CRITICAL CARE NURSING

CRITICAL CARE :

CRITICAL CARE IS A TERM USED TO DESCRIBE AS

THE CARE OF PATIENTS WHO ARE EXTREMELY ILL
AND WHOSE CLINICAL CONDITION IS UNSTABLE
OR POTENTIALLY UNSTABLE.
CRITICAL CARE UNIT
 IT IS DEFINED AS THE UNIT IN WHICH
COMPREHENSIVE CARE OF A CRITICALLY ILL
PATIENT WHICH IS DEEMED TO RECOVERABLE
STAGE IS CARRIED OUT.
PRINCIPLES OF CRITICAL CARE
EARLY DIAGNOSIS AND IDENTIFICATION OF THE
PROBLEM
ANTICIPATION OF POSSIBLE EVENTS AND
COMPLICATION
THE HOLISTIC APPROACH TO A CRITICAL ILLNESS
CONSIDERED THE USE OF TECHNOLOGY
PRIMUM NON NOCERE
THE PRACTICE OF EVIDENCE BASED MEDICINE
RECOGNITION OF THE LIMITS OF CRITICAL CARE
CRITICAL CARE NURSING
IT REFERS TO THOSE COMPREHENSIVE,
SPECIALIZED AND INDIVIDUALIZED NURSING
CARE SERVICES WHICH ARE RENDERED TO
PATIENTS WITH LIFE THREATENING
CONDITIONS AND THEIR FAMILIES.
HISTORICAL BACKGROUND
World War II
Shock wards established for resuscitation
Transfusion practices in early stages
After World war-II, nursing shortage forced grouping of
postoperative patients in recovery areas
 History Continued
 Polio epidemic
1950’s: use of mechanical ventilation (“iron lung”) for
treatment of polio
Development of respiratory intensive care units
At the same time, general ICU’s developed for sick and
postoperative patients
Collaboration between nurses and physicians
 1950’s & 1960’s – CV Disease most common diagnosis
 1960’s – 30-40% mortality rate for MI
 1965 – 1st specialized ICU – The Coronary Care Unit
 Emergence of Specialized ICU’s 
American Association of Critical-Care
Nurses - AACN
1969
 Educational support
Certification
 Largest professional specialty nursing organization 
Scholarships
 Research
Publishes 2 journals
 Local chapters
Political awareness
Provides standards of practice 
Conditions considered as Critical
 
ANY PERSON WITH LIFE THREATENING CONDITION
PATIENTS WITH :
ARF
AMI
CARDIAC TAMPONADE
SEVERE SHOCK
HEART BLOCK
ACUTE RENAL FAILURE
POLY TRAUMA,
MULTIPLE ORGAN FAILURE AND ORGAN DYSFUNCTION
SEVERE BURNS
NURSING ASSESSMENT:

NURSING ASSESSMENT IT IS THE FIRST STAGE OF

NURSING PROCESS IN WHICH THE NURSE
SHOULD CARRY OUT A COMPLETE AND
HOLISTIC NURSING ASSESSMENT OF EVERY
PATIENT’S NEEDS, REGARDLESS OF THE REASON
FOR THE ENCOUNTER.
COMPONENTS OF NURSING
ASSESSMENT
NURSING HISTORY:
Taking a nursing history prior to the physical examination allows a nurse to
establish a rapport with the patient and family.
Elements of the history include – Health Status Cause of present illness including
symptoms
Current management of illness
Past medical history including family’s medical history
Social history
 Perception of illness
 Psychological and Social Examination-
Client’s perception
Emotional health
Physical health
Spiritual health
Intellectual health
CONTD…
 Physical Examination : A nursing assessment includes physical
examination, where the observation or measurement of signs,
which can be observed or measured, or symptoms such as
nausea or vertigo, which can be felt by the patient.
