
and family education, health promotion and
rehabilitation. To achieve this holistic care process,
participation by the patient and his/her family is
always emphasized. At the forefront of critical care
science and technology, critical care nurses
maintain professional competence based on a
broad base of knowledge and experience through
continuous education
and evidence-based
research.
The intensive care unit (ICU) room is a highly
specialized environment, differing in many ways
from a standard hospital room. The intensive care
unit (ICU) provides a safe environment for the
critically-ill patient where optimal standards of
critical care can be delivered.
The Critical Care Unit can be broadly categorized
into two main units:
First, it could be categorized into age group
or medical specialties such as: Neonatal Intensive
Care Unit (NICU), Pediatric Intensive Care Unit
(PICU), or Adult Intensive Care Unit.
Secondly, it can be categorized into
specialty programs., labelled are General ICUs
such as Medical ICU, Surgical ICU, Cardio-thoracic
ICU, Respiratory, Neurosurgical and Trauma.
1) Level I:
→ These ICUs are referred to as high
dependency ICU.
→ Resuscitation, short term
mechanical ventilation and simple
invasive cardiovascular monitoring
for less than 24 hours.
→ Nurse patient ration is 1:3 and
medical staff are not present in the
unit all the time.
2) Level II:
→ These ICUs are located in general
hospital and undertake more
prolonged ventilation.
→ They usually provide a high standard
of general intensive care including
complex multi-system life support.
→ The Nurse Patient Ration is 1:2 and
junior medical staff is available in the
unit all the time and consultant
medical staff is available if needed.
3) Level III:
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 → These are TERTIARY REFERRAL UNIT for central-nursing
intensive care patients that provides station, either
comprehensive critical care including directly or
complex multi-system life support for an using cameras.
indefinite period. Patients are
→ Nurse patient ratio is 1:1. These levels individually
demonstrated commitment to monitored with
academic education and research. a variety of
bedside
physiologic
monitors, and
ICU rooms are designed to have redundant gas
1) Open Units: and electric sources.
→ In this type of pattern, any
attending physician with hospital The image on the right shows a typical ICU
admitting privileges can be the headwall with various components and utilities. Let
physician of record and direct us get to know what are the other EQUIPMENT
ICU care. INCLUDED IN THE ICU:
→ All other physicians are now
considered as consultants.
→ The admitting and other 1. Headwall: The wall behind the head of a
attending doctors dictate patient in an ICU, in which electrical, gas,
management, change and equipment mounts are deployed—
management or perform while headwalls are typical, columns and
procedures without consultation movable, jointed arms are used in some
or communication with a Critical units (ie, pediatric) to permit more flexible
Care Specialist.
bed/crib configurations
2. Physiologic monitor: A piece of medical
2) Closed Model: equipment that serves as a central
→ Management is coordinated by aggregation and display location for many
a qualified Critical Care medically significant physiologic variables,
Specialist. including electrocardiogram (ECG), various
→ The critical / intensive care pressure waveforms, noninvasive blood
specialist has clinical and pressure, pulse oximetry, respiration,
administrative responsibility.
temperature, and so on.
There is a multi-disciplinary team
of specially trained critical care 3. Telemetry: Electronic transmission of
staff. medical data to a central analysis station.
→ The “intensivist” is the final 4. Electrocardiography: Analysis and display of
common pathway for all
data regarding cardiac conduction and
medical decision-making
rhythm.
including the decision to admit
or discharge patients. 5. Pulse oximetry: Photoelectric, noninvasive
measurement of capillary oxygen levels
3) Transitional / Hybrid Model: This using light transmission through a capillary
combines aspects of open and closed bed to a receiver.
modes by staffing the ICU with 6. Impedance pneumography: A technique by
attending physician and/or team to which respiratory rate is measured using
work in association with primary electrical changes between ECG leads
physicians. Intensivists are locally present induced by changes in intrathoracic air
shared co-managed care between ICU volume during inspiration and expiration.
Staffs and private physicians. The ICU
Staff is considered as the final common 7. Wall oxygen supply: Oxygen is piped into
pathway for orders and procedures. hospitals from a central supply source
typically on the hospital grounds—gases are
ICU rooms are staffed with a higher nursing distributed to outlets throughout the hospital
staffing ratio, typically one nurse to two rooms, and which are both color coded and distributed
a premium is placed on patient visibility. Units are using gas specific connectors to
often constructed in such a manner that all patients mechanical ventilators and/or gas
can be under continuous observation from the blenders.

