Critical Care

Nursing
 Critical Care Nursing Concepts
• Critical
▫ (Crucial – Crisis – Emergency – Serious)

• Critical Care Nursing

▫ care of the seriously-ill clients from point of
injury/illness until discharge from intensive care

▫ Deals with human responses to life-threatening

problems

▫ Comprehensive, specialized, and individualized

nursing services which are rendered to patients with
life-threatening conditions
Critical Care Nursing Concepts
• Critical Care Nurse

▫ Care for clients who are very ill

▫ Provide one-to-one care

▫ Responsible of making life and death decision

▫ At risk of injury and illness

▫ COMMUNICATION SKILL is of optimum importance

Critical Care Nursing Concepts
• Critically-ill client
▫ Require more intensive and careful nursing care

▫ At risk for actual or potential life-threatening

health problems

▫ Examples:
▫ Post-operative clients with major surgery
▫ Illness involving vital organs
▫ Stable clients with signs of impending doom
Critical Care Nursing Concepts
• Classification of Critical Care Clients

▫ Level 0 : normal ward care

▫ Level I : at risk of deteriorating

▫ Level II : needs more observation or intervention

▫ Level III : multisystem failure

Critical Care Nursing Concepts
• PRINCIPLES OF CRITICAL CARE

▫ Continuous monitoring and treatment

▫ High intensity therapies

▫ Expert surveillance and efficiency

▫ Alert to early manifestations and recognition of

parameters denoting progress and deterioration
Critical Care Nursing Concepts
• Roles of Critical Care Nurse

▫ Care provider

▫ Educator

▫ Manager

▫ Advocate
Critical Care Nursing Concepts
• Goals of Critical care

▫ Towards the survival of the critically-ill patients

and restoring QUALITY of LIFE

▫ Helping families of critically-ill patients in coping

with stress
 Principles of Ethics
• beneficence • Privacy

• Non maleficence • confidentiality

• Autonomy • fidelity

• justice • veracity
 Contemporary Issues
• PATERNALISM
▫ Deliberate restriction of autonomy by
health care professionals based on the
idea that they know what is best for the
client

▫ Refers to instances in which the

principles of beneficence overrides
autonomy
 Contemporary Issues
• Informed Consent
❑A.K.A
❑Operative permit
❑Surgical consent

❑Patient’s autonomous decision about

whether to undergo certain diagnostic
procedure, therapeutic measures, or
surgical procedure
 Contemporary Issues
▫ Informed Consent
❑PURPOSE:
❑The client understands the nature of
the treatment and its advantages and
disadvantages
❑To indicate that NO COERCION was
made before signing
❑To PROTECT the client against
unauthorized procedure
❑To PROTECT the surgeon and the
hospital against legal actions
 Contemporary Issues
• Informed Consent
❑INCLUDES: ❑Obtained: MD
❑Name of Procedure ❑Secured :RN
❑Name of MD ❑Given : Pt
❑Name of witness (RN)

❑Date

❑Potential complication/Disfigurement
 Contemporary Issues
• Informed Consent
❑3 MAJOR ELEMENTS:

❑No Coercion/Voluntary
❑Sound Mind

❑Ultimate Decision Maker (patient)

 Contemporary Issues
• Informed Consent
❑REQUISITES FOR VALIDITY:
❑Written consent made by the client

❑ No signs of pressure
❑No sedation
❑24 hours before elective surgery

❑Legal age and mentally capable

❑2 surgeons signed the consent in emergency

❑Emancipated minor*

❑Authorized representative*
 Contemporary Issues
• Informed Consent
❑EMANCIPATED
MINOR:
❑A college student living away from home
❑In military service

❑Pregnant

❑Anybody who has given birth

❑ AUTHORIZED REPRESENTATIVE:
❑Minor
❑Unconscious

❑Psychologically incapacitated
 Contemporary Issues
• Informed Consent
❑EXEMPTIONS:

❑Experts agreed that the care is

EMERGENCY

❑Life-threatening condition

❑The client is unconscious and authorized

representative cannot be reached
 Contemporary Issues
• Advanced Directive
❑Statements made by the individual with
decision-making capacity that describe
the care or treatment he/she wishes to
receive when no longer competent

