UNIVERSIDAD DE MANILA

Republic of the Philippines

City of Manila

NCM 118
Nursing care of clients with Life Threatening conditions/ Acutely ill/ Multi-organ
problems/ High acuity and Emergency situations,
Acute and Chronic

Dr. Maria Charito Laarni S. Indonto

Professor
Learning objectives:
At the end of the 4 hours lecture, the students will understand and
comprehend, the following:
Introduction to Critical Care
A. Scope of Critical Care Practice
1. Development of Critical Care of Nursing Practice, Education and
Professional Activities in the Philippines
2. Critical Care Body of Knowledge Critical Care Competencies,
professional organizations
Learning objectives: (Cont.)
B. Leadership in Critical Care
1. Standards of Practice
2. Clinical Leadership

C. Management Systems and Resources

1. Resources and Supports in the Governance and Management of a Critical Care Unit
2. Physical Design and Equipment Requirements of a CCU
3. Human Resources Requirements, Supports and Training of the Workforce.
4. Leadership and Management Principles Influencing Quality, Efficacy and Appropriateness of a
CCU
5. Risk Management
Introduction to Critical Care
A. Scope of Critical Practice
The 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.

The critical care environment constantly support 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.
 Development of Critical Care of Nursing Practice, Education and
Professional Activities in the Philippines

The health care industry all over the world has been undergoing
significant changes over the past two decades and the Philippines has
been part of these transformational events having great impact on the
quality of nursing practice.
There are new expectations in the way nurses and the nursing practices
are to be delivered particularly now that there are many challenges that
besiege the nursing profession as a consequence of the complexities of
globalization.
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.
The framework of critical care nursing is a complex, challenging area of
nursing practice.
It utilizes the nursing process applying assessment, diagnosis, outcome
identification, planning, implementation, and evaluation.
The critical care nursing practice 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 need3
 Critical Care Body of Knowledge Critical Care Competencies,
professional organizations

In the Philippines, the 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.
To respond to this mission and commitment, a PRC-BON Working
Group in Developing the Nursing Specialty Framework was formed in
the 1996 to take on the task of setting the process-based framework and
guidelines for specialty nursing services. 
The expanding healthcare and nursing knowledge together with new
and evolving healthcare sites, structures, and technologies all have
contributed to the need and desire for specialty nursing organizations
like the Critical Care Nurses Association of the Philippines, Inc.
(CCNAPI) to revisit the existing statements of its Standards of Nursing
Practice to provide clear and updated statements regarding the scopes of
practice and standards of critical care nursing. 
Leadership in Critical Care
Standard of Practice
The CCNAPI adopt the Position Statement of the World Federation of Critical
Care Nurses on the Provisions of Critical Care Nursing Workforce also called”
the Declaration of Buenos Aires” ratified in the full council meeting last August
27, 2011 at the Sheraton Hotel, Buenos Aires, Argentina.
 
The declaration presents guidelines universally accepted by critical care
professionals, which should be adopted to meet the critical care nursing
workforce and the system requirements of a particular country or jurisdiction.
Leadership in Critical Care
Clinical Practice
In response to the changes and expansions within and outside the
healthcare environment, critical care nurses have broadened their roles
in the practice levels.
Competencies of critical care nurses are honed and developed to achieve
their roles in practice, management / leadership and research.
 The critical care nurses execute their practice roles 24-hours a day to provide high quality care to the critically ill patient.
 

1. Care Provider
A. Direct Patient Care
1.Detects and interprets indicators that signify the varying conditions of the
critically ill with the assistance of advanced technology and knowledge;
2.Plans and initiates nursing process to its full capacity in a need driven and
proactive manner;
3.Acts promptly and judiciously to prevent or halt deterioration of patients’
condition when conditions warrant, and
4.Co-ordinates with other healthcare providers in the provision of optimal care
to achieve the best possible outcomes.
B. Indirect Patient Care – Care of the Family