3 Page
 8. Wall air supply: Compressed air is piped to
ICU headwalls using a separate and distinct
piping system and is dispensed at the
bedside through a specific color coded
and connector specific gas outlet—air is
blended with oxygen to dispense specific
oxygen concentrations to the patient.
- In the United States, the color YELLOW is
used to indicate compressed air (whereas
BLACK and WHITE are used in the United
Kingdom). Wall air is typically supplied at 50
psi.
9. Wall suction: A separate suction system is
available at each ICU bedside and used for
a variety of applications including suction
on drains (ie, chest tubes, gastric tubes,
abdominal drains, etc.) and pulmonary
secretion removal.
Vacuum pressure is, approximately,
10 psi, and, as with medical gases,
vacuum lines have specific
connectors and are colored WHITE
in the United States (whereas they
are YELLOW in the United Kingdom)
10. Emergency power system: An electrical
supply system in a hospital that is
automatically set to convert to generator
power in the event of loss of external
electrical supply to a hospital—emergency
outlets are RED to distinguish them from
regular outlets
11. ICU rooms are often equipped with an
emergency call button
12. ICU room pressure may be adjustable to
allow keep air outside of the room from
coming in (positive pressure) in, for example,
patients at risk for nosocomial infections, or
to prevent air inside the room from leaving
(negative pressure) in, for example, patients
with highly contagious airborne organisms
13. Transducer: A device for converting energy
from one form to another, typically a
pressure wave to an electronic signal in the
ICU, where fluid waves are measured and
displayed
14. Infusion pump: A device that controls the
administration of medications or fluids
Intensive care unit (ICU) patients can develop a
variety of complications related to prolonged
immobilization and recumbent positioning while in
the ICU, and, increasingly, obese patients present a
number of specific challenges. ICU beds have a
common set of capabilities, and a variety of
specialty ICU beds have been developed for
specific patient populations including patients at
risk for decubitus ulcers, obese patients, patients
with fractures.
A STANDARD ICU BED typically has
electric and manual controls, side rails,
wheels and a brake, a removable
headboard to allow procedures (ie,
endotracheal intubation, vascular access)
from the head of the bed, and intravenous
(IV) pole mounts.
Things to Remember
■ ICU specialty beds are expensive and specific
indications should be developed for individual
bed usage.
■ The choice of specialty beds is usually made
collaboratively between the physician and
nursing members of the critical care time.
■ Individual hospitals often have a resource
person with specific expertise in specialty beds.
■ The increasing number of obese patients in the
healthcare system has led to the development of
new technologies such as bed scales, specialty
(ie, ceiling) lifts, and bariatric chairs for early
mobilization of these patients.
The field of critical care medicine has
embraced a standard whereby care is provided by
an interprofessional team of clinicians. ICU teams
are typically composed of an intensivist physician,
a clinical pharmacist, a dietician, several
respiratory therapists and bedside nurses, and other
health care providers such as clinical psychologists.
1. The INTENSIVIST, a physician with
specialized training in critical care
medicine, is the LEADER of the team and has
ultimate responsibility for medical decision-
making. An extensive body of literature
demonstrates that the presence of an
intensivist as team leader as opposed to a
physician without specialty critical care
training, is associated with lower mortality.
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 2. CLINICAL PHARMACISTS provide unique
expertise on drugs that are the cornerstone
of ICU treatment.
3. DIETICIANS provide unique expertise for
patients’ nutritional needs, and must
account for the problem that feeding
protocols are often contingent upon other
therapies.
4. RESPIRATORY THERAPISTS typically oversee
the provision of mechanical ventilation,
which is the central supportive therapy for
patients experiencing respiratory failure and
among the most common ICU treatment.
5. CRITICAL CARE NURSES are responsible for
closely monitoring and reporting changes in
patients’ health and wellbeing. Unlike other
members of the ICU team who care for most
if not all patients at any given time, nurses
only care for a subset of patients, typically
no more than two at any one time. Yet
nurses are central members of the ICU team
because they are directly involved in nearly
all ICU treatments, in that they are
responsible for assessing vital signs,
delivering drugs, and monitoring for
complications of therapy. Greater nursing
education and expertise is associated with
lower mortality among ICU patients
6. CLINICAL PSYCHOLOGISTS AND OTHER
BEHAVIORAL HEALTHCARE SPECIALISTS play
a unique role in that they specifically
address patients’ psychological recovery
and they provide care for patients, families,
and critical care providers.
