Introduction to Critical Care Nursing

Critical care

is a specialty within nursing that deals specifically

with human responses to life threatening

problems.

Critical care

is direct delivery of medical care for a critically ill or injured

patient.

True

True or False:

The aim of the critical care is to see that one provides a care such that patient improves and survives the acute illness or tides over the acute exacerbation of the chronic illness.

Florence Nightingale

Who started the concept of critical care?

Lydia Hall

In 1995, she originated the term (care cure, core) and developed the 3 steps: note observation, ministration, validation.

Dorothy Johnson

In 1959, she concluded “ Nursing seen as fostering the behavioral functioning of the client”

Jean Orlando

In 1961, she identified 3 steps: client’s behavior, nurse’s reaction, nurse’s action. “Nursing process set into motion by client’s behavior”

Weidenbach

In 1963, he/she was among the first to use it to refer to a series of phases describing the process.

Yura and Walsh

In 1967, they suggested the 4 components-APIE

ANA

In 1973, they published standards of nursing practice, Diagnosis distinguished as separate step of nursing process.

Critical Care Nurses of the Philippines

This organization 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.

PRC-BON

In the Philippines, this organization is committed to provide need-driven, effective and efficient specialty nursing care services of high standard and at international level within the obtainable resources

Emergency

A sudden, urgent, usually unforeseen occurrence requiring

immediate action

Triage

A French word trier meaning “to sort,” refers to the process of rapidly determining patient acuity.

1. Three-tier triage

2. Five-tier triage

3. Emergency Hospital Triage

Triage in Hospital setting

Emergent

What three-tier triage is this:

• Patients require immediate treatment within minutes or patients may die

• Involves emergency cases with problems in

  the ABC’s (airway, breathing and circulation).

• Within 15-30 minutes

Urgent

What three-tier triage is this:

• Evacuation is required within two hours to

  save life or limb;

• Delay in care may occur for a limited time

  without significant mortality;

• Can wait up to 2 hours

Non-Urgent

What three-tier triage is this:

• Patients have non-life threatening conditions and likely need only one resource to provide for their needs

• More than 2 hours

Emergent, Urgent, Non-urgent

What is the three-tier triage:

Resuscitation, Urgent, Non-urgent, emergent, less urgent

What is the five-tier triage?

Emergency Nursing Association (ENA ) 2011

Where is the five-tier triage based on?

Level 1 Resuscitation

This level includes patients who need immediate nursing and medical attention, such as those with cardiopulmonary arrest, major trauma, severe respiratory distress and seizures.

Level 2 Emergent

This level indicates that patients needs immediate nursing assessment and rapid treatment such as head injuries, chest pain, stroke, asthma and sexual assault injuries

Level 3 Urgent

This level indicates that patients need quick attention but can wait as long as 30 minutes for an assessment and treatment, such as with signs of infection, mild respiratory distress, or moderate pain

Level 4 Less Urgent

This level indicates patients in this triage category can wait up to 1 hour for an assessment and treatment, such as earache, chronic back pain, upper respiratory symptoms, and mild headache

Level 5 Non urgent

This level indicates that patients can wait up to 2 hours for an

assessment and treatment such as sore throat, menstrual cramps and other minor symptoms.

Richard Wuerz and David Eitel

The ESI 5-level triage acuity scale was developed by two ED physicians whom are?

Emergency Severity Index (ESI) version 5

Developed as a proxy measure of physiologic stability and risk for deterioration

Category 1

• obvious emergency

• treatable life threatening illness or injury

• cardiac arrest, chest pain, severe bleeding and shock

Category 2

• Serious but not life threatening needs/full evaluation/ tx by the physician

• Acute DOB, burns without any airway problems, multiple bone or join injuries

• Back injuries with or without spinal damage

Category III

• Pending emergency

• Abdominal Pain

• High Fever

Category IV

• Outpatient department cases

• Mild URTI

• Sore throat

• Low grade fever

Black, Red, Delayed, Minor

What are the colors of triage in mass casualties?

Expectant, Immediate, Delayed, Minor

What are the following designation of the colors for triage in mass casualties?

• Airway and alertness

• Breathing

• Circulation

• Disability

• Exposure and environmental control

• Facilitate adjunct and family

• Get resuscitation adjuncts

What are the primary survey consist of?