CRITICAL CARE

NURSING
BY MOSES CHIRA
.
1. CRITICAL CARE CONCEPTS
Objectives
By the end of the lesson the student should be able
to:
Describe critical care nursing critical care nurse,
critically ill patient.
Anaesthetiologist, anaesthetist, unconscious pa-
tient, terminally ill patient
Describe the types of patients who need critical
care nursing
Describe the facilities available for providing crit-
ical care nursing
Describe the ethics in critical care
 INTRODUCTION
Critical Care Nursing:

 Def 1. The practice of administering immediate and

continuous care to clients with actual or potentially
life-threatening health disorders

 Def 2. The nursing care given to a patient whose

health is in danger or in a crisis, so as to save their
life or prevent complications.

 The specialty that deals with human responses to life

– threatening problems
The purpose of critical care nursing is to:
.
 Provide care to severely ill patients with po-
tentially reversible conditions
 Provide close observation to a patient that
cannot be provided in a general ward
 Provide care to patient with potential or estab-
lished organ failure, especially lungs
 Reduce avoidable morbidity and mortality in
critically ill patients
 Critical care nurse: a licensed professional nurse
who ensures that critically ill patients and their
.
families receive optimal care .
 Critical care unit: Is a specially designed and
equipped facility staffed by skilled personnel to
provide critical care
 Critically ill patient: Is patient whose physical,
physiological and psychological state poses an
immediate threat to their life.
 Critically ill patients need total and specialised
nursing care
 Their survival rate will highly depend on your
quick and accurate intervention.
 .
 This should be prioritised on the ABC principles
of first aid care, which state that:
 Airway must be established and maintained
 Breathing established
 Circulation must be promoted and maintained
The intensive care team.
. team builds a conducive environment for heal-
This
ing or dying.
It comprises of;
Medical officers (Doctors)
Nursing officers
Physiotherapists
Nutritionists
Chaplains and other support staff.
 Criteria for admission to CCU
 Critically ill patients in a medically unstable
state who require intensive monitoring and
treatment that cannot be provided in a general
ward eg. Ventilator support.
 Patients requiring intensive monitoring who may
also require emergency interventions.
 Patients who are medically unstable or critically
ill and who do not have much chance for recov-
ery eg metastatic malignancy
 Post operative patients with respiratory compli-
cations require mechanical ventilation.
 DISCHARGE CRITERIA FROM CCU
 Dependent on the level of care in the ward, indi-
.
vidual patient needs, staffing and expertise
 Can be discharged if
a. Patient is stable and no longer requires active
organ support
b. The patient is no longer benefiting from the
treatment available
c. The patient (or family/partner) wish to transfer
to palliative care facilities
d. A persistent/ permanent vegetative state is con-
firmed
 Common critical disorders
 Brain injuries  Complex surgical pro-
 Cardiovascular dysfunc- cedures
tions  Respiratory failure
 Pulmonary dysfunctions  Postoperative manage-
 Childbirth Complica- ment
tions  Ischemic heart disorder
 Infection/sepsis  Sepsis and heart failure
 Shock and trauma  Multisystem alterations
 Endocrine abnormalities
 The categories of patients requiring
critical care includes those with:
1. Disorders of the cardiovascular system-
 E.G heart attacks (myocardial infarction), shock,
 Cardiac arrhythmias (abnormal heart rhythm),
heart failure (congestive heart failure or CHF),
 High blood pressure (emergency or urgency)
 Unstable angina (chest pain)
 Circulatory instability due to hypovolaemia.
. Cardiogenic shock
 Cardiac valvular disease
 Cardiac tamponade

2. vascular disorders
 Thoracic aneurysm
 Abdominal aortic aneurysm
 Vascular trauma
3. Neurological disorders may include
 Acute stroke (blood clot in the brain) cerebrovas-
.
cular accident
 Coma (unconscious)
 Bleeding in the brain (intracranial hemorrhage),
 Such infections as meningitis, and traumatic brain
injury (TBI),
 CNS depression sufficient to prejudice the airway
and protective reflexes
 Invasive neurological monitoring eg ICP
 Closed head injury
 Spinal cord injury
4. Pulmonary- Lung disorders can include
 .acute respiratory failure,
 pulmonary emboli (blood clots in the lungs),
 hemoptysis and respiratory failure.
 Acute respiratory distress syndrome

