INTRODUCTION TO CRITICAL CARE NURSING

● Critical Care Nursing

○ CCN is concerned with human responses to Life-threatening
problems e.g. trauma, major surgery, complications of illness, MI,
Brain Attack, Respiratory distress
○ The human response could be physiologic (Vital Signs) or
Psychological (No man is an island) phenomenon
○ The focus includes both the patient's and family's responses to illness
and involves prevention as well as cure e.g. advanced directives
○ It is a specialty within nursing that deals specifically with human
responses to life threatening problems
○ Deals dynamically with human responses to actual or potential
life-threatening problems

● Framework of CCN
○ Complex, challenging area if nursing practice which utilizes nursing
process applying assessment, diagnosis, outcome identification,
planning, implementation, and evaluation
○ In ICU, nursing process is quick e.g. atrial fibrillation, action is
preparing the defibrillation
○ In ICU, not permissible to admit with communicable diseases.
Isolation is needed
○ The CCN is based on a scientific knowledge and incorporates the
professional competencies specific to critical care nursing
○ Focused on restorative, curative (meds), rehabilitative, maintainable
(limping with walking devices), or palliative based on patient's need
○ It upholds multi and interdisciplinary collaboration in initiating
interventions to restore stability, prevent complications, achieve and
maintain optimal patient outcomes.
○ Occupational therapy (spoon holding)
○ Speech therapist
○ Physical therapist (Rang of motions)
● Competencies of nurses caring for the critically ill
○ Clinical judgment and clinical reasoning skills
○ Advocacy and moral agency in identifying and resolving ethicalities
e.g. nurse as bridge between patient and doctor like HAMA form
(Home against medical advice). Respect the decision of the patient.
■ Ethical issues:
■ Autonomy is self freedom
■ Non-maleficence is doing no harm e.g. handwashing,
right med calibration
■ Beneficence is doing good for the patient
■ Veracity is truthfulness

● Caring pratices that are tailored to the uniqueness of the patient and family
● Collaboration with patients, fam members, and heath care team members
(rule of delegation)
● Systems thinking the promotes holistic nursing care (not just the body, but
mind, spiritual)
● Response to diversity (care despite differences)
● Facilitator of learning for patients and members of family, healthcare team,
and community e.g. first is to ask, then
● Clinical inquiry and innovation to promote the best patient outcome
○ Environmental theory: wash hands, bonet,

● Standards of professional performance

○ Systematically evaluates the quality and effectiveness of nursing
practice
○ Evaluates own practice in relation to professional practice standards,
guidelines, statuess, rules and regulatyions
○ Acquires and maintains current knowledge and competency in
poatient care e.g. annual BLS training
○ Contributes to the professional development of peers and other
healthcare providers
 ○ Acts ethically in all areas of practice (all morals are ethical, not all
ethical are moral)
○ Uses skills communication to collaborate to provide care in safe,
healing, humane, and caring environment
○ Uses clinical inquiry and integrates research findings into practice
(evidence-based practice. Best practice is something that can be
utilized in other places and would yield the same result as the mother
source. Good practice is good to one place, but may not be to others)
○ Considers factors related to safety , effectiveness, cost, and impact
planning and delivering care
○ Provides leadership in the practice setting for the profession
(leadership influences, managers are designated by position with
authority and has the right to direct others)

● Scope of CCN
○ The scope is defined by the dynamic interaction of the:
■ Critical ill patient (LACKING)
■ Critical care nurse
■ Critical care environment
■ Constantly supports the interaction between the
critically ill patients
■ It entails readily available and accessible emergency
equipment, sufficient supplies and effective supporting
system to ensure quality patient care as well as staff
safety and productivity
○ Constant intensive assessment, timely critical care interventions, and
continuous evaluation of management through multidisciplinary
efforts
○ Palliative care should be instituted to alleviate pain and sufferings
(transition from a critical unit to hospice care, dying with dignity)
○ Critical nurses are trained and qualified to practice critical care
nursing
 ○ They possess the standard critical care nursing competencies in
Assuming specialized and expanded roles in caring for patients and
family.
○ Personally responsible to continuous learning and updating of
knowledge and skills
○ The critical care nurses carry out interventions and collaborates
patient care activities to address life-threatening situations that will
meet patient's Biological, psychological, cultural, and spiritual needs
○ The environment constantly supports the interaction between
thepatients family
○ entails readily

