NCM 118: DISASTER & EMERGENCY NURSING midterms 2 10|6|23 Concept of Critical Care (ICU Care) THE INTENSIVE CARE TEAM ‘These members builds an environment for healing or dying, + Doctor + Nurses + Therapists + Nutritionists + Chaplains + Other support staff CRITICAL CARE NURSING A specialty within nursing that deals specifically with humans responses to life-threatening problems. CRITICAL CARE UNIT NURSING REQUIREMENTS + All patient care Is carried out directly by or under supervision of a trained critical care nurse. + All nurses working in critical care should complete a clinicalididactic critical care course before assuming full responsibility for patient care, + Unit orientation is required before assuming responsibility {or patient care. + Nurse-to-parient ratios should be based on patient acuity according to written hospital policies. + All critical care nurses must participate in continuing ‘education. —An appropriate number of nurses should be trainedin highly specialized techniques such as renal replacement therapy, intra-aortic ballon pump monitorin, and intracranial pressure monitoring, + All nurses should be familiar with the indications for and ‘complications of renal replacement therapy. CRITICAL CARE NURSE ‘A critical nurse is a licensed professional who is responsible for ensuring that acutely and critically ill patients and their families receive optimal care, CRITICAL CARE UNIT Critical care unit is @ specially designed and equipped facility staffed by skilled personnel to provide effective and safe care for dependent patients with a life threatening problem. THE “EXPENSIVE” CARE UNIT Canada USA + 8% of total inpatient cost 20 - 28% of total inpatient + 0.2% of GNP cost + $1500 per day + 0.8% to 1% of the GNP = 1ICU day = 3 to 6 times non-ICU day — Higher costs in non-survivors —ICU resources are finite AIM OF THE CRITICAL CARE. ‘To see thal one provides a care such thalpatient improves and survives the acute illness or tides over the acute exacerbation of the chronic iliness. EVOLUTION OF CRITICAL CARE + Forty years of development in critical care and critical care nursing has given rise to a recognized specialty in nursing practice, + Critical care units have evolved over the last four decades in response to medical advances. HISTORICAL PERSPECTIVES + Florence Nightingale recognized the need to consider the severity of illness in bed allocation of patients and placed the seriously il patients near the nurses’ station. + In 1923, John Hopkins University Hospital developed a special care unit for neurosurgical patients. + Modern medicines boomed to its higher ladder after World War 2. + As surgical techniques advanced, it became necessary that post operative patient required careful monitoring and this came about the recovery room. + In 1952, the epidemic of poliomyelitis necessitated thousands of patients requiring respiratory assist devices and intensive nursing car, + At the same time came about newer horizons in cardiothoracic surgery, with refinements in intraoperative ‘membrane oxygen technique. + In 1953, Manchester Memorial Hospital opened a four bedded unit at Philadelphia and started operation, + By 1957, there were 20 units in USA, and; + In 1958, the number increased to 150. PURPOSE ‘An ICU may be designed and equipped to provide care for the patients with a range of conditions, or it may be designed and ‘equipped to provide specialized care to specific conditions. TYPES OF ICU's + Open — In this type, physicians admit, treat, and discharge. + Closed — In this type, the admission, discharge and referral Policies are under the control of intensivists.NCM 118: DISASTER & mid EMERGENCY NURSING 10|6/23 + Level 1 —This can be referred as high dependency and is where close monitoring, resuscitatio, and short term ventilation <24hrs has to be performed. + Level 2 — Can be located in general hospita, undertake more: prolonged ventilation. Must have resident doctors, nurses, access to pathology, radiology, etc. + Level 3 — Located in a major tertiary hospita, which is a referral hospital. It should provide all aspects of intensive care + The Open Model —allows many different members of the medical staff to manage patients in the ICU. + The Close Model —limited to ICU - certified physicians managing the care of all patients. + The Hybrid Mode! — combines aspects of open and closed models by staffing the ICU with an attending physician and/or team + Patient Monitoring + Life support and emergency resuscitation devices + Diagnostic devices + Acute care physiologic monitoring system —Pulse oximeter — Intracranial pressure monitor — Apnea monitor + Mobile X-rays + Portable Clinical Laboratory Devices — Blood AnalyzersNCM 118: DISASTER & EMERGENCY NURSING + Excellent care + Abundant resources — High nurse-patient ratios — Pharmacists, nutritionist, RT's, ete —High tech equipment Signs of deterioration quickly identified + “give thema chance” + Discomfort with death + Convenience Demand frequently exceeds supply. + A’ service for patients with fy_recoverable conditions who can benefit from more detailed observation and invasive treatment that can be safely provided in general wards or high dependency areas. + Potential or established organ failure + Factors to be considered — Diagnosis — Severity of lness —Age and functional status —Co-existing disease — Physiological reserve — Prognosis — Availability of suitable treatment — Response to treatment to date — Recent cardiopulmonary arrest — Anticipated quality of life — The patient's wishes Saaz ‘Admission criteria remain a ined + Identification of patients who can benefit from ICU