Intro to Critical Care

Knowledge Acquisition

competencies:

• competent in clinical judgment, teamwork and collaboration, clinical skills, and communication.

• advocacy, diversity, and client education.

Association of Critical Care Nurses (AACN) → progressive care units

Emergency Nurses Association (ENA)

Level of Competence

critically ill have multiple health issues

Benner’s Novice to Expert Model:

1. novice: uses policies to guide

2. advanced beginner

3. competent

4. proficient

5. expert: intuitive due high knowledge and experience + self-actualization

imposter syndrome vs self-assessment

Critical Care Nurse Foundational Competencies

• care for all ages and acute, chronic, rehabilitative and palliative care

• manage data and clinical judgement

• nurse actions to address situations, reduce risk and complications

• aware of diverse family needs

• advocate for end of life

• support safe and respectable enviroment

• self-care, adhere to professional values

• communicate and work as team

• strong medical knowledge, skills such as ventilation,

• professional development

critical care nursing process

assess: gather info/data regarding changes

analyze to prioritze

plan w/ collaborating with interprofessional and family + pt’s preferences → record plan = handoff

implement proper procedures when prioritizing problems, education, monitor response, and document properly

evaluate response, if it was desired outcomes and modify

care of pt who has chest pain

assess:

• CV: heart, VS, bilateral BP, peripheral/apical HR

• hx of illness.

• chest pain

intrepret cardiac enzyme: BMP, troponin, CK-MB

evaluate rhythms + ECG + cardiac monitoring

• check if STEMI, or non STEMI

triage, interprofesional, labs, IV assess, O2

prepare for transfer in case of cardiac catheterication or CPR

inc skills/experience = inc autonomy

provider relies on nurses ability to perform their role + vice versa

→ collaborative decision w/ interprofessional team

→ leadership must support nurse autonomy

→ comprehensive orientation and continuous support from experienced nurses

CCE =

american Association of Critical Care Nurses (AACN) → Critical Care Nurse (CCRN)

Emergency Nuses Association (ENA) = emergency + trauma CCE

• Trauma Nursing Core Course (TNCC) = renew q4y

• 1yr of critical care unit

, Society for Critical Care Medicine (SCCM) = offers Fundamental Critial Care Support (FCCS)

AHA advanced Cardiac Life Support (ACLS) = renew q2yr

strategies for growth:

• review physical assessment

  • expected heart sounds, VS, and identify reasons for alterations

  • cardiac enzymes

  • telemetry unit with rhythm strips, ECG

  • chest pain protocol

  • journal articles

  • review certifications, seek learning opportunities, feedback

  • critical care certification, CPR certification

  • time w/ preceptor, lab tech, IV team to practice advanced skills

  • accompany pt to catheterization lab

  
  

interprofessional teams:

intensivist = HCP specializes in critical care medicine

• critical care nurses, pharmacists, respiratory therapists, rehabilitation specialists, dietitians, social workers, case managers, spiritual care providers, critical care intensivist providers, and non-intensivist providers

mobilizing a ventilated pt

• HCP = Rx

  • pharmacist = coordinate with Rx

• dietitian = maximize nutrition

• respiratory therapist

• pt + family

• PT → mobilization

• nurse coordinates care + monitors response with mobilization and Rx

interpersonal daily rounds + input from pt

HCP asks for input from team = makes daily goal

nurses discusses changes over 24hrs = physical and mental functioning, CV/ resp/ GI, nutrition

pharmacist reports spontaneous awakening trials (SAT)and evaluation to pt response to Rx for pain, agitation, delirium

occupational and physical therapists

respiratory therapist in SAT and SBT

nutritionist

Social worker and case manager after discharge

family helps with previous medical records and social hx

Assessment:

critical care → ABCDEF + VS, head-to-toe, lab reports

emergency department index (ESI)

mass casualty → Sort, Assess, Life-saving interventions, Treatment, Transportation (SALT)

ABCDEF

A: Assess, prevent, and manage pain

→ 1-10 scale, behavioral pain scale (BPS), critical-Care Pain Observation Tool (CPOT)

some interventions can cause pain (ventilation, suction)

B: Breathing, spontaneous awakening trails (SAT), and spontaneous breathing trials (SBT)

mechanical ventilation: goal is to remove them from ventilation

causes pain, fear, and anxiety → opioids(morphine), and BZ (midazolam)

→ prevents pt from pulling on tubing

acute lung injury/ acute respiratory distress syndrome → require paralytic agents (rocuronium) → ventilation required

