Module 1: Introduction to Critical care

CRITICAL CARE (Intensive Care)

• Concerned patients with treatment, at risk, or recovering from potentially life threatening failure of one or more of the body's organ systems.

• Care on: Patient, Healthcare Team, Family

• is pivotal to healthcare, facilitating complex care in an ageing and sicker clients.

• can both pick up deteriorating patients on the ward and support patients in the aftermath of critical illness.

CRITICAL CARE UNIT

• Room filled with client attached to interventional technology, equipped facility, staffed by skilled personnel to provide effective and sale care for patient with a life-threatening problem that is potentially reversible.

Coronary Care Unit (CCU)

• Patients specifically with life threatening cardiac conditions

  • ex. myocardial infarction, cardiac arrest, pre-post heart catheterization. chest pain, pre-post open heart surgery.

Cardiovascular Intensive Care Unit (CICU)

• Post cardiac bypass

  • Others: post-op thoracic, aneurysm repair, abdominal aneurysm repair, thoracotomies

Surgical Intensive Care Unit (SICU)

• a specialized service in large hospitals that provides patients recover after extremely invasive surgery. Often patients may have other medical conditions that require close monitoring

  • Ex. Whipple's procedure, Orthopedic restrictions, Extensive abdominal repair.

  • This is managed by surgeons anesthesiologist

Trauma Intensive Care Unit (TICU)

• patients with various types of injuries and several diagnoses

• Nurses in this area must be prepared in any types of wounds and patient care

Pediatric Intensive Care Unit (PICU)

• Pediatric patients with life threatening conditions.

  • Ex. severe asthma, diabetic ketoacidosis, traumatic neurological injury, surgical cases (if the patient has a potential rapid deterioration or if a patient requires close monitoring)

Neonatal Intensive Care Unit (NICU)

• cares for neonatal patients who have not left hospital after birth.

• Ex. prematurity and associated complications, congenital disorder, congenital diaphragmatic hernia), complications resulting from the birthing process

Neurological Intensive Care Unit

• patients treated for brain aneurysms, brain tumors. stroke, post neurologic surgeries

Isolation Intensive Care Unit

• patients that need to be isolated that is suspected or diagnosed with contagious disease and need medical isolation care

High Dependency Unit

• an intermediate ward for patients who require close observation, treatment and nursing care that cannot be provided in a general ward

  • Others called it step-down unit, intermediate care area, or progressive care unit

American Association of Critical Care Nursing (AACN)

• established in 1969

• This association promotes the health and welfare critically ill patients by advancing the art and science of critical care nursing and supporting work environments that promote professional nursing practice.

Critical Care Nurses Association of the Philippines, incorporated (CCNAPI)

• February 1977;

• a national organization of nurses interested in the field of critical care nursing. This organization is accredited as a Provider of Continuing Professional education by the Professional Regulation Commission (PRC).

Direct patient care

• 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 patient care

• care of the family

• 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 Roles as Critical Care Nurses

• perform procedures beyond their professional boundary following clinical protocols

  • Ex. Weaning patients from ventilators, performing and interpreting ECG's, adjusting analgesia/ sedations, titrating

    intravenous and centra line medications

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

  care.

Patient Advocate

• acts in the best interest of the patient

• Monitors and safeguards the quality of care which the patient receives.

Management and Leadership role

• They oversee patient care, make management and budgetary decisions, set work schedules, coordinate meetings, and make decisions about personnel.

• The nurse manager ensuring that the work of the health care team is supported and contribute inpatient engagement.

Research role

• Engage self in nursing or other health -related research with or under supervision of an 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- player.

• To continuously ensure staff competencies hospitals should provide training opportunities

• This will enable critical care nurse to cope on the demands of the changing needs of critically ill patients.

Handoff

• Communication breakdowns occur during situations when patient information is being transferred or exchanged of care.

• involves providing information to the nurse who will be taking over the care of your patients. It should be given anytime patient care is transferred to another nurse. This may include at the end of your shift or if a patient is being transferred to another unit in the hospital.

• The purpose of report is to provide information about the patients you cared for. Although the information should be in the patient's chart, it is often more practical to present a brief synopsis of what is going on with the patient.

SBAR communication

• technique provides a framework for communication between members of the health care team about a patient's condition.

• (Situation-Background-Assessment-Recommendation)

• is an easy-to-remember strategy for framing any interaction. It provides a simple and focused way to establish expectations for what will be communicated and how between team members, which is critical for creating teamwork and fostering a patient safety culture.

Do not Resuscitate (DNR)

orders are only in effect if the patient does not have a heartbeat or has stop breathing altogether. This is not applied when the person is still breathing or undergoing treatment. This is a legal and ethical bind where written consent is a must.

Do not Intubate (DNI)

order means that chest compressions and cardiac drugs may be used, but no breathing tube will be placed through mouth into the trachea (windpipe) to help with breathing.

