NCM 118 - Nursing Care of Clients with Life- Threatening Conditions, Acutely Ill / Multi- Organ Problems, High Acuity and Emergency Situation

• Crucial, crisis, emergency, serious.

• Requiring immediate action.

• Total dependent

Critical

The delivery of specialized care to critically ill patients—that is, ones who have life- threatening illnesses or injuries.

Critical Care Nursing

is a term used to describe as the care of a patient who is extremely ill and whole clinical condition is unstable or potentially unstable.

Critical Care

“To be considered critical, an illness or injury must acutely impair one or more vital organ systems to such a degree that there is a high probability of life-threatening deterioration.”

Perrin and McLeod, 2018

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 need.

The framework of critical care nursing

1. Compassion

2. Communication

3. Consideration

4. Comfort

5. Carefulness

6. Consistency

7. Closure

7 C’s of Critical Care

• It 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.

Scope of Critical Practice

• high risk for actual or potential life- threatening health problems

• One who is ill requires more intensive and careful nursing care

Critically Ill Patient

• A licensed professional nurse who is trained and qualified to practice critical care nursing.

• Provide direct one on one care

• At high risk of injury or illness from possible exposure to infections

• Good communication skill

• Requires extensive knowledge and a continual desire to learn

Critical Care Nurse

• committed to provide need-driven, effective and efficient specialty nursing care services of high standard and at international level within the obtainable resources.

Professional Regulation Commission – Board of Nursing (PRC-BON)

was formed in the 1996 to take on the task of setting the process-based framework and guidelines for specialty nursing services.

PRC-BON Working Group in Developing the Nursing Specialty Framework

• Founded in 1969

• It offered educational / professional support

• Certification, Scholarships

• Largest professional specialty nursing organization

• Research - Publishes journals

• Provides standards of practice

American Association of Critical-Care Nurses (AACN)

• Founded in 1977

• RA 9173 allows for the development of the Comprehensive Nursing Specialty program through existing programs by CCNAPI, DOH and other institutions that provide certificate of training.

• A critical care nurse is a registered nurse who is a nursing degree holder, should have more than 3 years of uninterrupted practice experience in the critical field.

• A nurse who has attained advanced education and expertise in caring patients with critical problems.

Critical Care Nurses Association of the Philippines, Inc. (CCNAPI)

• revisited the existing Standards of Nursing Practice to provide clear and updated statements regarding the scopes of practice and standards of critical care nursing.

• 11 Core Competencies for Entry Level for Safe and Quality Nursing Care

• The CCNAPI Core Competencies of a Critical Care Nurse are stated according to the levels of expected behavior defining the actual knowledge, skills and abilities in the practice of critical care by a nursing professional.

Critical Care Nurses Association of the Philippines, Inc. (CCNAPI)

• is responsible for the promotion of man’s health and welfare for national development.

• It desires to support the professional and personal growth and development of initial core nurses. CCNAPI has organized itself into a national association committed to the ideals of service to the people, equality, justice and social progress.

Critical Care Nurses Association of the Philippines, Inc. (CCNAPI)

• The International Council of nurses (ICN) views health care as the rights of every individual regardless of financial, political, geographical, racial and religious consideration. This right includes the right to choose or decline care, including the right to accept or refuse treatment or nourishment; informed consent; confidentiality and dignity, including the right to die with dignity. It involves both the right of those seeking care and the providers.

• The World Federation of Critical Care Nurses (WFCCN) has considered the rights of the critically ill patients, WFCCN has agreed that the statement of the patient’s right from the ICN covers the requirement for position statement on the rights of the critically ill patients.

THE RIGHT OF THE CRITICALLY ILL PATIENT

• To promote optimal delivery of safe and quality care to the critically ill patients and their families by providing highly individualized care so that the physiological dysfunction as well as the psychological stress in the ICU are under control;

• To care for the critically ill patients with a holistic approach, considering the patient’s biological, psychological, cultural and spiritual dimensions regardless of diagnosis or clinical setting;

• To use relevant and up-to-date knowledge, caring attitude and clinical skills, supported by appropriate technology for the prevention, early detection and treatment of complications to facilitate recovery.