5. Endocrine disorders
 Diabetes insipidus
 Acute adrenocortical insufficiency
 Hyperosmolar coma
6. Renal disorders
.Acute renal failure
 Renal cell carcinoma
7. Hematological and immunocompetence dis-
orders
 Disseminated intravascular coagulation
 Infection in immunosuppressed transplant patient
Others: Medication monitoring for drug inges-
tion or overdose-Medication monitoring is essen-
tial, including careful attention to the possibility
of seizures and other drug side effects.
  Critical Care Facilities
1. Acute room.
 Referred to as an 'acute room', because of its
location, equipment, or condition of patients
nursed there
 Patients nursed here require life support equip-
ment and continuous monitoring
 Also needs full time communication with the
nursing team
The following equipment should be available
 .Suction equipment,.
 Oxygen administration equipment fully as-
sembled, ready for use..
 Intravenous administration apparatus,
 Adequate stocks of linen as patients nursed in
this room often require frequent changing of bed
linen.
 Observation equipment that is, thermometers,
stethoscope, blood pressure machine, a torch.
Patients in this room includes:
.
 Post-operative patients during the first 48 hours
 Unconscious patients
 Patients under special procedures, for example,
under water seal drainage,
 Patients with severe respiratory distress
 Intensive care unit (ICU)
 A room/unit in which a critically ill patient is
actively treated and monitored.
 The purpose is to maintain life until the precip-
itating causes of body failure can be identified
and successfully treated
The ratio of nurse to patient should be 1:1

Essential of an icu
 The minimum number of beds should be four. A
smaller number may not be cost effective.
.
 should be easily accessible to the casualty area,
the labour ward and the operating theatre
 should provide adequate space for storage of
equipment
 requires ventilation and heating systems, piped
gases
 Adequate lighting with emergency connection to
a standby generator
 A 24 hour laboratory service
 TYPES OF ICU
General Intensive Care Unit:
 This is where one unit admits all types of patients. This is
the most common in Kenya. It admits: adults, neonates,
paediatrics, cardiac care patients and burns patients, etc.
Coronary Care Unit:
 This admits only those suffering from coronary and heart
related emergencies. Examples are myocardial infarction
and heart surgeries.
Paediatric Intensive Care Unit:
 These admit general paediatric emergencies.
Neonatal Intensive Care Unit (NICU):
 Neonates requiring critical care are admitted and managed
here.
High Dependant Unit:
 .These function as a step down to ICU. Patients are
nursed in these units after discharge from ICU before
getting to the general wards.
Burns Unit:
 The burns unit is basically designed to reduce the risk of
infection. Infection in burns occurs as a result of the loss
of the mechanical barrier provided by the skin cover.
Renal Dialysis Unit:
 This room is designed to ensure maintenance and suste-
nance of the life of patients during the dialysis procedure
Philosophy of critical care nurses
 The patient, his/her family and friends have the right to
receive quality nursing care planned around the pa-
tient’s physical ,physiological, spiritual and social
needs.

 The patient has a right to have his/her perception of

his/her condition recognized, respected and acted upon.
 Critical care nursing is primarily concerned with cre-
.
ating an atmosphere where dignity and respect is
maintained for the individual patient, his/her family
and all members of the health care team.
 That the care given is based on individual needs as
identified and prescribed by the intensivists, primary
nurse and other health care providers who critically
apply current technical knowledge, skills and attitude
in providing quality care.
 