NURSING ALERT
In the modern ICU, family members are
increasingly considered to be part of the
ICU team, especially when they take on the
role of surrogate decision makers for loved
ones who are too ill to advocate for
themselves.
Critical Care Nurses are registered nurses, who are
trained and qualified to practice critical care
nursing. They possess the standard critical care
nursing competencies in assuming specialized and
expanded roles in caring for the critically ill patients
and their family. Likewise, each critical care nurse is
personally responsible and committed to
continuous learning and updating of his/her
knowledge and skills. The critical care nurses carry
out interventions and collaborates patient care
activities to address life-threatening situations that
will meet patient’s biological, psychological,
cultural and spiritual needs. Critical care nurses are
understandably very protective of their patients,
EIGHT CRITICAL CARE COMPETENCIES OF AACN
Ability to question and evaluate
practice in an ongoing manner,
using evidence-based practice
instead of tradition.
Use of competent data collection
with a more global grasp of
signs/symptoms; implementation of
nursing skills with a focus on
decision making and critical
thinking.
Implementation of a
compassionate, therapeutic, and
supportive environment in providing
care to patients when interacting
with families and other health care
providers.
Ability to protect and support the
basic rights and beliefs of patients
and families.
Negotiating and navigating within
the system of health care to
provide resources that benefit the
patient and family.
Promote and provide opportunities
for formal and informal learning for
patients, families, and members of
the health care team.
Analyzing and implementing care
based on differences in
sociocultural, economic, gender,
and cultural-spiritual aspects of
patients, families, and other
members of the health care team.
Capitalizing on the unique
contributions made by each person
in achieving positive outcomes
based on collaboration with
patients, families, and members of
the health care team.
5 Page
wanting to make sure optimal outcomes are
achieved.
In order to set aside what is unique about critical
care nursing, the AACN has clearly defined eight
critical care competencies that encapsulate the
functions of these nurses.
These competencies are part of the synergy
model the AACN developed in the 1990s.
The is used as a guide to
help with certified critical care practice. It is based
upon the assumptions that:
(1) patient characteristics are a driving
force to nurses,
(2) nursing competencies are needed to
attend to patient needs,
(3) the patient characteristics are a driving
force behind the critical care competencies, and
(4) when the patient characteristics and
nursing competencies are in harmony, optimal
patient care and outcomes are achieved.
In response to the changes and expansions within
and outside the healthcare environment, critical
care nurses have broadened their roles in the
practice levels. Competencies of critical care
nurses are honed and developed to achieve their
roles in practice, management / leadership and
research.
A. Practitioner Role: The critical care nurses
execute their practice roles 24-hours a day
to provide high quality care to the critically
ill patient.
1. Care Provider
✓ Detects and interprets indicators that signify the
varying conditions of the critically ill with the
assistance of advanced technology and
knowledge; (Direct patient care)
✓ Plans and initiates nursing process to its full
capacity in a need driven and proactive
manner; (Direct patient care)
✓ Acts promptly and judiciously to prevent or halt
deterioration of patients’ condition when
conditions warrant, and (Direct patient care)
✓ Co-ordinates with other healthcare providers in
the provision of optimal care to achieve the best
possible outcomes. (Direct patient care)
✓ Understands family needs and provide
information to allay fears and anxieties (Indirect
patient care – Care of the Family)
✓ Assists family to cope with the life-threatening
situation and/or patient’s impending death
(Indirect patient care – Care of the Family)
2. Extended roles as critical care nurses: Critical
care nurses have roles beyond their professional
boundary. With proper training and in
accordance with established guidelines,
algorithms, and protocols that are continuously
reviewed and updated, Critical care nurses
also perform procedures and therapies that are
otherwise done by doctors. Such procedures
and therapies are:
✓ Sampling and analyzing arterial
blood gases;
✓ Weaning patients off ventilators;
✓ Adjusting intravenous analgesia /
sedations;
✓ Performing and interpreting ECGs;
✓ Titrating intravenous and central line
medicated infusion and nutrition
support;
✓ Initiating defibrillation to patient with
ventricular fibrillation or lethal
ventricular tachycardia;
✓ Removal of pacer wire, femoral
sheaths and chest tubes,and
✓ Other procedures deemed
necessary in their respective
institutions under a clinical protocol.