care is extremely difficult + Demand for ICU services exceeds supply. + Rationing of ICU beds is common, + Uses specific conditions or diseases appropriateness of ICU admission + 48 diagnosis / 8 organ systems —Acute MI with complications —Cardiogenic shock — Complex arrhythmias — Acute respiratory failure — Status epilepticus, SAH to determine + Vials signs —HR <40 or > 150 — SBP <80 — MAP < 60 —DBP > 120 —RR>35 + Laboratory values. — Sodium < 110 or 170 — Potassium < 2.0 or > 7.0 —Pa02< 50 —pH<7.1 o> 7.7 — Glucose > 800 mg/dl. — Calcium > 15 mg/dL. —Toxic drug level with compromise + Radiologic —ICH, SAH, contuson with AMS or focal neuro signs — Ruptured viscera, bladder, liver, uterus with hemodynamic instability. — Dissecting aorta + EKG —Acute Ml with complex arrhythmia, hemodynamic instability, or CHF — Sustained VT or VF — Complete heart block with instability + Physical findings (acute onset) — Unequal pupils with LOC — Bums > 10% BSA —Anuria — Airway obstruction —Coma — Continuous seizures —Cyanosis| — Cardiac tamponade Physiologie status has stabilized — Need for ICU monitoring and care no longer necessary. + Physiologic status has deteriorated — Active intervention no longer planned, + Monitoring care of patients with moderate or potentially severe physiologic instability. + Require technical support + Frequent monitoring of vital signs + Frequent nursing interventions, + Not necessarily artificial life supportNCM 118: DISASTER & mid EMERGENCY NURSING 10|6/23 + Do not require invasive monitoring + Require less care than ICU + Require more care than general ward + 22% of ICU bed days + 6180/7440 admissions with less than a 10% risk of requiring active treatment based on this monitoring. + Reduced costs with ICU demonstrated « Increased patient satisfaction + Reduces costs + Reduces ICU LOS + No negative impact on outcome + Improves patient/family satisfactionNCM 118: DISASTER & EMERGENCY NURSING A short term strategic therapy with action-oriented interventions that focus on solving the immediate problem. ‘An adjustive reaction or habitual patterns of behavior that an individual uses in response to actual or imagined stress in order to maintain psychologic integrity. + Alleviation of the acute distress + Restoration of independent functioning + Prevention of psychological trauma + External (Situational) Crisis. —A specific event apparent to another observer; resolved in 41-2 months. — Example: events that threaten physical health, ability to ‘obtain food, clothing, or shelter, loss of loved onelvalued object. — May affect one or more individuals + Internal (Subjective) Crisis —Not obvious to outside observers — Example: aging, loss of independence, fear and guilt; threat to a deeply held belief or a loss of faith + Phase-of-life (Maturational) Crisis — Occurs during normal and predictable changesiphases throughout life, — Example: aging eventually brings loss of strength, mobility, and other declining abilities + Disasters (Adventitious) Crisis ‘A. Heroic phase — Immediately after the event, altruistic and heroic behavior. B. Honeymoon phase (1 week to 3 - 6 months) — feelings of community sharing with high social attainment C. Disillusionment phase (2 months to 1 - 2 years) —feelings of disappointment, anger, resentment, bitterness over expectations of support that were not met D. Reconstruction phase (2 months to 1 - 2 years) — physical & emotional reinvestment + Shock + Numbness + Denial + Dissociative Behavior + Confusion + Disorganization + Difficulty making decisions. + Suggestibilty + Physiologic s/s: sweating, dizziness + The individual's perception of the event + The presence of active situational supports + The person's coping mechanism, skills, and techniques nausea, vomiting, tremors, profuse Stress Seecehs ‘Stato of sequoia ‘Need restore equlibium Balancing actors (one or more balancing eta perception ofthe ent | [Distr propane he event Pus ano ‘Adequate suatonal spoors_| [No adequate stuaoal poor] Pus Ano ‘Asequat coping mecranioms | [Ne adequate coping mechan] RESULT IN RESULT IN Resour othe pction Protom nasties 1 t ‘Equtecum regained Deseautboun cortres Woot CRISSNCM 118: DISASTER & — EMERGENCY NURSING + Assessment of the individual and the problem + Planning of therapeutic intervention + Intervention + Resolution of the crisis: + Anticipatory planning + Intervene immediately, as close to the event as possible + Stabilize the ictims by restoring a semblance of order and routine + Facilitate understanding of the event by gathering facts, listening, and teaching + Focus on problem solving + Encourage self-reliance + Express caring and consolation + Assess the realities of the situation + Develop and begin to utilize an immediate plan for intervention + Coordinate with other agencies. + Anticipate future needs related to the crisis. + Summary - The nurse helps the client to summarize the changes. + Open Connection - Nurse asissts client as needed in making realistic plans for the future, + Anticipatory Planning - Nurse asks client what he will do if a similar event occurred in the future + Failure to learn from experience — Itis the ct's optimism, aided by trained professionals, that determines successful crisis resolution. + Existing mental disorder — Impaired abilty to think clearly and use executive functions of logic, reasoning and judgment leads to a greater difficulty resolving a crisis + Secondary gain — Occurs when the ct. uses a crisis or illness for additional personal reasons or reward, + Therapist-client boundary problems — Overidentification or countertransference — Nurse is at increased risk for developing PTSD.