1.Understands family needs and provide information to allay fears and

anxieties and
2.Assists family to cope with the life-threatening situation and/or
patient’s impending death.
2. Extended roles as Critical Care Nurses
Critical care nurses have roles beyond their professional boundary. With proper training and in
accordance with established guidelines, algorithms, and protocols that are continuously
reviewed and updated, critical care nurses also perform procedures and therapies that are
otherwise done by doctors. Such procedures and therapies are:
a. Sampling and analyzing arterial blood gases;
b. Weaning patients off ventilators;
c. Adjusting intravenous analgesia / sedations;
d. Performing and interpreting ECGs;
e. Titrating intravenous and central line medicated infusion and nutrition support;
f. Initiating defibrillation to patient with ventricular fibrillation or lethal ventricular tachycardia;
g. Removal of pacer wire, femoral sheaths and chest tubes, and
h. Other procedures deemed necessary  in their respective institutions under a clinical protocol.
3. Educator
As an educator, the critical care nurse must be able to:
1.Provides health education to patient and family to promote
understanding and acceptance of the disease process thus facilitate
recovery and
2.Participates in the training and coaching of novice healthcare team
members to achieve cohesiveness in the delivery of patient care
4. Patient Advocate
The critical care nurses’ role includes being an advocate – someone who acts or intercedes on
behalf or another.
Typically, the critical care nurse may be in the best position to act as the liaison between
patient and family and other team members and departments because they are the healthcare
professionals with the most interpersonal contact with the patients.
To perform this function adequately, the nurse must be knowledgeable about the involved in all
aspects of the patient’s care and have a positive working relationship with other team members.

The critical care nurses are expected to:

1.Acts in the best interests of the patient and
2.Monitors and safeguards the quality of care which the patient receives.
Management and Leadership Role
The critical care nurse in her management and leadership role will be able to  assume
the following responsibilities:
1.Performance of management and leadership skills in providing safe and quality care;
2.Accountability for safe critical care nursing practice;
3.Delivery of effective health programs and services to critically-ill patients in the acute
setting;
4.Management of the critical care nursing unit or acute care setting;
5.Taking the lead and supervision of nursing support staff, and
6.Utilization of appropriate mechanism for collaboration, networking, linkage –building
and referrals.
Role in Research
The critical care nurse’s role in research will entail the following
responsibilities:
1.Engage self in nursing or other health – related research with or under
the supervision of an experienced researcher;
2.Utilization of  guidelines in the evaluation of research study or report
3.Application of the research process in improving patient care infusing
concepts of quality improvement in partnership with other team-
players.
ADVANCED PRACTICE LEVEL
The development of the Advanced Practice Nursing is the future direction in the
Philippines and to be bench marked with other countries. For now, a thorough study of
Advanced Practice in critical care  is being undertaken to align with the PRC- BON
initiative on specialization framework.

The current global healthcare environment demands critical care nurses to have
advanced knowledge and skills to provide the highest possible level of care to the
critically ill patients. CCNAPI supports the following descriptions of advanced practice
roles.
Expanded Roles
1. Nurse Specialist/ Clinical Nurse Specialist
The education and preparation of the critical care nurse practitioner is provided by
the respective hospitals.

CCNAPI recommends that a graduate study or a master’s degree program should

support the development of critical care nursing specialization goes beyond the
basic baccalaureate nursing degree.

Advanced educational preparation refers to the critical care nursing educational

program  run by the university offering Advanced Nursing Studies or other
recognized advanced critical care program offered in the Philippines and overseas
Acute Care Nurse Practitioner
Acute Care Nurse Practitioner (ACNP) in the critical care unit takes lead in developing evidence-
based practices to meet changing clinical needs and facilitates patient care processes across
professional and organizational boundaries.

The qualification of Acute Care Nurse Practitioner (ACNP) includes:  should have the recommended
number of post registration (licensed experience) nursing experience which are spent in the critical
field, exhibiting in –depth professional knowledge and skills.

An Acute Care Nurse Practitioner (ACNP) is a holder of: a) clinical master’s degree in a clinical
nursing specialty (Medical-Surgical) such as Critical Care Nursing or b) master’s degree in nursing
or related discipline such as management together with recognized critical care training
qualifications.