3. Educator: As an educator, the critical care nurse
must be able to:
1. Provides health education to patient and
family to promote understanding and
acceptance of the disease process thus
facilitate recovery and
2. Participates in the training and coaching of
novice healthcare team members to
achieve cohesiveness in the delivery of
patient care.
4. Patient Advocate: The critical care nurses’ role
includes being an advocate – someone who
acts or intercedes on behalf or another.
Typically, the critical care nurse may be in the
best position to act as the liaison between
patient and family and other team members
and departments because they are the
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 healthcare professionals with the most
interpersonal contact with the patients. To
perform this function adequately, the nurse
must be knowledgeable about the involved in
all aspects of the patient’s care and have a
positive working relationship with other team
members. The critical care nurses are expected
to:
✓ Acts in the best interests of the patient
and
✓ Monitors and safeguards the quality of
care which the patient receives.
B. Management and Leadership Role: The
critical care nurse in her management and
leadership role will be able to assume the
following responsibilities:
✓ Performance of management and
leadership skills in providing safe
and quality care;
✓ Accountability for safe critical care
nursing practice;
✓ Delivery of effective health
programs and services to critically-
ill patients in the acute setting;
✓ Management of the critical care
nursing unit or acute care setting;
✓ Taking the lead and supervision of
nursing support staff, and
✓ Utilization of appropriate
mechanism for collaboration,
networking, linkage – building and
referrals.
C. Role in Research: The critical care nurse’s
role in research will entail the following
responsibilities:
✓ Engage self in nursing or other
health – related research with or
under the supervision of an
experienced researcher;
✓ Utilization of guidelines in the
evaluation of research study or
report
✓ Application of the research
process in improving patient care
infusing concepts of quality
improvement in partnership with
other team-players.
The development of the Advanced
Practice Nursing is the future direction in the
Philippines and to be bench marked with other
countries. For now, a thorough study of Advanced
Practice in critical care is being undertaken to align
with the PRC- BON initiative on specialization
framework.
Expanded Roles
1. Nurse Specialist / Clinical Nurse Specialist:
The critical care nurse specialist is
responsible for building up nursing
competencies in the ICU entity. He / She
contributes to continuous improvement in
critical care nursing through staff and client’s
education and uphold quality nursing
guidelines on patient care through clinical
research and refinement of ICU Standards.
2. Acute Care Nurse Practitioner: Acute Care
Nurse Practitioner (ACNP) in the critical care
unit takes lead in developing evidence-
based practices to meet changing clinical
needs and facilitates patient care
processes across professional and
organizational boundaries.
3. Outcome Specialist: Outcome management
has been introduced into the healthcare
system to ensure achievement of quality
and cost-effectiveness in the delivery of
patient care. Some critical care units have
adopted clinical pathways (e.g., Critical
Pathways, Protocols, Algorithms and Orders)
in the management of specific diseases
such as Acute Myocardial Infarction and
Cardio-thoracic Surgeries. Qualified nurse
experts are involved in the development
and implementation of patient outcomes
management
Certification validates knowledge of critical
care nursing, promotes professional excellence,
and helps nurses to maintain a current knowledge
base. Advanced education and training play a
pivotal role in becoming certified critical care
nurse. It is important to realize that the critical care
nurse’s accumulated knowledge extends beyond
one’s basic level of nursing education.
Due to the need to master and coordinate
many cognitive and psychomotor skills, it is ideal
that a nurse gains experiences prior to entering the
critical care environment. Recruitment, orientation,
training and education of critical care nurses can
7 Page
be viewed as a continuum of learning, experience
and professional development. The relationships
between the various components related to
practice, training and education are illustrated
below, on a continuum from ‘beginner’ to ‘expert’
and incorporating increasing complexities of
competency. All elements are equally important in
promoting quality critical care nursing practice.
Practice- or skills-based continuing education
sessions support clinical practice at the unit level.
Appropriate preparation of specialist critical care
nurses is a vital component in providing quality care
to patients and their families. A central tenet within
this framework of preparation is the formalized
education of nurses to practice in critical care
areas.
Formal education – in conjunction with experiential
learning, continuing professional development and
training, and reflective clinical practice – is required
to develop competence in critical care nursing. The
knowledge, skills and attitude necessary for quality
critical care nursing practice have been
articulated in competency statements in many
countries
As advanced specialty, like any other nursing
specialty, critical care nurses must adhere to
standards. Standards serve as guidelines for clinical
practice. The standards of professional
performance describe expectations of the acute
and critical care nurse.