• require extreme vigilance to make sure ventilation is running properly

• propofol is common for sedation

Spontaneous awakening trials (SAT) → daily stop of sedatives and narcotics

Spontaneous breathing trials (SBT) → stopping ventilation for spontaneous breathing

• if they exhibit: agitation, inc 35/min, O2 <89%, cardiac dysrhythmia = failed (SBT)

SAT + SBT check if pt can breath w/o assistance

Choice of analgesia and sedation:

assess pt 6 or more times per day

to wean off ventilation = pt should be awake, no distress, able to cooperate (1qd)

Scales: from unarousable to dangerously agitated

• Richmond Agitation-Sedation Scale (RASS)

• Sedation-Agitation Scale (SAS)

• Ramsay Sedation Scale

Delirium: Assess, prevent, and manage

→ longer stay, discharge to post acute, inc death, lasting decline in cognitive function

→ s/s:

1. hyperactive → agitation and restless

2. hypoactive → apathy and withdrawn

vs. dementia = delirium can be reversed

vs depression = preceded by several weeks of low interest/mood

→ risk factors:

• pain or mood RX

• stroke, heart attack, fall injury, progressive lung/liver, dementia, PD/ chronic terminal illness

• fluid E/I

• internal toxins shock or sepsis

• O2 low, pain, hx of delirium

• sensory impairment or deprivation or overload

tools: assess at least x2/day

• Confusion Assessment MEthod for ICU (CAM-ICU)

• Intensive Care Delirium Screening Checklist (ICDSC)

strategies to prevent delirium:

• wean off ventilation

• refrain from restraints

• removed urinary catheters when not required

• minimize noise from alarms

• turn off lights at night, opens blinds during the day

• ambulate pt ASAP

• Assist w eyewear and hearing aids

Early mobility:

sever muscle weakness which impact long-term

evaluated daily for mobility → if not able → appropriate interventions for readiness and LOC → provide ROM, sitting on the side of bed, or chair

if not at all → electrical neuromuscular stimulation

at most lightly sedated

Family engagement

family and pt centered care → encourage participation and encouraged to be present

code blue

not yet cardiac arrest + can require skill/expirence to be recognized → rapid response teams (RRTs)

→ critical care nurse, a pharmacist, a respiratory therapist, and a provider

developing sepsis and respiratory failure → acute inpatient deterioration

clinical triggers for RRT

Resp alteration:

• distress, inc HR, or low RR

CV alteration:

• inc/dec HR, or dysrhythmia

severe hypotension/ hypertension SBP = 60/160

AMS = confusion or restlessness

O2 less than 90%

→ code blue

staff roles:

1. nurse that finds pt + calls code, → CPR

2. other staff bring code cart + attach cardiac monitor

3. AED is attached

4. Code Blue Team takes over → leader becomes stationed next to code cart

5. pt’s nurses manages environment and communicates w/ family

6. one nurse becomes recorder

7. rotate compressions

8. One nurse ensures IV access

9. resp therapist or anesthesia will ventilate pt

10. others act as runners

11. → transfer to critical care unit

12. debrief

Code Cart Content ← document after each use, documented/checked q24hrs

• defib + defribillation/cardioversion/pacing pads

  • battery charged defibrillator → maintain charge during power outage

  • + non-battery powered code cart

• bag valve / facemasks

• O2 tube/ tank

• CPR backboard

• Meds:

  • epinephrine

  • amiodarone

  • sodium bicarbonate, calcium

  • glucose

• IV access start, angiocatheters, needles, syringes, spinal needles (pericardiocentensis), scalpels, sutures, arterial line catheters nasal packs, balloon for severe nose bleed, magnet to reset malfunction pacemakers

• Resp equipment = batteries, light bulb, laryngoscope, tape, CO2 detector, xylocaine spray

• central venous catheter, chest tube, thoracostomy kit, suture set, trauma tourniquet, sterile stapler, burr hole manual drill kit

• IV fluids/ tubing, blood administration sets

family presence during resuscitation:

• if present → family recognize the efforts made to save pt’s life

• give chance of say goodbye in case cannot be saved

care for pt end of life → aid in dying, withdraw from life saving equipment, stop tx, + palliative care

→ aid in dying: depends on each state

→ withdrawing lifesaving equipment: ventilator/ NG

• advanced derivative

stopping resuscitation efforts → continue to deteriorate during resuscitation → HCP determines when death is imminent

Compassionate Care:

P: Prepare to discuss the issue in advance if there is time.