• To provide palliative care to the critically ill patients in situations where their health status is progressing to unavoidable death, and to help the patients and families go through their painful sufferings.

Goals of Critical Care Nursing (CCNAPI, 2014)

• Traumatic injuries from such events as automotive collisions, falls, gunshots

• Cardiovascular disorders, such as heart failure and acute coronary syndromes (unstable angina and myocardial infarction [MI])

• Surgeries, such as abdominal aortic aneurysm repair and carotid endarterectomy

• Respiratory disorders, such as acute respiratory failure and pulmonary embolism

• GI and hepatic disorders, such as acute pancreatitis, acute upper GI bleeding, and acute liver failure

• Renal disorders, such as acute and chronic renal failure

• Cancers, such as lung, esophageal, and gastric cancer

• Shock caused by hypovolemia, sepsis, and cardiogenic events (such as after MI)

Common Cases in Critical Care Units

• Should be capable of providing immediate resuscitation for the critically ill and short- term cardio-respiratory support because the patients are at risk of deterioration;

• Has a major role in monitoring and preventing complications in "at risk" medical and surgical patients;

• Must be capable of providing mechanical ventilation and simple invasive cardiovascular monitoring;

• Has a formal organization of medical staff and at least one registered nurse.

• A certain number of nurses including the nurse in-charge of the unit should possess post-registration qualification in critical care or in the related clinical specialties; and

• Has a nurse: patient ratio of 1:1 for all critically ill patients.

Level 1

• Should be capable of providing a high standard of general critical care for patients who are stepping down from higher levels of care or requiring single organ support/support post-operatively;

• Capable of providing sustainable support for mechanical ventilation, renal replacement therapy, invasive hemodynamic monitoring and equipment for critically ill patients of various specialties such as medicine, surgery, trauma, neurosurgery, vascular surgery;

• Has a designated medical director with appropriate intensive care qualification and a duty specialist available exclusively to the unit at all times;

• The nurse in-charge and a significant number of nursing staff in the unit have critical care certification; and

• A nurse: patient ratio is 1:1 for all critically ill patients.

Level 2

• Is a tertiary referral unit, capable of managing all aspects of critical care medicine (This does not only include the management of patients requiring advanced respiratory support but also patients with multi-organ failure);

• Has a medical director with specialist critical / intensive care qualification and a duty specialist available exclusively to the unit and medical staff with an appropriate level of experience always present in the unit;

• A nurse in-charge and most nursing staff have intensive care certification; and

• A nurse: patient ratio is at least 1:1 for all patients at all times

Level 3

• Also known as Intensive Care Unit (ICU) or Intensive Treatment Unit (ITU)

• A special department of the hospital or healthcare facility that provides intensive care medicine

• Caters to patients with severe or life- threatening illnesses and injuries, which require constant care, close supervision from life support equipment and medication in order to ensure normal bodily functions.

• Staffed by highly trained physicians, nurses, respiratory therapists and other members of the healthcare team who specialize in caring for critically ill patients

Critical Care Unit (CCU)

By Age Group

By Specialty

By System Operation

Categorization of CCU

• Neonatal

• Pediatric

• Adult

By Age Group

• Medical

• Surgical

• Respiratory

• Neurosurgical

• Cardio-thoracic

• Trauma

• Cardiac

By Specialty

• Open System

• Closed System

• Hybrid System

By System Operation

• This model allows many different members of the medical staff to manage patients in the ICU. − In this type, physicians admit, treat and discharge without consultation or communication with a Critical Care Specialist (intensivist).

Open Model

• This model is limited to ICU-certified physicians managing the care of all patients. − In this type, the admission, discharge and referral policies are under the control of intensivists (a medical practitioner who specializes in the care of critically ill patients)

Closed Model

• This model combines aspects of open and closed models by staffing the ICU with an attending physician and/or team to work in tandem with primary physicians

Hybrid Model

• This system defines those that will benefit most from the ICU (Priority 1) to those that will not benefit at all (Priority 4) from ICU admission.