● Roles of the CCN Nurses (LACKING)

○ Practitioner role:
■ Direct
■ (administers the meds)
■ Detects and interprets indicators that signify the varying
conditions of the critically ill with the assistance of
advanced technology and knowledge
■ Plans and initiates nursing process to its full capacity in a
need-driven and proactive manner
■ Acts promptly and judiciously to prevent or halt
deterioration when conditions warrant.
■ Coordinates with other healthcare providers in the
provision of optimal care to achieve the best possible
outcomes.

● Indirect
○ Care of the family
○ ask fam members to administer
○ Understands family needs and provide information to allay fears and
anxieties
 ○ Assists family to cope with the life-threatening situation and/or
patient's impending death

● Extended role as CCN

○ Sampling and analyzing arterial blood gas
○ Weaning patients off ventilations
○ Adjusting IV Analgesia and sedations
○ Performing and interpreting ECGs
○ Titrating IV and central line medicated infusion and nutrition support
○ Initiating defibrillation to patient with ventricular fibrillation or lethal
ventricular tachycardia
○ Removal of pacer wire, femoral sheaths and chest tubes
○ Other procedures deemed necessary by their respective institution
under a clinical protocol
● Educator
○ Provides health education to patient and family to promote
understanding and acceptance of the disease process and to facilitate
recovery
○ Participates in the training and coaching of novice healthcare team
members to achieve cohesiveness in the delivery of patient care.
● Patient advocate
○ Acts as bridge between patient and other members of team (if stroke,
cant talk)
○ Acts in the best interest of the patient
○ Monitors and safeguards quality of care
● Management and leadership role
○ Perform management and leadership skills in providing safe and
quality care
○ Accountability for safe critical care nursing practice
○ Delivery of effective health programs and services to critically ill
patients in the acute setting
○ Management of the critical care nursing unit or acute care setting
○ Take lead and supervision among nursing support staff
 ○ Utilize appropriate mechanism for collaboration, networking, linkage-
building and referrals
● Researcher role
○ Engage in nursing research under experienced researcher
○ Utilize guidelines in the evaluation of research study or report
○ Apply the research process in improving patient care infusing
concepts of quality improvement and in partnership with other
team-players
● Expanded roles
○ Nurse specialist
○ Advanced practice nurse (prescribe)
○ Outcomes manager

WEEK 2

LEADERSHIP AND MANAGEMENT IN CCN

● Charge nurse carries out order

● Staff nurse is executing doctors order
● Head Nurse has direct supervision over staff nurses
● Staff - charge - head - supervisor - chief

NATURE AND FUNCTION OF CRITICAL CARE NURSING

● Florence Nightingale cares for wounded soldiers during crimean war
● She is also the first researcher
● Round the clock constant factor for critically- ill patients and family e.g. 7-3, 3-11, 11-7
○ Continuity of care is ensured through end of shift endorsement
● Acts as the glue the holds the ICU together
● Fine-tune, coordinates, and communicates the many aspects of treatment and care
○ Since multi-disciplinary
● Responds to actual or potential life-threatening problems
○ CPR, Oxygenation
○ ICU, not for little girls
● Technical competent
 ○ Manipulate the machines e.g. infusion pumps, defibrillator
○ So, training is important

Qualifications
● Skill: 24 Months experience in a job that specializes in intensive care nursing; life
support, ventilators, emergency situations
● Knowledge: Continuing education-lifelong learning; work autonomously in defined
situations
● Attitude: Holistic care to patients and families; Responsible for the quality of delivery of
care