The techniques used may include Inspection, Palpation,
auscultation and Percussion in addition to the vital signs like
temperature, pulse, respiration , BP and further examination of
the body systems such as the cardiovascular or musculoskeletal
systems.
 Documentation of Assessment: The Assessment is
documented in the patient’s medical or nursing records, which
may be on paper or as part of the electronic medical record
which can be assessed by all members of the health care team.
CLASSIFICATION OF CRITICAL CARE
UNITS
LEVEL - I :
PROVIDES MONITORING, OBSERVATION AND SHORT TERM VENTILATION
NURSE PATIENT RATIO IS 1:3 AND THE MEDICAL STAFF ARE NOT PRESENT
IN THE UNIT ALL THE TIME.

LEVEL - II :

PROVIDES OBSERVATION, MONITORING AND LONG TERM VENTILATION
WITH RESIDENT DOCTORS. THE NURSE-PATIENT RATIO IS 1:2 AND JUNIOR
MEDICAL STAFF IS AVAILABLE IN THE UNIT ALL THE TIME AND
CONSULTANT MEDICAL STAFF IS AVAILABLE IF NEEDED.

LEVEL - III :

PROVIDES ALL ASPECTS OF INTENSIVE CARE INCLUDING INVASIVE
HAEMODYNAMIC MONITORING AND DIALYSIS. NURSE PATIENT RATIO IS
ONE TO ONE.
TYPES OF CRITICAL CARE UNIT
NEONATAL INTENSIVE UNIT (NICU)
SPECIAL CARE NURSERY (SCN)
PAEDIATRIC INTENSIVE CARE UNIT (PICU)
 PSYCHIATRIC INTENSIVE UNIT (PICU)
CORONARY CARE UNIT (CCU)
CARDIAC SURGERY INTENSIVE CARE UNIT (CSICU)
 CARDIOVASCULAR INTENSIVE CARE UNIT (CVICU)
MEDICAL INTENSIVE CARE UNIT (MICU)
MEDICAL SURGICAL INTENSIVE CARE UNIT (MSICU)
OVERNIGHT INTENSIVE RECOVERY (OIR)
CONTD..
NEUROSCIENCE / NEUROTRAUMA INTENSIVE CARE
UNIT (NICU) NEURO INTENSIVE CARE UNIT (NICU)
BURN INTENSIVE CARE UNIT (BNICU)
SURGICAL INTENSIVE CARE UNIT (SICU)
 TRAUMA INTENSIVE CARE UNIT (TICU)
 SHOCK TRAUMA INTENSIVE CARE UNIT (STICU)
TRAUMA –
NEURO CRITICAL CARE INTENSIVE CARE UNIT (TNCC)
RESPIRATORY INTENSIVE CARE UNIT (RICU)
GERIATRIC INTENSIVE CARE UNIT (GICU
SEVEN C`s OF CRITICAL CARE
COMPASSION
COMMUNICATION
CONSIDERATION AND AVOIDANCE OF CONFLICT
COMFORT
CAREFULNESS
CONSISTENCY
CLOSURE
PRINCIPLES OF CRITICAL CARE NURSING
ANTICIPATION : The first principle in critical care is
Anticipation. One has to recognize the high risk patients
and anticipate the requirements, complications and be
prepared to meet any emergency. Unit is properly
organized in which all necessary equipments and
supplies are mandatory for smooth running of the unit
EARLY DETECTION AND PROMPT ACTION : The
prognosis of the patient depends on the early detection of
variation, prompt and appropriate action to prevent or
combat complication. Monitoring of cardiac respiratory
function is of prime importance in assessment.
CONTD..
 COLLABORATIVE PRACTICE : Critical Care, which has originated as
technical sub-specialized body of knowledge has evolved into a
comprehensive discipline requiring a very specialized body of
knowledge for the physicians and nurses working in the critical care
unit fosters a partnerships for decision making and ensures quality and
compassionate patient care. Collaborate practice is more and more
warranted for critical care more than in any other field.