Priority Model

• This model uses specific conditions or diseases to determine appropriateness of ICU admission. (described in critically ill patient)

Diagnosis Model

• This model uses vital sign ranges, physical findings, diagnostic and laboratory findings.

Objectives Parameter Model

• These are critically ill, unstable patients in need of intensive treatment and monitoring that cannot be provided outside of the ICU. Treatments include ventilator support, continuous vasoactive drug infusions.

• Examples of these patients may include post-operative or acute respiratory failure patients requiring mechanical ventilatory support and shock or hemodynamically unstable patients receiving invasive monitoring and/or vasoactive drugs

Priority 1

• These patients require intensive monitoring and may potentially need immediate intervention.

• Examples include patients with chronic comorbid conditions who develop acute severe medical or surgical illness

Priority 2

• These unstable patients are critically ill but have a reduced likelihood of recovery because of underlying disease or nature of their acute illness.

• Examples include patients with metastatic malignancy complicated by infection, cardiac tamponade, or airway obstruction

Priority 3

• These are patients who are generally not appropriate for ICU admission.

• Admission of these patients should be on an individual basis, under unusual circumstances and at the discretion of the ICU Director.

Priority 4

• are registered nurses, who 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 the critically ill patients and their family.

• personally responsible and committed to continuous learning and updating of his/her knowledge and skills.

Critical Care Nurses

• is a licensed professional nurse who is responsible for ensuring that acutely and critically ill patients and their families receive optimal care.

Critical Care Nurse

• 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 of patients’ condition when conditions warrant, and

• Coordinates with other healthcare providers in the provision of optimal care to achieve the best possible outcomes.

Direct patient care

• 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.

Indirect Patient Care

• 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.

Extended Roles as Critical Care Nurses

• Makes independent assessments

• Plans and implements patient care

• Provides direct nursing care

• Makes clinical observations and executes interventions

• Administers medications and treatments

• Promotes activities of daily living

Staff Nurse

• Assesses patients' and families learning needs; plans and implements teaching strategies to meet those needs

• Evaluates effectiveness of teaching

• Educates peers and colleagues

• Possesses excellent interpersonal skills

Nurse Educator

• Acts as an administrative representative of the unit

• Ensures that effective and quality nursing care is provided in a timely and fiscally sound environment

Nurse Manager

• Manages comprehensive care of an individual patient

• Encompasses the patient's entire illness episode, crosses all care settings, and involves the collaboration of all personnel who provide care

• Is involved in discharge planning and making referrals

• Identifies community and personal resources

• Arranges for equipment and supplies needed by the patient on discharge

Case Manager

• Provides primary health care to patients and families; can function independently

• May obtain histories and conduct physical examinations

• Orders laboratory and diagnostic tests and interprets results

• Diagnoses disorders

• Treats patients

• Counsels and educates patients and families

Nurse Practitioner

• Participates in education and direct patient care

• Consults with patients and family members

• Collaborates with other nurses and health care team members to deliver high-quality care

Clinical Nurse Specialist

• Reads current nursing literature

• Applies information in practice

• Collects data

• Conducts research studies

• Serves as a consultant during research study implementation

Nurse Researcher

• critical care nurse should be engaged in the ongoing process of questioning and evaluating practice and providing informed practice.

Clinical Inquiry

• clinical reasoning which includes clinical decision-making, critical thinking, and a global grasp of the situation, coupled with nursing skills acquired through a process of integrating formal and experiential knowledge

Clinical Judgement

• nursing activities that create a compassionate, supportive, and therapeutic environment for patients and staff, with the aim of promoting comfort and preventing unnecessary suffering

Caring Practices

• respecting and supporting the basic rights and beliefs of the critically ill patient

Advocacy and Moral Judgement

• managing the existing environmental and system resources for the benefit of patients and their families

Systems Thinking

• creatively modify or develop patient/family educational programs and integrate family/patient education throughout the delivery of care

Facilitator of Learning

• sensitivity to recognize, appreciate, and incorporate diversity into the provision of care

Response to Diversity

• working with others in a way that promotes each person's contributions toward achieving optimal and realistic patient/family goals.