 Philosophy ct….
 That for each patient: continuity, individualization,
and excellence of care is best achieved when planned
and evaluated by a single professional nurse ( pri-
mary nursing).
 That co-ordination requires ongoing collaboration
of professionals.
 The professional nurse respects the expertise and
judgement of other professionals and is similarly re-
spected.
SEVEN Cs OF CRITICAL CARE
Compassion .
Communication (with patient and family).
Consideration (to patients, relatives and col-
leagues) and avoidance of Conflict.
Comfort: prevention of suffering
Carefulness (avoidance of injury)
Consistency
Closure (ethics and withdrawal of care).
Critical Care Unit nursing requirements

.
All patient care is carried out directly by or under supervi-
sion of a trained critical care nurse
All nurses working in critical care should complete a clin-
ical critical care course before assuming full responsibility
for patient care
Unit orientation is required before assuming responsibility
for patient care
 .
 Nurse-to-patient ratios should be based on patient acuity
& according to written hospital policies.
 WHO recommendations is ratio of one or two nurse(s) to
one patient
 All critical care nurses must participate in continuing edu-
cation
 An appropriate number of nurses should be trained in
highly specialized techniques such as renal replacement
therapy, intra-aortic balloon pump monitoring and in-
tracranial pressure monitoring.
 All nurses should be familiar with the indications for and
complications of renal replacement therapy
 COMMON PROBLEMS
OF CRITICALLY ILL PATIENTS
1. Nutrition:
 The primary goal of nutritional support is to prevent or
correct nutritional deficiencies.
 This is usually accomplished by the early provision of en-
teral nutrition or parenteral nutrition
 a. Enteral Nutrition

 Refers to delivery of nourishment by feeding tube in the

gastrointestinal tract

 Delivered through a large bore nasal or oral gastric tube

(short-term use) OR

 Small bore feeding tubes or gastrostomies (long-term use)

 Preferred route for nutritional supplementation in criti-

cally ill patients
 b. Parenteral nutrition

Refers to infusion of nutrients using a venous catheter

located in a large, usually central vein

Used when nutrition supplement is needed and enteral

feedings cannot be initiated within 24 hours of ICU ad-
mission

Formulated by providing dextrose, lipids, protein, elec-

trolytes, water, and vitamin elements
 NB: Should be considered only when the enteral route is
.unsuccessful
traindicated
in providing adequate nutrition or con-