 COMMUNICATION : Intra professional, inter departmental and inter
personal communication has a significant importance in the smooth
running of unit. Collaborative practice of communication model unlike
the traditional practice model enhances better outcome as far as
patient, nurse, physician and hospital are concerned. This model
centres around the patient, fosters individual clinical decision making,
uses integrated medical records and join review of care.
CONTD..
PREVENTION OF INFECTION : Nosocomial infection cost a
lot in the health care services. Critically ill patients requiring
intensive care are at a greater risk than other patients due to
the immunocompromised state with the antibiotic usage and
stress, invasive lines, mechanical ventilators, prolonged stay
and severity of illness and environment of the critical unit
itself.
CRISIS INTERVENTION AND STRESS REDUCTION :
partnerships are formulated during crisis. Bonds between
nurses, patients and families are stronger during
hospitalization. As patient advocates, nurses assist the patient
to express fear and identify their grieving pattern and provide
avenues for positive coping.
CRITICAL CARE UNIT
ORGANIZATION OF ICU/ DESIGN OF ICU :
Should be at a geographically distinct area within the
hospital, with controlled access.
There should be a single entry and exit.
However, it is required to have emergency exit points in
case of emergency and disaster.
There should not be any through traffic of goods or
hospital staff. Supply and professional traffic should be
separated from public/visitor traffic.
CONTD..
Safe, easy, fast transport of a critically sick pt should
be a priority in planning its location. Therefore, the
ICU should be located in close proximity or ER, OT,
trauma ward etc.
Corridors, lifts and ramps should be spacious enough
to provide easy movement of bed/trolley of a critically
sick patient.
Close, easy proximity is also desirable to diagnostic
facilities, blood bank, pharmacy etc.
CONTD..
BED STRENGTH:
It is recommended that total bed strength in ICU should be
between 8-12 and not less than 6 or not more than 24 in any
case. 3-5 beds per 100 hospital beds for a Level III ICU or 2 to
20% of the total no of hospital beds. 1 isolation bed for every
ICU beds.
BED AND ITS SPACE: 150-200 sq.ft per open bed with 8 ft in
between beds. 225-250 sq.ft per bed if in a single room. Beds
should be adjustable, no head board, with side rails and
wheels. Keep bed 2 ft away from head wall.outlets, 3 suction
outlets (gastric, tracheal and underwater seal), 2
compressed air outlets and 16 power outlets per bed. Storage
by each bedside. Hand rinse solution by each bedside.
CONTD..
Equipment shelf at the head end. Hooks and devices
to hang infusions/ blood bags, extended from the
ceiling with a sliding rail to position. Infusion pumps
to be mounted on stand or poles. Level II ICUs may
require multi channel invasive monitors. ventilators,
infusion pumps, portable X ray unit, fluid and bed
warmers, portable light, defibrillators, anaesthesia
machines and difficult airway management
equipments are necessary.
CONTD..
Patient must be situated so that direct or indirect
visualisation by health care providers is possible at all
times.
Signal should be modulated to a level that will alert
staff. Noise level should not exceed 45dB at daytime,
40 dB in evening and 20 dB at night.(International
noise council)
Walls and ceiling should be constructed of materials
with sound absorption capabilities.
Contd..
Storage areas
Should have a total of 25-30% of all patient and central
station areas for storage.
Separate clean and dirty utility rooms with its own
access.
Good communication systems, staff lounge, food
areas must be marked out.
Should be an area to teach and train students
Contd..
Central nursing station
Should provide a comfortable area of sufficient size to
accommodate all necessary staff functions.
X-ray viewing area
Separate room or distinct area near each or ICU cluster
for viewing and storage of radiographs
Work area and storage
For critical supplies should be located within or
immediately adjacent to each ICU.(crash cart, portable
monitors, refrigerator, double locking safe for controlled
substances)
Contd..
Reception area
Each ICU should have a reception area to control
visitors access.
