NCM 118: NURSING CARE OF CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTE ILL/MULTI ORGAN PROBLEMS, HIGH ACUITY

AND EMERGENCY NURSING Course

Background: This course deals with concepts, principles, theories and techniques of Nursing Care of Sick Adult Clients with Life-Threatening
Conditions, Acutely Ill/Multi-Organ Problems, High Acuity and Emergency Situation toward Health Promotion, Disease Prevention,
Restoration and Maintenance, and Rehabilitation.
Objective: The Learners are expected to provide safe and appropriate and holistic Nursing Care to groups of Clients with Health Problems and
Special Needs utilizing the Nursing Process.
Course Credit: Theory- 4 Units, 72 hours
Course Placement: Fourth Year-First Semester Course Prerequisite: NCM 116

Critical care nursing

is the specialty within nursing that deals specifically with human responses to life-threatening problems. These problems deal dynamically with
human responses to actual or potential life-threatening illnesses
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.
Professional Regulation Commission – Board of Nursing (PRC-BON) is committed to provide need-driven, effective and efficient specialty nursing
care services of high standard and at international level within the obtainable resources
The Critical Care Nurses Association of the Philippines, Inc. (CCNAPI)

PrC-BON Working Group Developing the Nursing Specialty Framework (1996)

-take on the task of setting the process-based framework and guidelines for specialty nursing services
Working group members: clinical nurse Practitioners, nurse educators and nurse managers

Goals of Critical Care Nursing

To promote optimal delivery of safe and quality care to the critically ill patients and their families by providing highly individualized care
so that the physiological dysfunction as well as the psychological stress in the ICU are under control
To use relevant and up-to-date knowledge, caring attitude and clinical skills, supported by appropriate technology for the prevention, early detection
and treatment of complications to facilitate recovery.
To provide palliative care to the critically ill patients in situations where their health status is progressing to unavoidable death, and to help the
patients and families go through their painful sufferings.

Critical nursing should be: patient-centered, safe, effective and efficient.

The nursing interventions are expected to be delivered in a timely and equitable manner

Categories of Critical Care Unit

The Critical Care Unit can be categorized according to patients’ age group or medical specialties.
A. Age Group
1. Neonatal
2. Pediatric
3. Adult

Levels of Care Provision

Guidelines on Critical Care Personnel and Services published in 2003 by the Critical Care Medicine
Stratified by the phil. Society of critical care medicine (psccm), society of pediatric critical care medicine (spccm) and ccnapi
apply the 3 levels of classifications accordingly
capable of providing immediate resuscitation for the critically ill and short-term cardio-respiratory support because the patients are at risk
of deterioration

Level 1
Has a major role in monitoring and preventing complications in “at risk” medical and surgical patients;
Must be capable of providing mechanical ventilation and simple invasive cardiovascular monitoring;
Has a formal organization of medical staff and at least one registered nurse.
A certain number of nurses including the nurse in-charge of the unit should possess post-registration qualification in critical care or in the related
clinical specialties; and
Has a nurse: patient ratio of 1:1 for all critically ill patients
.
B. Specialty
In the existing environment, majority of the Critical Care Units in the Philippines provide service for patients of various specialties. They are labeled
as General ICUs. In certain hospitals, the critical care unit / service is dedicated to the following specific groups:
1. Medical, Surgical, Cardio-thoracic, Cardiac, Respiratory, Neurosurgical and Trauma
Level 2
Should be capable of providing a high standard of general critical care for patients who are stepping down from higher levels of care or
requiring single organ support/support post-operatively;
Capable of providing sustainable support for mechanical ventilation, renal replacement therapy, invasive hemodynamic monitoring and
equipment for critically ill patients of various specialties such as medicine, surgery, trauma, neurosurgery, vascular surgery;
Has a designated medical director with appropriate intensive care qualification and a duty specialist available exclusively to the unit at all times;
The nurse in-charge and a significant number of nursing staff in the unit have critical care certification; and
A nurse: patient ratio is 1:1 for all critically ill patients.

Level 3
Is a tertiary referral unit, capable of managing all aspects of critical care medicine (This does not only include the management of
patients requiring advanced respiratory support but also patients with multi-organ failure);
Has a medical director with specialist critical / intensive care qualification and a duty specialist available exclusively to the unit and medical
staff with an appropriate level of experience present in the unit at all times;
A nurse in-charge and the majority of nursing staff have intensive care certification; and
A nurse: patient ratio is at least 1:1 for all patients at all times

System Operation of Critical Care Units

A. Open System
The admitting and other attending doctors dictate management, change management or perform procedures without consultation or
communication with a Critical Care Specialist.
A Critical Care Specialist may be available for advice or be consulted to provide interventional skills (optional).
No designated person who assumes the “gatekeeper” role.
.
B. Closed System
Management is coordinated by a qualified Critical Care Specialist.
The critical / intensive care specialist has clinical and administrative responsibility.
There is a multi-disciplinary team of specially trained critical care staff.
The “intensivist” is the final common pathway for all medical decision-making including the decision to admit or discharge patients Irrespective of the
ICU “System” Operations, i.e., open system or closed system, or a mixture of the two,
there should be a designated group of registered nurses under unique management to provide highly specialized care to the critically ill patients. The
nurse in-charge and the majority of nursing staff in each unit should have the relevant qualification in the specialty of the respective
Unit.