The Acute Care Nurse Practitioner executes the nursing team leader’s responsibilities as designated
in the position of Advanced Nurse Practitioner
Outcome Specialist
Outcome management has been introduced into the healthcare system to
ensure achievement of quality and cost-effectiveness in the delivery of
patient care.
Some critical care units have adopted clinical pathways (e.g., Critical
Pathways, Protocols, Algorithms and Orders) in the management of
specific diseases such as Acute Myocardial Infarction and Cardio-
thoracic Surgeries.
Qualified nurse experts are involved in the development and
implementation of patient outcomes management.
 CHALLENGES OF
CRITICAL CARE NURSES
The challenging needs that the advanced critical care practitioner will face from the
critical care nursing service and its environments demand for them to consider the
following objectives:

1.To develop, foster and maintain a level of knowledge about the norms, values, beliefs,
patterns of illness, health and care needs of the people;
2.To analyze and evaluate critical care nurses specialty skills and their evolving roles;
3.To review current studies and researches and to examine contextual issues that will
enable evaluation and synthesis of new knowledge, traditional techniques, religious and
cultural influences to be applied in nursing practice, particularly evidence-based nursing
practice, and
4.To exercise professional judgments expected of them in the critical care clinical setting.
TRAINING OF NURSES FOR CRITICAL CARE SERVICES

The institution / hospital should provide training opportunities to ensure

staff competencies. 
This will enable the nurses working in the critical care units to cope
with the complexities and demands of the changing needs of the
critically ill patients. 
The following training activities should be supported  by the higher
level of management to maintain a high standard of care.
 Orientation Program/ Preceptorship and
mentoring program

New recruits to the critical care units shall attend an orientation program
and be given opportunities to work under senior staff supervision.
Experienced staff in the unit should be readily available for
consultation.
In-Service Training Program
a. Unit / hospital based training courses / workshop / seminar at hospital
level
b. On-the-job training and bedside supervision
  
Critical Care Nursing Program
(Post Graduate Specialty Program)

Critical Care Nurses Association of the Philippines, Inc. recommends

that all practicing CCN shall continuously update their knowledge,
skills and behavior through active participation in Critical Care Nursing
Education or its related field.
The following are the categories of Critical
Care Nursing Education
1. Post Graduate Courses
• Post graduate courses are part of higher education taken after a Bachelor’s Degree that are
accredited from the Commission on Higher Education (CHED) or the Professional
Regulation Commission—Board of Nursing (PRC-BON).

• It is recommended that this course has been reviewed, evaluated and endorsed to the
accrediting body by the Critical Care Nurses Association of the Philippines, Inc.

• Likewise it is further recommended that the World Federation of Critical Care Nurses policy
statement of education shall be used as a framework for designing a critical care nursing
program. (Please see Declaration of Madrid, 2005 Annex I)
Certificate Courses
• Certification courses provides recognition and designation earned by a
professional nurse after completing with satisfaction the requirements
of the course and has earned qualification to perform a job or task.

• The certification courses should be recognized and accredited by the

Professional Regulation Commission— Board of Nursing (PRC-BON)
or other authorized accrediting body.
This shall include but not limited to the following:
• Advanced Cardiac Life Support
• Pediatric Advanced Cardiac Life Support
• Newborn Resuscitation
• Continuous Renal Replacement Certification
• Advanced Intravenous therapy
• Stroke Nursing
Continuing Professional Education (CPE)
• Continuing Professional Education Programs is a type of education that consist of
updated knowledge and other pertinent information that will help the Critical
Care Nurse to attain broader understanding  of critical care practice and its related
field.

• The goal includes Critical Care Nurses development of skill, behavior that will
help them view the critically ill person in a holistic dimension

• CCNAPI recommends that all practicing CCN shall ensure the they continuously
update their knowledge, skills and behavior through active participation in related
critical care nursing education and must earn at least 20 credit units per year
The updated educational component includes but not limited to the
following:
• Advanced/Comprehensive Critical Assessment
• Critical Care Practitioner
• End-of-Life and Palliative Care
Standards of Critical Care Nursing Practice

Critical care specialty addresses the management and support of patients with
severe or life-threatening illness.

The goal of critical care nursing is to promote optimal adaptation of critically

ill patients and their families by providing highly individualized care, so that
the critically ill patients adapt to their physiological dysfunction as well as the
psychological stress in the Critical Care Unit or Intensive Care Unit (ICU).