Reception should be linked with ICU by telephone or
other intercom system.
Special procedure rooms
It should be located within or immediately adjacent to
ICU.
Should be sufficient to accommodate necessary
equipment and personnel.
Contd..
Equipment storage
Area must be provided for securing of large patient care
equipment items not in active use.
Nourishment preparation room
Should be identified and equipped with food
preparation services, an ice making machine, a sink with
hot and cold running water, a counter top stove or
microwave and a refrigerator.
Staff lounge
To provide, comfortable and relaxing environment for
staff. Secured locker facilities, shower and toilet should
present
Contd..
Conference room
May have multiple purposes including continuing
education, multidisciplinary patient care conferences.
Visitors lounge/waiting room
One and one-half to two seats per critical care beds
are recommended. Public toilet facilities, drinking
water, public telephone and dining facilities must be
available.
Contd..
UTILITIES
Electrical system
A safe electrical system is essential to prevent shock
hazards.
electrical system should be connected to generator for
the use at time of power failure.
Generally 110 volt electrical outlets with 30 amp circuit
breakers should be located within few feet of each
patients bed.
Sixteen outlets per bed are desirable.
Contd..
Water supply
Must be from a certified source especially if HD is to
be performed.
Hand washing sinks must be available at entrance to
patient modules.
Oxygen, compressed air and vaccum
Centrally supplied oxygen and compressed air must be
provided.
Atleast two oxygen outlet per patient are required.
One compressed air outlet per bed and three vaccum
outlets per bed.
Contd..
Lighting
General overhead illumination plus light from
surrounding should be adequate for routine nursing tasks.
Separate lighting for emergencies and procedures should
be located.
Environmental control systems
Suitable and safe air quality must be maintained all times.
Central air conditioning system and recirculated air must
pass through appropriate filters.
Temperature should be adjusted around 68-72 F.
Adequate air exchange should be possible (20 times/hr is
recommended.
CONTD..
STAFFING :
 Medical Staff – the best senior medical staff to be appointed as an
Intensive Care Director or Intensivist . Less preferred are other
specialists from anaesthesia / medicine who has clinical commitment
elsewhere. Junior staff are intensive care trainers and trainees on
deputation from other disciplines. Nursing staff – The major teaching
tertiary care ICU requires trained nurses in critical care.
The number of nurses ideally required for such unit is 1:1 ratio,
however it might not be possible to have such members in our set up.
So 1 nurse for 2 patients is acceptable. The no of trained nurses should
also be worked out by the type of ICU, the workload and work
statistics and type of patient load.
Allied Services – Respiratory services, Nutritionist, Physiotherapist,
Biomedical engineer, technicians, computer programmer, clinical
pharmacist, social worker / counsellor and other support staff, guards
and grade IV workers.
Contd..
Equipment in ICU
1. Monitoring equipment : electronically monitored
parameters of respiratory and perfusion status.
2. Resuscitative equipment: ventilators, defibrillators,
ET tubes etc..
3. Supportive equipment: special ICU bed, alternating
pressure air mattress, infection control protocols.
CRITICAL CARE NURSE
Factors to be considered in recruiting Critical Care
Nurses are:
Intra and interpersonal factors
Technical Qualifications.
Educational background
Clinical Experience.
PRIME RESPONSIBILITIES OF A CRITICAL
CARE NURSE:
Continuous monitoring
Keep ready emergency trolley / crash Cart
Efficient Individualized Care.
Counseling and information to family.
Application of policies and procedures
Proper records of all activities
Maintain infection control principles.
Keep update with advance information.
QUICK REFERENCE PROTOCOL FOR
MANAGING EMERGENCY IN ICU
Quickly review the patient - Identity, History ,
Physical Exam. Be with the patient, ask for help. Place
the patient in a suitable position
Attach the cardiac monitor and call for crash cart.