SCOPE OF CRITICAL CARE NURSING

Is defined by the dynamic interactions of the critically ill patient/family, the critical care nurse and the critical care environment to bring about optimal
patient outcomes through nursing proficiency in an environment conducive to the provision of this highly specialized care.
Dynamic interactions
It requires:
Constant intensive assessment,
timely critical care interventions
continuous evaluation of management through multidisciplinary efforts
Palliative care should be instituted
Critical Care Nurses
registered nurses, trained and qualified to practice critical care nursing.
possess the standard critical care nursing competencies in assuming specialized and expanded roles in caring for the critically ill patients
and their family.
is personally responsible and committed to continuous learning and updating of his/her knowledge and skills.
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 environment

constantly supports the interactions between the critically ill patients, their family and the critical care nurses to achieve desired patient
outcomes.
It entails readily available and accessible emergency equipment, sufficient supplies and effective support system to ensure quality patient care as
well as staff safety and productivity.
Legal and ethical issues in critical care nursing
Ethical principles:
Autonomy, Beneficence, Non-maleficence, Justice, Veracity and fidelity
Legal and ethical issues in informed consent
Based on the principle of autonomy
Connotes voluntary agreement, permission or compliance
Permission of the patient to perform an act to his/her body for purposes of diagnostic or treatment
Issues arise due to presence of acute illness or life threatening condition that alter their capabilities to make medical decisions

Four elements of consent: Voluntariness, Capacity, Knowledge and Decision making

Types of consent
Implied consent-the agreement given by a person's action (even just a gesture) or inaction, or can be inferred from certain
circumstances by any reasonable person
Expressed consent (verbal or written)- permission for something that is given specifically, either verbally or in writing
guidelines
Given voluntarily
If patient is not mentally capable to give consent it can be obtained from a surrogate or legal next of kin
Given by a person of sound mine and 18 years old and above
Requires a disclosure of basic information considered necessary for decision making
Patients should be free from pain and depression during informed consent
Invalidation of consent
Consent from minor
Under fear, fraud or misrepresentation
Patient is not fit to consent
Language barrier
Under intoxication, sedation or semi-conscious
Inadequate information on possible risks or treatment
Medico-legal case
Any case where in the discipline of medicine comes to help the legal fraternity in its discharge of duties
Interface of medicine and law is multi-dimensional and can be complex and perplexing
Be very cautious in dealing with medico-legal cases
Request of not registering the case should not be accepted
Should be registered as soon as the physician suspects foul play
Any case brought by the police for examination, treatment, reporting, referrals for expert management and advised are received
promptly

Cases considered as mlc

Injuries
Burn
Assault
Intoxication or poisoning
Cases referred from court
Suspected or evident abortion
Not natural caused comatose
Dead on arrival or unexpected death
Self-inflicted injuries or attempted suicide
-it is important to notify the police, preservation and collection of sample and dying declaration if there is any.

Medico-legal documentation
A legal necessity
Should be correct, clear, chronological and contemporaneous
Consent before procedure is mandatory, legal and moral requirement (3yrs )
72 hours- production of records upon legal request
All medical information and documentation should be very specific
restraints
Chemical or physical
Any interventions that limits a person to move
Can cause trauma, depression, muscular atrophy, nosocomial infection, anger, contractures, continence of limbs, constipation, increase
agitation and decline functional and cognitive state because it limits autonomy
Used only when all managing the problem method has failed and employed with caution and least restrictive method as possible

Cardiopulmonary resuscitation decisions

Cpr- used to reversed the clinical signs of death
Aha 2000- healthcare providers may stop cpr when 30 minutes (adult/child) or 15 minutes (newborn) of attempt has not restored any
signs of life
Presence of “do not resuscitate” order
Advanced directives
Financial status is the deciding factor
Autonomy of patient is a weak concept
Withholding or withdrawal of life support
Withholding is to never initiating a treatment
Withdrawal is stopping a treatment that has been started
Ending treatment due to sound moral reason does not violate professional obligations
Needs careful decisions between health care professionals and the patient/family
Clarify technical terms, weigh treatment options, consider the values an wishes, context of prognosis and treatment
Final decision should reflect the patients wishes
considerations
Patient’s Glasgow coma scale of is 5 and below, absence of pupil and motor response for 3 days after arrest
Communication
Provide consistent and honest information
Discuss properly the pros and cons, burden vs benefits
Recognize family anticipatory grieving and provide support

Organ donation
Potential donor may agree to donate organ by signing a donor card but a final consent for donation by the patient or legal surrogate
should be signed before the organ transplantation team harvest the organ
Everyone has the right to donate an organ
Ethical principles involved are respect for person, autonomy, beneficence, nonmaleficence, justice and fidelity
Nurses acts as advocate to donors and recipients and must be a skilled assessor for possible organ donors
Cost vs outcome
Five most concerned ethical issues
Protection of patient’s rights and human dignity
Risky provision of care (aids, hepa b etc)
Respecting informed consent to treatment
Staffing patterns (limit nursing care)
Use or non-use of restraints
Ways to resolve ethical issues:
Gather relevant facts and identify the decision maker and stakeholders
Identify ethical problems, involve others in assessment and use appropriate consultation resources
Analyze problems using ethical standards, guidance and resources
Guided deliberation and justification of choice/s
Evaluation and reflection