To achieve this, standards should be developed to serve as a guide for

monitoring and enhancing the quality of intensive care nursing practice
The following 11 Standards are intended to furnish nurses with directions in providing quality care and
excellence in Critical Care Nursing:
 
1.  The critical care nurse functions in accordance with legislation, common laws, organizational
regulations and by-laws, which affect nursing practice.
 
2. The critical care nurse provides care to meet individual patient needs on a 24-hour basis.
 
3. The critical care nurse practices current critical care nursing competently.
 
4. The critical care nurse delivers nursing care in a way that can be ethically justified.

5. The critical care nurse demonstrates accountability for his/her professional judgment and actions.

6. The critical care nurse creates and maintains an environment which promotes safety and security of
patients, visitors and staff.
7. The critical care nurse masters the use of all essential equipment, available services
and supplies for immediate care of patients.

8. The critical care nurse protects the patients from developing environmental induced
infection.

9. The critical care nurse utilizes the nursing process in an explicit systematic manner to
achieve the goals of care.

10. The critical care nurse carries out health education for promotion and maintenance
of health.

11. The critical care nurse acts to enhance the professional development of self and
others.
Reference
https://www.ccnapi.org/news-and-events/critical-care-nursing-guidelin
es-standards-and-competencies/
Management Systems and resources ICU
Intensive Care Units (ICUs) consume a large proportion of hospital
resources and they are focused places in the hospital with well-
defined boundaries.
Medical resources such as drugs, supplies and equipment constitute
a high proportion of costs in this unit.
The management of these resources is an important factor in
controlling hospital costs.
The management of resources is the responsibility of individual
staff working in the care units.
Nurses as the largest group providing healthcare in the hospital are
the main users of resources and equipment at their workplace.
Thus, they play key roles in the appropriate use of health resources.
Shortage of resources, administrative methods, and organizational
culture are among the factors that affect the delivery of nursing care
and use of resources.
As well, the ICU environment with certain characteristics such as
critically ill patients, high mortality rate, unpredictable nature of the
work, high use of resources, and more expensive equipment have
led to a specific care culture.

Within this context, culture and beliefs can have an effect on the
efficiency of nursing activities and resource management.
Culture is defined as a set of shared values and notions that
influence the method of practicing activities in the working
environment.

Realizing the culture, especially tacit knowledge regarding resource

management requires an understanding of individuals’
perspectives, actions, speech, beliefs, and how they make sense of
their own experiences.
Resources and Supports in the Governance and Management
of a Critical Care Unit

Implementing resource management strategies can improve the

utilization of nursing resources, leading to better nurse job
satisfaction, reduced turnover and lower labor costs.
 Physical Design and Equipment
Requirements of a CCU

Equipment used in an Intensive Care Unit ranges from

familiar equipment, such as blood pressure monitors, to
highly specialised devices, such as dialysis machines.
 Human Resources Requirements, Supports
and Training of the Workforce.
There are many different work tasks and workplace hazards related to the ICU setting.

The workplace hazards include the physical environment of the ICU, working conditions, psychosocial factors,
ergonomic factors, biological factors and chemical factors that cause ICU workers to have health problems.

The occurrence of occupational health problems in ICU workers not only leads to decreased job satisfaction
and productivity but also increases absenteeism and burnout.

Moreover, this situation adversely affects patient care and increases the cost of treatment.

Recognising occupational hazards and risks arising from the work environment will assist in planning
strategies to protect and promote health programmes for ICU workers.

Understanding the importance of occupational health and safety practices by all institutions is a key factor to
improve quality of life, work efficiency and work satisfaction of ICU workers.
 Leadership and Management Principles Influencing Quality,
Efficacy and Appropriateness of a CCU

The rewards of teamwork and productive leadership in

healthcare today.

Is the combination of teamwork and leadership important in

nursing and healthcare?

The answer to that question is “Yes!” 

Strong leadership skills enable teams to provide high

quality, visible, and effective patient care.
Risk Management in ICU
Clinical risk management focuses on improving the quality and
safety of health care services by identifying the circumstances
and opportunities that put patients at risk of harm and acting to
prevent or control those risks.