 Maintain ABC Along with expert team Introduce IV,
CV line and TP
Administer medication as needed. Carry on
Investigations - ABG, ECG, Urea, Creatinine , Blood
Sugar, Cardiac enzymes. Maintain Fluid and
Electrolytes . Record right things at right time rightly.
Legal and ethical issues in
critical care nursing
INTRODUCTION
Ethics have always been an integral part of nursing.
Nurses at all levels/areas of practices experience a range of
ethical issues during the course of their day- to-day work.
Critical care has come to be associated with high- tech,
aggressive & often risk-filled medical care.
The critical care nurse are often confronted with ethical &
legal dilemmas related to various ethical principles & it has
increased dramatically since the early 1990s.
Many dilemmas are by products of advanced medical
technologies & therapies developed over the past several
decades.
ETHICAL PRINCIPLES
Autonomy: respect the patients choice
Beneficience: doing or active promotion of good
Non maleficience: not to do harm.
Justice: fairness in every situation
Veracity: duty to tell the truth
Fidelity: duty to keep promises
Legal and Ethical Issues
1.Informed Consent
Consent problems arises because patients experiencing acute,
life threatening illness that interfere with their ability to make
decisions on treatment/ participation in clinical research.
 The informed consent is based on the principle of autonomy.
Consent denotes voluntary agreement, permission or
compliance.
 It implies to permission by the patient to perform an act on
his body either for diagnosis or therapeutic procedure.
The four elements of consent are; voluntariness ,capacity,
knowledge, Decision making
Points to be considered in consent
Consent must be given voluntarily
 If patient is not mentally capable (critical patients)
informed consent should be obtained from surrogate
or legal next of kin
 It should be given by a person of sound mind & above
the age of 18 years.
Requires the disclosure of basic information
considered necessary for decision making
 Patients providing consent should be free from pain &
depression
CONTD..
Consent is invalid in:
Consent obtained from a minor
Consent given under fear, fraud or misrepresentation
Consent obtained from the person who is not fit
Consent obtained in language not understood by the
person
Consent obtained from person under sedation,
intoxication or semiconscious
Consent obtained without providing adequate
information on the possible risks are invalid under law.
Legal and Ethical Issues
2. Medico legal cases
is any case where the discipline of medicine comes to
help the legal fraternity in its discharge of duties.
The MLC should be registered as soon as physician
suspect’s foul play or case brought several days after
the incident.
The MLC is received in hospital by; any case brought
by police for the purpose of examination & reporting &
any case referred for expert management & advice.
Following Cases Should be Considered As MLC& to be Intimate
To The Police Regarding Such Cases,
• All cases of injuries/burns
• Alleged cases of assault
• All cases of suspected or evident of poisoning or intoxication
• Case referred from court
• Cases of suspected or evident Count criminal abortion
• Cases of unconscious/comatose where its cause is not natural
or not clear
• Cases brought dead/dead on arrival/sudden unexpected death
• Cases of suspected self inflicted injuries or at tempted suicide
The important considerations in MLC are notification to police,
collection & preservation of samples, recording of dying
declaration etc.
Legal and Ethical Issues
3.Medical documentation
The proper medical documentation is legal necessity.
A good record should be correct, clear,
comprehensive, chronological & contemporaneous
 It is the fact that good records are indispensible for
proper care & treatment of patients.
Consent from patients before carrying out any
procedure is mandatory legal, ethical & moral
requirement. Similarly the document once prepared
has also to be preserved for specified period of time (3
years from the date of commencement of treatment).
Legal and Ethical Issues
4.Use of Restraints
Restraints are intervention that limits a person’s freedom to
move. It can be physical or chemical.
Physical restraint can lead to: skin trauma, muscular
atrophy, nosocomial infection, constipation, incontinence,
limb injury, contractures, depression, anger, decline in
functional & cognitive state & increasing agitation.