❑ Two forms:
❑ Treatment directive (living will)
❑ Proxy Directive (Durable Power of Attorney)
 Contemporary Issues
• End-of-Life-Issues
❑ Nutrition and Hydration
❑Given thru NGT, IV, or duodenal feedings,
or gastrostomy

❑CONTINUE
❑Nutrition and hydration status expedites

the patients return to an acceptable level of

functioning
❑DISCONTINUE

❑Non-beneficial
 Contemporary Issues
• Pain Management
❑One of the main components of palliative
care
❑Done if there is a decision to forego life-

sustaining treatment

❑“should provide interventions to relieve

pain and other symptoms in the dying patient
even when those interventions entails risks
of hastening death”
❑ANA (Code for Nurses)
Assessment framework
• Do Not Resuscitate (DNR) orders
❑Also known as “No Code”
❑Withhold CPR

❑No other heroic act to be perform on the

patient

❑Nurse documents participation on the

discussion
Critical Care Nursing Concepts
• Common Critical Care Unit Equipments

▫ Cardiac Monitor
▫ Pulse oximeter
▫ Swanz-Ganz Catheter
▫ Arterial lines
▫ Central venous catheter
▫ Nasograstic Tube
▫ Chest tubes
▫ Endotracheal tubes
▫ Urinary catheters
▫ Tracheostomy
▫ Ventilator
Assessment
framework for
critical nursing
Assessment framework
❑Starts from the awareness of the nurse of
the client’s admission and continues until
transition to the next phase of care

❑ STAGES:
❑Pre- arrival assessment

❑Admission quick-check

❑Comprehensive Admission Assessment

❑On-going Assessment
Assessment framework
• PRE-ARRIVAL ASSESSMENT
❑Begins when the information is received
about the pending arrival of the patient

❑ Abbreviated report on patient

❑Complete room set-up including verification

of proper equipment functioning
Assessment framework
• ADMISSION QUICK CHECK
❑General appearance
❑Aiway

❑Instruct the client to talk

❑Rise and fall of chest

❑Rate, rhythm, depth, symmetry

❑ Breathing
❑Check for tongue obstruction

❑Circulation

❑Cerebral perfusion (change in LOC)

❑Chief complaint

❑Check pulse

❑Drugs and Dx tests and Disability

• DISABILITY:
Is the patient alert & responding ?

Normal /signs: The patient is aler and

responding to questions in a logical manner when
assessed (Alert/responds to voice/responds to
pain/no response,unconscious)

Possible reasons for Unresponsiveness:

Hypoxia Ketoacidosis (ketone breath)
Head injury Drugs
Stroke
Nursing Action:

• Place patient in the recovery position unless

a spinal injury is suspected.
EXPOSURE
• Assessment Data:
1. Evidence of trauma/injury
Normal signs:
(-) signs of physical damage to the person,
comfortable in any position; calm facial
expression.
Abnormal signs:
Unresponsive patient with facial
grimacing, frowning;n signs of bruising,
Physical trauma, Foreign object in the
person, abnormal movement of the
chest; immobility.
 Disability: Evidence of trauma

• Nursing Action:

1.Attempt to open the airway where safe and

possible for the patient.

2.If you suspect the person may have a

cervical spine injury, open the airway using
a jaw thrust rather than a head tilt.
• Assessment Data #2:
2. Is there evidence of factors that may be
related to the patient’s condition?

Normal Findings: A safe environment

Abnormal findings (+):
Causes of injury or trauma include:
empty medication packets,
empty bottles of alcohol,
sharp objects, etc.

Nrsg Action: Look for causes of injury or

trauma
Disability Assessment
• Assessment Data:
Is there evidence of fluid loss, blood loss?

Normal signs: No signs of loss of body fluids

Abnormal signs:
Evidence of vomiting and/or diarrhea.
Blood loss
Loss of fluid through burns

Nrsg Action: Risk assessment for

hypovolemic shock.
Quick Guide when undertaking a rapid assessment and
response to CLINICAL DETERIORATION
Assessment Abnormal Interpretatio
Data Signs n/Nrsg
Action
Pt. is confused,
ALWAYS listen
Have you unable to give and be alert to
listened to appropriate info regardless
the answers; how confusing
patient’s unresponsive, it can seem;
relative/s’ unconscious. note the time;
story of the It may be
important.
event?
Assessment Abnormal Signs Interpretation/Nrsg
Data Actions

>The patient may >If the patient is

be a registered not for
resuscitation, this
Do you DNR ; dated and
does not mean
know the signed with an that active Tx has
patient? agreed time frame. been witheld.
>Pt. admitted in Always ask to
the last 24 H & has obtain a
no prescribed collaborative
agreement of the
limiting directives.
Px Care Plan.
>Pt. is not known >If the patient is a
by the staff. recent admission
and no info
 Abnormal Signs Interpretation/
Ax Data Nrsg Action
is available, then
assume that all active
treatment continues.