Collaboration

• To develop, foster and maintain a level of knowledge about the norms, values, beliefs, patterns of illness, health and care needs of the people;

• To analyze and evaluate critical care nurses' specialty skills and their evolving roles;

• 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

• To exercise professional judgments expected of them in the critical care clinical setting.

CHALLENGES OF CRITICAL CARE NURSES

• TRAINING OF NURSES FOR CRITICAL CARE SERVICES

• ORIENTATION PROGRAM / PRECEPTORSHIP AND
  MENTORING PROGRAM

• IN-SERVICE TRAINING PROGRAM

• CRITICAL CARE NURSING PROGRAM (POST
  GRADUATE SPECIALTY PROGRAM)

• CONTINUING PROFESSIONAL EDUCATION (CPE)

Nurses’ Education

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).

Post Graduate Course

• Certification courses provides recognition and designation earned requiremess of nu sourte comples eared squitcaton he/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.

Certification Course

• 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).

• Care standards for critical care nursing provide measures for determining the quality of care delivered, and also serve as means for recognizing the competencies of nurses in intensive care specialty.

STANDARDS OF CRITICAL CARE NURSING PRACTICE

1. The critical care nurse functions in accordance with legislation, common laws, organizational regulations and by-laws, which affect nursing practice.

11 STANDARDS OF CRITICAL CARE NURSING PRACTICE

2. The critical care nurse provides care to meet individual patient needs on a 24-hour basis.

11 STANDARDS OF CRITICAL CARE NURSING PRACTICE

3. The critical care nurse practices current critical care nursing completely

11 STANDARDS OF CRITICAL CARE NURSING PRACTICE

4. The critical care nurse delivers nursing care in a way that can be ethically justified

11 STANDARDS OF CRITICAL CARE NURSING PRACTICE

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

11 STANDARDS OF CRITICAL CARE NURSING PRACTICE

6. The critical care nurse creates and maintains an environment which promotes safety and security of patients, visitors and staff.

11 STANDARDS OF CRITICAL CARE NURSING PRACTICE

7. The critical care nurse masters the use of all essential equipment, available services and supplies for immediate care of patients.

11 STANDARDS OF CRITICAL CARE NURSING PRACTICE

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

11 STANDARDS OF CRITICAL CARE NURSING PRACTICE

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

11 STANDARDS OF CRITICAL CARE NURSING PRACTICE

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

11 STANDARDS OF CRITICAL CARE NURSING PRACTICE

11. The critical care nurse acts to enhance the professional development of self and others.

11 STANDARDS OF CRITICAL CARE NURSING PRACTICE

The nurse caring for acute and critically ill patients collects relevant patient health data.

Standard of Care I: Assessment

The nurse caring for acute and critically ill patients analyzes the assessment data in determining diagnoses.

Standard of Care II: Diagnosis

The nurse caring for acute and critically ill patients identifies individualized expected outcomes for the patients.

Standard of Care Ill: Outcome Identification

The nurse caring for acute and critically ill patients develops a plan of care that prescribes interventions to attain expected outcomes.

Standard of Care IV: Planning

The nurse caring for acute and critically ill patients implements interventions identified in the plan of care.

Standard of Care V: Implementation

The nurse caring for acute and critically ill patients evaluates the patient’s progress toward attaining expected outcomes

Standard of Care VI: Evaluation

The nurse caring for acute and critically ill patients systematical evaluates the quality and effectiveness of nursing practice.

Standard of Professional Practice I: Quality of Care

The practice of the nurse caring for acute and critically ill patients reflects knowledge of current professional practice standards, laws, and regulations.

Standard of Professional Practice II: Individual Practice Evaluation

The nurse acquires and maintains current knowledge and competency in the care of acute and critically ill patients

Standard of Professional Practice Ill: Education

The nurse caring for acute and critically ill patients interacts with and contributes to the professional development of poors and other healthcare peoviders as colleagues.

The nurse caring for acute and critically il pationts interacts with and contributes to the professional devolopment of poors and other healthcare peoviders as colleagues.