Because restraints limit movement they also limit autonomy
Considering the physical, psychological & ethical aspects of
physical restraint (risks & benefits), it is advocated that such
is only used when all other methods of managing the
problem have failed, employed with caution & as a last
resort & use least restrictive method possible.
Legal and Ethical Issues
5.Decisions regarding life sustaining treatment
Cardio pulmonary resuscitation decisions
• Ethical questions arise on use of CPR & emergency
cardiac care
Withholding or withdrawal of life support
• “Withholding” refers to never initiating a treatment,
whereas “withdrawing” refers to stopping a treatment once
started
.• The distinction between not starting a treatment &
stopping it is not itself of ethical significance; what is
whether the decision is consistent with the patient’s
interests & preferences.
Contd..
Points to be considered
Withdrawal of life support is indicated if the patient has Glasgow
coma score is less than 5, absence of pupil & motor response 3
days after arrest.
Communicate frequently throughout the critical care stay, not just
when death is imminent
Provide consistent, honest information.
 Keep the discussion on withholding/withdrawing life support
based on patient wishes & the burden versus benefits of the
various options
 Recognize that the patient & family are anticipatory grieving &
provide support.
 Most decisions regarding withdrawal/ withholding of life support
are not made in courts. It made based on open communication
with patient, family & surrogate as appropriate.
Legal and Ethical Issues
6.Organ Donation
The important ethical principles useful in decision
making on transplantation include respect for
persons, autonomy, beneficence, Nonmaleficence,
justice & fidelity.
• Critical care nurses are in a position to act as the link
between potential organ donor & organ transplant
recipients & point out the need for critical care nurses
to learn the process of identifying potential donors
ETHICAL ISSUES OF MOST CONCERN
The five most frequently cited ethical issues reported by
the nurse surveyed were:
 Protecting patients’ rights & human dignity
Providing care with possible risk to your health (eg.
TB, HIV, violence)
Respecting/not respecting informed consent to
treatment
Staffing patterns that limit patient access to nursing
care
Use/non use of physical/chemical restraints
WAYS TO RESOLVE ETHICAL PROBLEMS IN
CRITICAL CARE SETTING
1. Gather the relevant facts & identify the decision
maker(s) & the stakeholders
2. Identify the ethical problem(s). Involve others in the
process & use consultation resources as appropriate.
3. Analyze the problem using ethical guidance &
resources
4. Deliberate about the action alternatives in light of
guidance; choose one & justify the choice.
5. Evaluate & reflect.
Psychosocial components of critical
care nursing
Emotional response to illness
Adaptation : is the series of response made by the
individual in reaction to stressors. Stress is manifested
in various ways:
Anxiety is defined as an uneasy feeling of impending
danger.
Anger is a strong emotional response characterised by
feeling such as resentment, dislike and feeling of
vengeance when this is directed to the self it is labeled
as guilt.
Contd..
Depression is a stage of mourning marked by low
esteem.
Fear is induced in these patients in the critical care
unit due to many factors.
Denial is the refusal to accept the reality of a situation
cognitively or affectively. It is the initial human
response to loss.
NURSING MANAGEMENT OF CRITICALLY ILL
PATIENTS
Respiratory care
Cardiac care
Gastrointestinal care
Neuromuscular care
Bladder and bowel care
Infection control measures
Communication
Comfort and reassure
Communication in critical care
nursing
Takes many forms of communication- patient and nurse,
nurse and patient, patient and relatives.
Two types-verbal and non verbal
Effective communication and good IPR improves positive
well being of the patient and family.
Develop open, trusting relationship with patient and family.
Assess the family’s ability to grasp information
Repeat and reinforce information
Interpret the technical and medical language
Maintain continuity of care between the unit and ward
areas.
Transitional care
Refers to the coordination and continuity of health
care during a movement from one health care during a
movement from one health care setting to either
another or to home, between health care practitioners
and settings as their condition and care needs change
during the course of a chronic or acute illness.
THANK YOU