Critical care nurses adhere standards of care, and
these standards provide a framework for the quality
of care delivered by the nurse as well as a guide for
how care is to be delivered.
The AACN Standards for Acute and Critical Care
Nursing Practice describe practice for nurses who
care for critically ill patients. The standards of
practice delineate the nursing process.
is an illness where a patient is
suffering from a severe failure of one or more of their
organs such as the heart, lung or kidneys (Intensive
Care Society 2011). The aim of recognizing and
managing the critically ill or ‘at risk’ ward patient is
to detect the deteriorating patient as quickly as
possible so that appropriate plans can be made
about the ongoing care of the patient. Timely
detection of
patients’
deterioration
and
appropriate
clinical
interventions
can minimize
the likelihood
of serious
adverse
events.
The developed by the AACN has
served as the foundation for certified practice since
the late 1990s. It has eight patient characteristics
and eight nurse competencies that constitute
nursing practice form the basis of the model. THE
FOLLOWING PATIENT CHARACTERISTICS DRIVE THE
NURSING COMPETENCIES:
1) RESILIENCY—the capacity to return to a
restorative level of functioning using
compensatory/coping mechanisms; the
ability to bounce back quickly after an
insult.
2) VULNERABILITY—susceptibility to actual or
potential stressors that may adversely affect
patient
3) STABILITY—the ability to maintain a steady-
state equilibrium
4) COMPLEXITY—the intricate entanglement of
two or more systems (eg, body, family,
therapies)
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 5) RESOURCE AVAILABILITY—extent
resources (eg, technical, fiscal, personal,
psychological, and social) the
patient/family/community bring to the
situation
6) PARTICIPATION IN CARE—extent to which
patient/family engages in aspects of care
7) PARTICIPATION IN DECISION MAKING—extent
to which patient/ family engages
decision making
8) PREDICTABILITY—a characteristic
allows one to expect a certain course of
events or course of illness
A deteriorating patient is identified by worsening physiological
signs and symptoms. However, recognizing physiological
deterioration can be complex and is influenced by many
Factors, such as:
individual physiological response that may vary widely
age
functional capacity
gender
culture
past medical history
The term ‘CRITICALLY ILL’ is used to describe people
who have acute, life-threatening conditions but who
might recover if they are given prompt, appropriate,
effective and often highly technical nursing and
medical care. Critically ill patients, the conditions
from which they suffer and the care and treatment
they need are so varied that elements from every
chapter in this book are relevant to their care.
Patients who present in a critically ill state can be
considered in three main categories:
→ Those who have never before had a
significant illness and who have suffered a
sudden, acute life-threatening event, e.g.
extensive trauma, severe burns, near
drowning, major childbirth complications or
deliberate self-harm.
→ Those who suffer from chronic illness,
perhaps involving frequent previous
hospital admissions, e.g. chronic pulmonary
airways disease (COPD) or chronic
pancreatitis, and who present as critically ill
as a combination of their chronic illness with
a life-threatening event.
→ Those who have become critically ill as a
result of surgery – in some cases, the life--
…threatening situation is not expected,
of while in others, postoperative critical care
is a recognized necessity.
n order to have a better representation of what
conditions usually admitted into the ICU, it is
important to regroup them according to body
systems, followed below:
I
in
SYSTEM DISEASES / DISORDERS
that CARDIAC SYSTEM Acute MI with complications,
Cardiogenic shock, Complex
arrythmias requiring close
monitoring and intervention,
Acute congestive heart failure
with respiratory failure and/or
requiring hemodynamic support,
Hypertensive emergencies,
Unstable angina, cardiac
tamponade, Dissecting aortic
aneurysm, Complete heart block
PULMONARY SYSTEM Acute respiratory failure requiring
ventilatory support, pulmonary
emboli with hemodynamic
instability, massive hemoptysis
NEUROLOGIC Intracranial hemorrhage,
DISORDER meningitis with altered mental
status or respiratory compromise,
CNS or neuromuscular disorders
with deteriorating neurologic or
pulmonary function, status
epilepticus, severe head injured
patients,
DRUG INGESTION Hemodynamically unstable drug
AND OVERDOSE ingestion, drug ingestion with
significantly altered mental status
with inadequate airway
protection, seizures following
drug ingestion
GASTROINTESTINAL Life threatening GI bleeding
DISORDERS including hypotension, angina,
continued bleeding, or with
comorbid conditions, hepatic
faiure, severe pancreatitis
ENDOCRINE DKA complicated by
hemodynamic instability, altered
mental status, respiratory
insufficiency, or severe acidosis,
severe hypercalcemia with
altered mental status,
hypo/hypernatremia with
seizures
SURGICAL Post-operative patient requiring
hemodynamic
monitoring/ventilatory support or
extensive nursing care
OTHERS Environmental injuries such as
lighting, near drowning
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As critical care is a limited resource, it needs to
target those patients who are most likely to benefit
from admission to critical care units. Although
decisions relating to admission are complex and
multifactorial, and it is difficult to provide clear
guidance on admission criteria, it is clear that
decisions relating to admission (or, more
importantly, non-admission) should be based on
objective, ethical, and transparent decision-
making processes.