• Cardiac arrest: to intubate or not?

Palliative care

is an approach that improves the quality of life of patients (adults and children) and their families who are facing problems associated with life-threatening illness.

• It is care for patients with life-threatening illnesses and their families

• It can be given in homes, health centers, hospitals, and hospices

• It improves the quality of life

• It benefits health systems by reducing unnecessary hospital admissions

• It relieves physical, psychosocial, and spiritual suffering

• It can be done by many types of health professionals and volunteers

International Patient Safety Goal

were developed in 2006 by the Joint Commission International (JCD). Health care professionals have been challenged to reduce medical errors and promote an environment that facilitates safe practices

1. Identify patients correctly

2. improve effective communication

3. improve the safety of high alert medications

4. ensure correct site, correct procedure, correct patient surgery

5. reduce the risk of healthcare-associated infections

6. reduce the risk of patient harm resulting from falls

IPSG1 - Identify patients correctly

• Using 2 identifiers (Name and ID band)

• Before administering medications, blood, or blood products

• Before providing treatments and procedures

• Policies and procedures support consistent practice in all situations

IPSG2 - improve effective communication

• Complete verbal and telephone order

• were written down by the receiver

• Read back by the receiver of the order

• Confirmed by the individual who gave the order

IPSG3 - improve the safety of high alert medications

• Medications involved in a high percentage of error and sentinel events

• Medications that carry a higher risk for adverse outcomes

• Look-alike /sound-alike medications

• Policies and procedures are developed to address the identification, location, labeling and storage of high alert medications

• The policies and procedures are implemented

IPSG4 - ensure correct site, correct procedure, correct patient surgery

• Uses an instantly recognized mark for surgical site, identification and involves the patient in the marking process.

• Uses a checklist to verify preoperatively the correct site, correct procedure, and correct patient and that all documents and equipment needed are on hand, correct, and functional.

• The full surgical team conducts and documents\ a time-out procedure just before starting a surgical procedure.

• Policies and procedures are developed that support uniform process to ensure the correct site, correct procedures, and correct patient.

IPSG 5 - reduce the risk of healthcare-associated infections

• Follow and adapted hand hygiene guideline

• Implements an effective hand hygiene program

• Policies and procedures are developed that support continued reduction of health care - associated infections (HCAI)

IPSG6 - reduce the risk of patient harm resulting from falls

• Implements a process for the initial assessment of patients for fall risk and reassessment of patients when indicated by a change in condition or medications

• Measures are implemented to reduce fall risk for those assessed to be at risk.

• Measured are monitored for results, both successful fall injury reduction and any unintended related consequences.

Level 1 Care

• 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 medical officer available to the unit at all times

• 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 2 Care

• 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

• Always has a designated medical director with appropriate intensive care qualification and a duty specialist available exclusively to the unit

• 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 3 Care

• 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

• Always 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 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 always.

Level of Acuity

• help nurse managers set appropriate staffing levels in acute care, long-term care and other treatment and rehabilitation settings., patients requiring a greater degree of observation and intervention from nurses receive a higher acuity rating.

• Nurses must monitor these patients on a regular basis since they can swiftly deteriorate. As a result, increased staffing levels are required in high- acuity units and facilities. Acuity scales are frequently used by nurse managers to determine how many nurses are required for specific shifts.

Endotracheal tube

is a tube that is inserted through the patients’ mouth into their windpipe. It is used in the ICU for patients who are having difficulty breathing because of a lung problem, or for patients who are not awake enough to breathe for themselves. The Tube is connected to tubing which is connected to a ventilator.

Mechanical Ventilator.

has different setting, and it is adjusted according to the needs of a patient. Sometimes the patient is taking their own breaths and we support these, or sometimes we need to set the device to give them each breath. The nurse at the bedside will be able to explain the level of support that your relative needs, and why.

Tracheostomy

A surgical procedure where a hole is made in a patient’s neck and a small tube is inserted into their windpipe. Tube is then attached to the ventilator, or oxygen support. is sometimes and option to patients who require long term ventilation, difficult weaning from the ventilator, and patients with copious secretions. When a patient no longer requires ventilator support and only needs oxygen therapy, oxygen tube can be connected

Arterial Line

This is a line that goes into the patients’ artery. It allows the nurse to see the blood pressure continuously and also allows the nurse to take bloods when required. It is a red line that usually goes into a patients arm and is connected to the cardiac monitor (the box that looks like a tv) and shows the blood pressure constantly.

Cardiac Monitor

is a device that you control to record the electrical activity of your heart (ECG). This device is about the size of a pager. It records your heart rate and rhythm. are used when you need long-term monitoring of symptoms that occur less than daily. Continuous cardiac monitoring allows for prompt identification and initiation of treatment for cardiac arrhythmias and other conditions.