 (e.g.,
paralytic ileus
diffuse peritonitis
intestinal obstruction
pancreatitis
GI ischemia
intractable vomiting
severe diarrhea)
 … ct
.
Common Problems Associated with Parenteral Nutrition
include;
 Gut mucosal atrophy
 Overfeeding
 Hyperglycemia
 Increased risk of infectious complications
 Increased mortality
 2. Anxiety:
 The primary sources of anxiety for patients includes
 the perceived or anticipated threat to physical
health,
actual loss of control or body functions
an environment that is foreign.
 Clinical indicators can include
agitation,
increased blood pressure,
increased heart rate,
patient verbalization of anxiety
restlessness.
 To help reduce anxiety, the nurse should:
. Encourage patients and families to express concerns,
ask questions,
State their needs
Include the patient and family in all conversations
Explain the purpose of equipment and procedures.
Anti-anxiety drugs and complementary therapies
may reduce the stress response and should be con-
sidered EG……
 3. Pain
 The control of pain in the CCU patient is paramount.
 Inadequate pain control is often linked with agitation and
anxiety and can contribute to the stress response.
 CCU patients at high risk for pain include patients
1. who have medical conditions that include ischemic, in-
fectious, or inflammatory processes;
2. who are immobilized;
3. who have invasive monitoring devices, including en-
dotracheal tubes;
4. who are scheduled for any invasive or noninvasive
procedures
sedatives and an analgesic agent are a practical and effec-
tive strategy for sedation and pain control
 4. Impaired communication
 This can be distressing for the patient who may be unable
to speak.
 Due to sedative and paralyzing drugs or an endotracheal
tube… ETT
 Alternative methods of communication, eg notepads or
computer keyboard may be used
 Nonverbal communication is important
 Comforting touch and ongoing evaluation of response
should be provided.
 Families should be encouraged to touch and talk with the
patient even if the patient is unresponsive or comatose.
 5. Delirium
 Definition; Sudden onset of disturbances in cognition,
attention and perception.
 Results to confused thinking
 Manifest as hyperactive, hypoactive, or mixed
 Mixed type is most prevalent in CCU
 Delirium in CCU patients ranges from 15% to 40%.
 .
Factors predisposing the patient to delirium include
1. Advanced age,
2. Preexisting cerebral illnesses,
3. Environmental factors that can contribute to delirium eg
sleep deprivation, anxiety, sensory overload and immobi-
lization.
4. Physical conditions such as hemodynamic instability,
hypoxemia, hypercarbia, electrolyte disturbances, and se-
vere infections
5. Certain drugs (e.g sedatives, furosemide, antimicrobials)
have been associated with the development of delirium
 .
Management of Delirium
 The CCU nurse must identify predisposing factors and
appropriate therapy (e.g., correction of oxygenation, use
of clocks and calendars).
 If the patient demonstrates unsafe behavior, hyperactivity,
insomnia, or delusions symptoms may be managed with
neuroleptic drugs.
 The presence of family members may help reorient the pa-
tient and reduce agitation.
 Decrease drugs that contribute to delirium or discontinue
them
 Limit unnecessary noise, lights (to reduce the sensory
overload)
 Provide patients with eyeglasses or hearing aides
 6. Sleep problems
 May be due to noise, anxiety, pain, frequent monitoring,
or treatment procedures.
 Sleep disturbance is a significant stressor in the CCU
 Contributes to delirium and possibly affecting recovery
and can decreases patient immunity.
 The environment should be structured to promote the
patient’s sleep-wake cycle
 Hoooooow????
 By
.clustering activities,
scheduling rest periods,
dimming lights at nighttime,
opening curtains during the daytime (natural
light),
obtaining physiologic measurements without
disrupting the patient,
limiting noise
providing comfort measures.
Switch of the TV
ISSUES RELATED TO FAMILIES
 Family members play a valuable role in the pa-
tient’s recovery
 should be considered members of the health care
team.
 How do they contribute to the patient’s well-be-
ing?
1.. Providing a link to the patient’s personal life
2. Advising the patient in health care decisions or
functioning as the decision maker when the pa-
tient cannot
3. Helping with activities of daily living
4. Providing positive, loving and caring support
 Needs of Families of Critically
ILL Patients
 The major needs of families of critically ill patients have
been categorized as
informational needs
reassurance needs
and convenience needs

 Lack of information is a major source of anxiety for the

family

The family needs reassurance regarding the way in which

the patient’s care is managed and decisions are made
 .
The family should be invited to meet the health care team
members.

 Rigid visitation policies in CCUs should be less restric-

tive.