The Levels of Care was first devised in 2000 by the
Department of Health to help replace traditional
boundaries that labelled patients as critical care
patients or ward patients. But years of research,
these levels were too simplistic, and were soon
superseded by levels published by the Intensive
Care Society, which gave further guidance about
what might be appropriate patient management
at each level.
Decisions to admit patients to ICU or discharge
them to the ward are determined by the severity of
their illness. is a composite of
the magnitude of the acute disease, the patient’s
physiological reserve, and the concurrent level of
treatment and organ system support.
The UK guidelines on admission to and discharge
from ICUs and HDUs were developed in response to
adverse publicity surrounding the lack of intensive
care beds. The working party chose simple criteria
based on dependence on organ system support
linked to intensive care (level 3) or high
dependency care (level 2). The classification has
stood the test of time, perhaps because it is
permissive, rather than constraining.
The assessment and management of the
deteriorating patient needs to be undertaken
within a framework of safe practice that minimizes
the risk and optimizes the outcome for the patient.
The main AIM in managing the deteriorating,
acutely ill patient is rapid assessment and
resuscitation in order to make the patient safe,
rather than making a definitive diagnosis.
The adverse signs and symptoms
exhibited by deteriorating patients
can be detected using the
assessment system of Airway,
Breathing,
Circulation, Disability and Exposure
(ABCDE).
The ABCDE assessment process is a comprehensive
approach that enables identification of the major
signs and symptoms of the deteriorating patient, so
that appropriate clinical interventions can be
instigated that may prevent further deterioration.
A – AIRWAY: The aim of the airway assessment
is to establish the patency of the airway and
assess the risk of deterioration in the patient’s
ability to protect their airway with an effective
cough and gag reflex
B – BREATHING: Breathing function should only
be assessed after the airway has been judged
as adequate, although some information
about respiration function can be gathered
during the initial airway assessment
C – CIRCULATION: The aim of assessing the
circulatory system is to determine the
effectiveness of the cardiac output, which is
essential for the adequate oxygenation of the
vital organs.
D – Disability: Disability involves the review of
the patient’s neurological status and its
assessment should only be undertaken once A,
B and C have been optimized, as these
parameters can all affect the patient’s
neurological status.
E – EXPOSURE: By the time the assessment
reaches ‘E’ (Exposure) there should be a good
understanding of the patient’s problems, initial
clinical interventions should be under way and
the patient should be showing signs of
improvement.
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 These were introduced to try to help ward
staff to recognize and respond to deteriorating
patients on general wards. The systems use routine
physiological measurements, and
✓ each measurement is given a
numerical value depending on the
variation from normal parameters.
✓ The individual parameter scores are
added together and
✓ an aggregate score is then
obtained that highlights the need for
patient review.
Put simply, the HIGHER THE SCORE, THE
MORE ILL THE PATIENT IS. The early
warning scores are linked to an
escalation process.
You may want to read further on the following tools:
1. NEWS abnormal observation values and
escalation
2. Acute Life-threatening Events Recognition
and Treatment (ALERT©)
3. Acute Physiologic Assessment and Chronic
Health Evaluation II (APACHE II)
4. 2nd Simplified Acute Physiology Score (SAPS
II), 5. Sequential Organ Failure Assessment
(SOFA) score.
The nursing care of the critically ill patient is
an extensive and specialized area of care that
cannot be fully addressed in this chapter, hence it
will serve as an overview.