Responds to actual or potential Life-threatening problems

● Continuous, close monitoring of the patient and attached apparatus
○ Close watch
● Dynamic analysis and synthesis of complex data
○ Putting information and data altogether
● Anticipation of complications (Proactive planning, reactive planning)
○ Side rails for fall
○ Complications for meds side effects
● Complex decision-making, execution, and evaluation of interventions
● Enhancement of the speed and quality of recovery
● Emotional support of the patient and family, including through the end of life support

Ideal Set-Up
● Where 24 hour medical care is rendered with life-threatening injuries and illness
● Organizational and geographic section for clinical activity and care, operating in
coordination with other departments integrated in a hospital
○ Should be stand-alone
Function
● To monitor and support threatened or failing vital functions in critically ill patients, with
illnesses that can endanger life, and that adequate diagnostic measures and medical or
surgical therapies are performed to improve their outcome
Men and women of ICU
● A team specially-trained healthcare providers are involved in rendering specialized
treatments with the use of machines to constantly monitor vital signs
 ● With dedicated medical, nursing and allied health staff that operates with defined
policies and procedures, with its own quality improvement, continuing education, and
research programs
○ Lacking in Philippines: research and education

CCU Nursing discipline

● The specialty within nursing that specifically deals with human responses to
life-threatening problems. These problems deal dynamically with human responses to
actual or potential life-threatening illnesses
○ Critical care:
○ Palliative: alleviate suffering, dignified death with no pain
● Assisting, supporting, and restoring the patient toward health, or to ease the patient's
pain, or to prepare them for dignified death (World federation of critical Nurses)

THE CCU NURSE

● The CCN is licensed professional nurse who is responsible for ensuring that all acutely
and critically ill patients receive optimal care
● Basic to the provision of optimal care is individual professional accountability through
○ Adherence to the standards of nursing care of acutely ill patients (BON is the law
which regulates the practice, Conduct of conduct is PNA)
○ Commitment to act in accordance with ethical principles
● Essential elements:
○ Nursing expertise
○ Ability to observe patients
○ Appropriate nursing intensity

CCU Patients
● Patients who are at high risk for mortality due to present health problems (AACN, 2015)
● At high risk of actual or life threatening health problems

Conditions that need ICU

● Stroke with comatose

Contemporary critical care

● Provided by a multidisciplinary team of healthcare professionals equipped with an
extensive education and expertise in the specialty field of critical care
 ● Physicians intensivist/ specialty physicians
● Nurses (CCN)
● Pharmacists
● Respiratory therapists, and other specialized therapists
● Social workers (Coordination for discounts and insurance)
● Clergy and other religious sect
● Critical care is provided in specialized units, with emphasis on the continuum of care,
with an efficient and seamless transition of care from one setting to another
○ Transition:
● Settings:
○ Adult / pediatric / neonatal
○ Step-down - telemetry - progressive or transitional care units
○ Interventional radiology departments
○ Post-Op recovery units (PACU)

● CRITICAL ILLNESS
○ Any disease process which causes physiological instability leading to disability or
death within minutes or hours
○ Disturbance of these systems generally has the most immediate life-threatening
effects
■ Neurological
■ Respiratory
■ Cardiovascular
○ Common signs:
■ Hypotension
■ Tachycardia
■ Tachypnea
■ Reduced level of urine output
■ Altered level of consciousness
○ The presence of 2 or more of these signs strongly suggests that the patient is
critically ill and at risk of death
○ Cardinal Signs
Management system and resources
● Picture
● Do not admit to ICU without IV Access
THE ICU
● May constitutes up to 10% of total hospital beds
● Multidisciplinary ICUs require more beds than single-specialty ones
● Large ICUs are divided into pods (8-15) for clinical management

Intensive Care
● Practice administering immediate and continuous care with actual or potentially
life-threatening health disorder:
○ Brain injuries
○ Cardiovascular dysfunctions
○ Pulmonary Dysfunctions
○ Childbirth
○ Shock and trauma
○ Infection and sepsis (Negative pressure room,
○ Endocrine abnormalities
○ Multisystem alterations
○ Complex surgical procedures (anything to do with the brain)