>If the patient does

not have a recent Hx
of continuous care by
the nursing staff then
ensure that a baseline
of Ax details is
redorded for
comparison.
Ax Data AbN Signs Int/ Nrsg
Actions
Vital Below or above Assess the patient
Signs the normal range in context:

Arterial ABG: Alkalosis New scores?

Blood or Acidosis
Gas Normal: (+) pattern or
Analysis pH: 7.35 -7.45 trend in
PaO2: deterioration?
11.5 -13.5 kPa
PaCO2: Evidence of
4.5 -6.0 kPa sepsis?
HCO3: Recent history of
24 – 27 mmol/L head trauma?
Ax Data Abnormal Sx Int/Nrsg Action
ECG (+) of abnormal
complexes and
irregularities in rate

Urine Output Normal:

Pedia: > 0.5 ml/Kg
body wt/H
Adult: 1 ml/Kg body
wt/H

(+) Oliguria/
(+) Polyuria
Negative urine balance
despite rigorous fluid
replacement
 Ax Data AbN Sx Int/Nrsg Action
Fluid Balance Fluid balance < or
> = based on a
minimum input of
2 L/24 H.

Central Venous Mid-axilla:

Pressure (CVP) <Hypovolaemia:
CVP: <2-6 mmHg
Hpovolemia/cardi
ac failure.
CVP: . 2-6 mmHg

Level of APVU: PV-U

Consciousness GCS: <15
 Ax Data Abnormal Sx Int/Nrsg Action
Pain Ax Elevated pain
Score

Normal:
Results of Blood Glucose: 4-8
Studies mmol/L
Creatinine:
60-120
micromol/L
Na: 135-145 mmol/L
K : 3.5 – 4.5
Mg : 1.25 – 2.5
Cl: 95 – 108
WCC: 4-12
10(9)/L
Assessment framework
• Comprehensive Admission Assessment
❑In-depth assessment
❑Past medical History

❑Past hospitalizations

❑Medications

❑Allergies

❑Social history

❑Interaction processes

❑Vices

❑Psychosocial assessment

❑Behavior

❑Emotion culture
Assessment framework
• Comprehensive Admission Assessment

❑ Physical Assessment
❑Nervous system

❑GCS scoring

❑Pupil assessment

❑LOC

❑Trauma

❑Cardiovascular system

❑Check for pulses

❑Check perfusion
Assessment framework
• Comprehensive Admission Assessment
❑ Physical Assessment
❑Respiratory system

❑Breathing pattern

❑Arterial blood gas result

❑Auscultation

❑Secretions

❑Urinary system

❑Amount

❑Color

❑Odor

❑Dx: BUN/Crea/UA
Assessment framework
• Comprehensive Admission Assessment
❑ Physical Assessment
❑Gastrointestinal system

❑Nutrition and hydration status

❑Contour and symmetry of abdomen

❑IAPePa

❑Integumentary System

❑Check the integrity

❑Ulcer stages:

❑Stage I

❑Stage II

❑Stage III

❑Stage IV
Assessment framework
• ON-GOING ASSESSMENT

❑ Done periodically

❑ Unstable patients: every 15 mins

❑ Stable patients: every 2-4 hours

Communication: SBAR
• SBAR :
a structured communication tool used as
as a framework for improving
interprofessional communication and patient
safety.

As a tool, it meets the quality requirements

for safe and effective clinical documentation
of care.
• S: SITUATION
-Identify yourself, your location and the
patient. Describe the problem, your
concern and reason for calling.

B: BACKGROUND
- Provide the patient’s reason for admission,
diagnosis and relevant history.

A: ASSESSMENT
- provide both your subjective concerns and
objective data. Offer provisional Dx/ clarify your
concern
• R: RECOMMENDATION/S
- explain what you need, when and where.