Infusion Pumps

Majority of these patients will need these pumps. These are pumps that you will see beside the patient, and they control the amount of medication or fluid that a patient receives and how fast or slow it can be given. You will see fluids and bags of medication hanging over these on a pole. The fluid or medication flows through plastic lines and passes through the pump and into the patient.

Central Line

This is a line that goes in through one of the large blood vessels in the neck or the groin. This line allows us to give multiple medications at the same time, and to give strong medications that can only go through a large vessel. The medications flow through the pumps and connect to these lines into the body. The ICU team usually place this line in the ICU, or sometimes it is done in theatre before an operation.

Thrombo- Embolic Deterrent Stockings (TEDS).

You may notice the patient is wearing long green socks. These tight-fitting socks help prevent the development of blood clots in the legs. These clots can form due to the pooling of blood in veins during long periods of inactivity. Some people wear similar socks when taking a long flight.

Nasogastric Tube

This tube goes through a patients nose and down into their stomach. It allows us to feed them when they are too unwell to eat and drink as they normally would or when their appetite is reduced due to illness. We can also give them medication through this tube.

Total Parenteral Nutrition

is intravenous administration of nutrition, which may include protein, carbohydrate, fat, minerals and electrolytes, vitamins and other trace elements for patients who cannot eat or absorb enough food through tube feeding formula or by mouth to maintain good nutrition status. Achieving the right nutritional intake in a timely manner can help combat complications and be an important part of a patient’s recovery

Urinary Catheter

In the ICU, a patient may have a device put in place to monitor an hourly output. This allows us to calculate how much fluid is going in, versus how much is coming out. We can get ensure that we prevent patients becoming fluid overloaded or dehydrated.

Informed Consent

• consent is based on the principle of autonomy; competent adults have the right to self-determination or to make decisions regarding their acceptance or rejection of treatment.

• It is a process that entails the exchange of information between the health care provider and the patient or patient’s proxy.

  • Elements:

    1. Competence

    2. Voluntariness

    3. Disclosure of Information

Competence

refers to a person’s ability to understand information regarding a proposed medical or nursing treatment. is a legal term and is determined in court.

Voluntariness

Consent must be given voluntarily, without coercion or fraud, for the consent to be legally binding. This includes freedom from pressure from family members, healthcare providers, and payers. Persons who consent should base their decision on sufficient knowledge

Disclosure of Information

Basic information considered necessary for decision making

includes the following:

• A diagnosis of the patient’s specific health problem and condition

• The nature, duration, and purpose of the proposed treatment or procedures

• The probable outcome of any medical or nursing intervention\

• The benefits of medical or nursing interventions

• The potential risks that are generally considered common or hazardous

• Alternative treatments and their feasibility

• Short-term and long-term prognoses if the proposed treatment or treatments are not provided

Patient self-determination act

• Discussions regarding advance directives and end-of-life wishes should be made as early as possible, preferably before death is imminent.

• The ideal time to discuss advance directives is when a person is relatively healthy, not in the critical care or hospital setting.

• This allows more time for discussion, processing, and decision making.

Advance directives

• is a communication that specifies a person’s preference about medical treatment should that person become incapacitated.

living will

• will provides a mechanism by which individuals can authorize the withholding of specific treatments if they become incapacitated.

• When completing a _______, individuals can add special instructions about end-of-life wishes.

durable power of attorney

• for health care is more protective of patients’ interests regarding medical treatment than is the living will.

• for health care, patients legally designate an agent whom they trust, such as a family member or friend, to make decisions on their behalf should they become incapacitated

Ethical Decision Making

• This model provides a framework for evaluating the related ethical principles and the potential outcomes, as well as relevant facts concerning the contextual factors and the patient’s physiological and personal factors.

• Using this approach, the patient, family, and healthcare team members evaluate choices and identify the option that promotes the patient’s best interests

Ethical Principles

• Principles facilitate moral decisions by guiding the decision-making process, but they may conflict with each other and may force a choice among the competing principles based on their relative weight in the situation.

• Principlism is a widely applied ethical approach based on four fundamental moral principles to contemporary ethical dilemmas:

Respect for Autonomy

• states that all persons should be free to govern their lives to the greatest degree possible.

• principle implies a strong sense of self-determination and an acceptance of responsibility for one’s own choices and

  actions.

• means to respect their freedom of choice and to allow them to

  make their own decisions.

Beneficence

• is the duty to provide benefits to others when in a position to do so, and to help balance harms and benefits.

• In other words, the benefits of an action should outweigh the burdens.

Nonmaleficence

• the explicit duty not to inflict harm on others intentionally.

Justice

• requires that health care resources be distributed fairly and equitably among groups of people.

• is particularly relevant to critical care because most healthcare resources, including technology and pharmaceuticals, are expended in this practice setting.

Veracity

states that persons are obligated to tell the truth in their communication with others.