GOAL OF ICU
● To create a healing environment
○ Improves physical and psychological states of patients staff and visitors
○ Helps to reduce medical errors (Meds among others)
○ Improve patient outcomes
○ Reduce length of stay (economic reasons)
○ Increase social support for patients (relatives, friends,
○ Cost-reducing

LAYOUT OF ICU
● Should allow rapid access to relevant acute areas
● Available, open, round the clock communication lines between depts
● Safe transport of critically ill patients (elevator)
○ No xray and 2d echo transpo because portable are used
● Single entry and exit point with receptionist
● Areas dedicated to public reception, patient management and support services
 ● Total floor area = 2.5-3 times the area devoted to patient care

High-dependency unit
● Specialty staffed and equipped area
● Provide a level of care between intensive and general ward care
● Located within or immediate adjacent to an ICU complex and care and are often staffed
by the ICU Personnel
● May act as a step up or step down unit
● Provides invasive monitoring and support for patients with or at risk of developing acute
(or acute-on-chronic) single organ failure.

LEVELS OF ICU
● LEVEL 1:
○ Small district hospitals (Labuan, ciniput, Provide resuscitation and short-term
cardiorespiratory support
■ Mechanical ventilation
■ Simple invasive cardiovascular monitoring
○ Major role: Monitor and prevent complications of high risk medical surgical
patients "at risk patients"
○ Policies are established to determine which patients require transfer and where
they ought to be transferred
○ Establishes relationship with levels 2 and/or 3 units
○ Certified intensive care specialist medical director
○ Some training and experience with critically-ill children

● LEVEL 2:
○ Large general hospitals
○ Provide a high standard of general intensive care
■ Multisystem life support
■ With medical officer on site
■ Access to pharmacy pathology and radiology facilities at all times
○ Certified intensive care specialist medical director and majority of other
specialties
○ Patients admitted must be referred to the attending intensive care specialist for
management
 ○ Referral and transport policies with level 3 unit should be in place

● LEVEL 3:
○ Major tertiary referral hospital;
○ Provide all aspects of intensive care management for indefinite period
○ Committed to education and research
○ Complex investigations and imaging and support by specialists of all disciplines
○ Staffed by intensive care specialist with trainees
■ Junior medical staff
■ Critical care nurses
■ Allied health professionals
■ Clerical and scientific staff
PATIENT CARE ZONE (3 ZONES AREA)
● PATIENT CARE ZONE
○ Single rooms for isolation, equipped with anterooms for handwashing, gowning,
and storage of isolation materials
○ Suitable and safe air quality
○ Negative pressure ventilated for contagious respiratory infections
○ HEPA-Filtration (High Efficiency Particulate Filtration)
○ Each bed: Non splash hand wash basin (elbow foot operated taps), hand
disinfection facility
○ Adequate appropriate lighting for clinical observation
○ Patients should be able to be seen at all times
● CLINICAL SUPPORT ZONE
○ Adequate space for staff interaction, mentoring and socialization
○ Houses:
■ Central monitor
■ Satellite pharmacy
■ Drug preparation area
■ Communication (Telephone, computer, patient's records, reference
books, and policy and procedure manuals)
■ Satellite sterile and non sterile areas
■ Critical care is primarily at the bedside
● UNIT SUPPORT ZONE
○ Storage areas
 ○ Separate clean and dirty utility rooms
○ Laboratory 1: facility for estimating blood gases, glucose, electrolytes,
hemoglobin, lactate, and clotting status
○ Pneumatic tube or equivalent system to transfer specimens to pathology
○ Offices
○ Washrooms
○ Staff lounge
○ Conference room
Equipment at the bedside
● Cardiac monitor
● Iv pumps
● Ventilators
● Intubation set
● Defibrillator
● Emergency drugs
● Bed