The primary responsibility of the nurse in the critical
care setting is to provide physical and
psychological care for patients and help prevent
complications. Assessment, continuous monitoring,
drug administration, comfort (e.g. analgesia,
toilette), psychological support, assistance with
communication, advocacy, skin care, positioning,
feeding, and early detection of complications (e.g.
line infection) are vital nursing roles which have a
profound effect on outcome. Nurses also provide
essential support for relatives, doctors,
physiotherapists and other caregivers (e.g.
technicians).
American
Association of
Critical-Care
Nurses: The AACN
is a professional
organization that
was established in
1969 to represent
critical care
nurses. The AACN
is the largest nursing specialty organization in the
world, with over 80,000 members, dedicated to
providing knowledge and resources to those
caring for acutely and critically ill patients.
The MISSION of the organization focuses on
assisting acute and critical care nurses to attain
knowledge and influence to deliver excellent care.
The VISION of the organization supports creating a
healthcare system driven by the needs of patients
and families in which critical care nurses make their
optimal contributions, which is described as
synergy. The synergy model is shown on the right.
Society of
Critical Care
Medicine:
The SCCM is
a
multiprotection scientific and
educational organization. The SCCM was
founded in 1970 by a group of physicians, and it
has grown to more than 15,000 members in over
100 countries. The Society of Critical Care Medicine
(SCCM) is the largest non-profit medical
organization dedicated to promoting excellence
and consistency in the practice of critical care.
CCNAPI is the national organization of nurses
interested in the field of critical care nursing. It was
founded in
February
1977 with
approved
SEC
registration (CN 200813601), a founding member of
the World Federation of Critical Care Nurses (2001)
and accredited as a Provider of Continuing
Professional Education by the Professional
Regulation Commission (Provider Number 2009-019)
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WORLD FEDERATION OF CRITICAL
CARE NURSES: The WFCCN is an
international federation comprised
of national critical care nursing
associations from over 50 countries
and regions. It was founded on 30
October 2001 in Sydney Australia.
The KEY AIMS of the WFCCN are to
represent critical care nursing at an
international level and to help
improve critical care nursing
practice worldwide. WFCCN
supports effective international
cooperation between health
professionals, institutions, agencies,
healthcare industry and charities
that have an interest in the care of
critically ill patients.
The standards of care for the acute and
critical care nurse build upon ANA’s Nursing: Scope
and Standards of Practice to delineate
expectations in this specialty environment, and it
uses the nursing process as its framework. The
dynamic and circular nature of the nursing process
is apparent in the nurse’s continuous collection
(recollection) and assessment (reassessment) of
data, the patient’s response to care, formulation
(reformulation) of the outcomes to be expected,
and provision of interventions based on these data.
The circular nature of the nursing process assumes
that nurses include the patient, the family, and the
healthcare team in the formulation of the plan
ASSESSMENT: The nurse caring for the acutely and
critically ill patient collects comprehensive data
pertinent to the patient’s health or situation. Its
competencies include the following:
✓ Collects data from the patient, family, other
healthcare providers, and the community,
as appropriate, to develop a holistic picture
of patient needs
✓ Prioritizes data collection based on patient
characteristics related to the immediate
condition and anticipated needs
✓ Uses valid evidence-based assessment
techniques, instruments, and tools
✓ Documents relevant data in a clear and
retrievable format
DIAGNOSIS: The nurse caring for the acutely and
critically ill patient analyzes and synthesizes data
from the assessment in determining nursing
diagnoses or conditions relevant to care. Its
competencies include the following:
✓ Derives diagnoses or relevant conditions
from the assessment data
✓ Validates diagnoses with the patient, family,
and other healthcare providers
✓ Documents diagnoses and relevant issues in
a clear and retrievable format
OUTCOMES IDENTIFICATION: The nurse caring for the
acutely and critically ill patient identifies expected
outcomes for the patient. Its competencies include
the following:
✓ Identifies outcomes from assessments and
diagnoses
✓ Respects patient and family perspectives
and values in formulating culturally
appropriate outcomes in collaboration with
the patient and family, and with the
interprofessional team
✓ Considers associated risks, benefits, current
evidence, clinical expertise, and cost when
formulating expected outcomes
✓ Modifies expected outcomes based on
changes in patient condition or situation
✓ Documents outcomes as measurable goals
in a clear and retrievable format
PLANNING: The nurse caring for the acutely and
critically ill patient develops a plan that prescribes
strategies and alternatives to attain outcomes. Its
competencies include the following:
✓ Employs critical thinking and judgment in
developing an individualized plan using best
evidence
✓ Collaborates with the patient, family, and
interprofessional team to develop the plan
✓ Establishes priorities and continuity of care
within the plan
✓ Includes strategies for health promotion and
prevention of further illness or injury within
the plan
✓ Considers associated risks, benefits, current
evidence, clinical expertise, resources, and
cost when developing the plan
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 ✓ Documents the plan in a clear and ecriticalcare2015.pdf?target=52a9338 4-d0fd-40c7-
8c20-d26d41c3f1df
retrievable manner
3. Berry, C. (2020). Introduction to
the Approach to the
IMPLEMENTATION: The nurse caring for the acutely Critically Ill Patient.