 Family members of patients undergoing invasive proce-

dures, should be given the option of being present at the
bedside during these events
 Other family needs are
 Personal care about the patients
 A believe there is hope
 Waiting room near the patient
 To be called when patient changes arise
 Knowing the prognosis
 Answering of questions honestly
 Knowing specific facts about patient’s progress
 Being allowed to see the patient frequently
.
 Provision of information
 Patient goals
 Written instructional guidelines to provide in-
formation about critical care
 Means of contacting the nurse
 Consistency in the nurse
 Open visiting hours
 Access to telephones, bathrooms and food
 Good communication
PSYCHOLOGICAL ISSUES
IN CCU
They focus/affect the following;
Patient
Nurses
Family
It has been estimated that 30-70% of
the patients experience severe psycho-
logical stress with resulting feelings of
powerlessness, anger and the develop-
ment of the ICU syndrome
 ICU STRESSORS
Patients admitted to the ICU are faced with a multitude
of stressors
Loss of privacy
Artificial lighting on 24 hours/day
Lack of windows
Constant noise
Lack of stimuli to the patients-huge machine
new faces
 ICU syndrome
 A syndrome that occurs on the 3 - 7 day in the ICU charac-
terized by severe psychological stress with resulting feel-
ings of powerlessness, anger .
 A.K.A ICU PSYCHOSIS
The common features of the syndrome are;
 Clouding of the consciousness brain fog
 Decreased attention span
 Disorientation
 Memory loss
 Labile emotion-swinging moods
 It clears within 48 hours after the patient is transferred out
of the ICU
Cont……
Environment factors that have been identified as
causing the ICU syndrome are:
1. Sleep deprivation
2. Sensory deprivation
3. Sensory overload
 Cont……
Patient related factors causing the ICU syndrome are:
1.Age..advanced
2.Severity of illness
3.History of psychological problems
4.Cardiopulmonary bypass
5.Prolonged surgery and anesthesia time
6.Metabolic abnormalities
7.Medications
The main nursing goal for patients with ICU psychosis is to
reduce the environmental factors
NURSES STRESSORS
Nurses who work in an ICU also face many stressors. Some
of the stressor facing nurses in an ICU are:
1.Management
2.Interpersonal relationship
3.Patient care
4.Lack of reward
5.Crisis atmosphere
6.Shortage staff
NURSE SATISFACTION
But along with these stress are many a satisfaction
of working in an ICU
1.Exercise intellectual skill
2.Saving someone’s life.
3.Increased opportunities for learning
4.Challenging complex multisystem problems
5.Use of technical equipment-ECG machines me-
chanical ventilators.
 ETHICAL ISSUES IN ICU
 Ethics is the formal systematic study of moral beliefs.
 Morality is the adherence to informal personal values
 In health care, the focus on ethics has intensified in re-
sponse to controversial developments, including:
 increased technological advances
diminished health care and
financial resource.
 Both of the areas have an impact on the role of the pro-
fessional nurse.
 Common ethical principles
Autonomy:
 Derived from the Greek words autos (“ self
‘’) nomos ( “rule or law’’ ) and thus
 Refers to self rule.
 Autonomy entails the ability to make choice
free from external constraints
Beneficence:
 The duty to do good and to active promotion
of benevolent e.g. goodness, kindness and
charity.
 May also include the injunction not to inflict
harm (nonmalificence).
.
Confidentiality:
 This principle relates to the concept of pri-
vacy
 Information obtained from an individual
will not be disclosed to another unless it
will benefit the person or there’s a direct
threat to the social good
Fidelity:
 promise keeping; the duty to be faithful to one’s
commitment
Justice:
 it states that like cases should be treated alike
Non-maleficence:
 the duty not to inflict as well as to prevent and
remove harm
.
Respect for persons:
 Frequently used synonymously with au-
tonomy
 However, it goes beyond accepting the no-
tion or attitude that people have autono-
mous choice to treat others in such way that
enable them to make the choice
Veracity
 The obligation to tell the truth and not to lie
or deceive others.
.
Paternalism:
 The intentional limitation of another’s au-
tonomy justified by an appeal to benefi-
cence or the welfare or needs of another
ENDLIFE ISSUES
Pain control:
 Patients with excruciating pain require high doses
of narcotics
 Fear of respiratory depression or unwarranted fear
of addiction should not prevent nurses from at-
tempting to alleviate pain for patients experiencing
acute pain
DNR ORDERS (Do Not Resus-
citate)
 DNR orders is usually a controversial issue
 When patient is competent to make decision
for DNR, his or her choice should be honored
(autonomy ) or respect for individual.
 However DNR is at times interpreted to mean
that the patient requires less nursing care,
when these patients actually have significant
medical & nursing needs all of which demand
attention
.
 Ethically, all patients deserve and should re-
ceive appropriate nursing intervention re-
gardless of their resuscitation status
Ethical dilemmas / components
of ethical reasoning
 Identify the problem- is the care appropri-
ate
 Determine the relevant facts of the case- pts
medical, mental, and emotional condition
and the current care plan
 Consider the values and ethical condition
of every one involved.
 Determine possible options for resolving
the dilemma
.
 Consider the consequences of each option
identified
 Identify relevant ethical principles for each
option identified.
 Prioritize acceptable options
 develop and implement a plan to resolve
the dilemma
 Evaluate the resolution of the dilemma
In summary critical care nursing fo-
cuses;
CCN entails a team approach!
.

THE END
XIEXIE