and critically ill patient implements the plan Its https://www.msdmanuals.com/professional/critical-
competencies include the following: care-medicine/approach-to-thecritically-ill-
patient/introduction-to-the-approach-to-the-critically-
ill-patient
✓ Employs strategies to promote and maintain
safe environment 4. Booker, K. (2015). Critical Care Nursing Monitoring and
Treatment for Advanced Nursing Practice. John Wiley
✓ Coordinates implementation of the plan & Sons, Inc.
with the patient, family, and 5. Burns, S. (2014). AACN Essentials of Critical Care Nursing
interprofessional team 3rd edition. McGraw Hill Education.
✓ Intervenes to prevent and minimize 6. Ervin, J. N., Kahn, J. M., Cohen, T. R., & Weingart, L. R.
complications and alleviate suffering (2018). Teamwork in the intensive care unit. The
✓ Facilitates learning for patients, families, and American psychologist, 73(4), 468–477.
the community https://doi.org/10.1037/amp0000247
✓ Documents implementation in a clear and 7. Geevarghese, F. (2018). Concepts and Principles of
retrievable format Critical Care Nursing.

✓ Provides age- and developmentally 8. Hall, J., Schmidt, G. and Kress, J (2015). Principles of
appropriate care in a culturally and Critical Care. McGraw-Hill Education

ethnically sensitive manner 9. Hanson, C (2009). Procedures in Critical Care. The

McGraw-Hill Companies, Inc.

EVALUATION: The nurse caring for the acutely and 10. Meta, R. (2015). Critical Care Nursing.
https://www.slideshare.net/rsmehta/1-critical-
critically ill patient evaluates processes and care53532785
outcomes. Its competencies include the following: 11. Morton, P, and Fontaine, D. (2013). Critical Care
Nursing: A Holistic Approach 10th edition. Lippincott
✓ Conducts systematic and ongoing Williams & Wilkins
evaluations using evidence-based 12. Sole, M, Kline, D., and Mosely, M. (2013). Introduction to
techniques, tools, and instruments Critical Care Nursing 6th Edition. Elsevier.
✓ Collaborates with the patient, family, and 13. Terry, C. and Weaver, A. (2011). Critical Care Nursing
interprofessional team in the evaluation DeMYSTiFieD. The McGraw-Hill Companies, Inc
process 14. Vincent, J., Abraham, E., Moore, F., Kochanek, P., and
✓ Revises the assessment, diagnoses, Fink. M. (2017). TEXTBOOK OF CRITICAL CARE 7th Edition.
Elsevier Inc.
outcomes, and interventions based on the
information gained during the evaluation 15. Webb, A., Angus, D., Finfer, S., Gattinoni, L., and Singer,
M. (2016). Oxford Textbook of Critical Care 2nd Edition.
process
Oxford University Press
✓ Documents the results of evaluation in a
clear and retrievable format

WRAP-UP ACTIVITY

Based on the above learning inputs, give

your general perspective about critical care
nursing. When finished, kindly take a picture of your
output and post it in the discussion forum for this
lesson.

REFERENCES

1. Aitken, L., Chaboyer, W. and Elliott, D. (2016). Scope of

Critical Care Practice. https://nursekey.com/scope-of-
critical-care-practice/
2. Bell, L. (2015). American Association of Critical-Care
Nurses (AACN) SCOPE AND STANDARDS FOR ACUTE
AND CRITICAL CARE NURSING PRACTICE. AACN Critical
Care Publication.
https://my.pba.edu/ICS/icsfs/scopeandstandardsacut

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