R: Relate to the client and family.

E: Elicit client and caregiver wishes.

P: Provide education specific to the needs of the client and their family.

A: Acknowledge emotions and concerns.

R: (foster) Realistic hope (such as the wish for a peaceful death, support).

E: Encourage questions and continue to be available for ongoing communication.

D: Document.

→ manifestation control, physical cleanliness, and removal of an endotracheal tube or other tubing

(SAGE and THYME model, and SPIKES mode)'

resilience

→ risk for burnout ← heavy workload, insufficient staffing, emotional exhaustion related to a feeling of a lack of personal accomplishment, perceived or real lack of support or recognition from administration,, influence burnout

to minimize stress:

• Practice mindfulness, compassion for self and others.

• Incorporate diaphragmatic breathing.

• Participate in recreational activities.

• Relaxation exercises.

• Decrease use of social media.

• Participate in peer support sessions.

• Address needs for food, drink, rest, and sleep.

• Build positive and nurturing relationships in the workplace.

• Balance work and life.

• Develop emotional intelligence.

Emergency department

Triage nurse → assess VS + pt interview (cc), hx of present illness + focused assessment

emergent: life-threatening

urgent: not immediately life threatening

delayed: minor injuries or can be delayed

5- tier Emergency Severity Index (ESI)

1–Resuscitation: life saving intervention

2–High risk:

• chest pain, suicide ideation

• AMS (confused, lethargic)

• severe pain 7<

• severe distress = sexual assault, partner violence, acute grief

• immediately provide tx w/ → IV access, O2, cardiac monitoring, (ECG)

3–Two resources needed:

• lab test, XR, IV fluids, simple procedure

4–One resource needed

5–No resources needed.

Resuscitation requirement:

• open airway, breathing? O2

• pulse? quality, rhythm, HR of pulse

• hx of intubated

• immediate medication/ IV blood transfusion or fluid volume

• apneic, pulseless, severe resp distress

• acute AMS, unresponsive?

assess in disaster:

primary triage: tx at scene and priotize pt for evacuation or trauma unit

secondary: ED triage (w/ 3 / 5 tools)

tertiary: exits the ED and moves to OR or ICU

assess in trauma

SALT

→ primary survey (ABCDE)

since airway obstruction, respiratory arrest, shock due to hemorrhage, and head injuries cause most deaths

Airway: Assess mouth, larynx, pharynx, trachea, bronchi, and bronchioles

• obstruction/ aspiration

• laryngotracheal trauma

• allergic reaction / edema

Breathing: Assess respiratory distress (sweating, central cyanosis, use of accessory muscles), respiratory rate <12 or >20, oxygen saturation < 90%, stridor, wheezing, asymmetrical rise and fall of chest

• asthma, secretions, COPD

• partial airway obstruction,

Circulation: cardiac arrest, hemorrhage, MI

Disability: assess neuro using → AVPU ( Alert, Responds to voice, Responds to Pain, Unresponsive)

• metabolic abnormalities such as hypo/hyperglycemia

• hypoxia

• head injury

Exposure: preserve evidence ( cloth, impaled objected, weapons, drugs, bullet)

• child, elder, partner abuse,

• sexual assault, homicide, suicide, drug overdose

→ secondary/ tertriary survey

2nd: head-to-toe assessment for injuries not addressed in primary

• pts can improve one system and decline in another

3rd: uncover injuries that may have been missed (ex. brain injury or w/ emergency surgery) by disharge

Hand off

SBAR,

ED nurse is faced w/ multiple interruptions

• identify information to communicate

• use checklist, forms, protocols, and SBAR

• receiver asking questions, better when face to face

• coordinate all data and communicate all in one time

• communicator name/ contact → background pt → lab results/ VS → events leading to injury → assessment/ plan of care → interventions provided → Rx, allergies, code status

• deliver where minimal interruptions, include team members or family

• electrical health records

Legal issues

abide for external and internal regulations

state laws except if Federal entities including the Department of Veterans Affairs, the Department of Defense, and the Indian Health Service

Emergency Medical Tx and Active Labor Act (EMTALA) → 1986

prevent refusing care from uninsured pt

any pt who has medical or psych condition reports to the ED must have throughout evaluation before discharge or transferred + documentation

pt can sue the hospital for personal injuries in civil court,

if violated EMTALA → risk of losing Medicare

COVID 19 → send pt to alternative location for medical screening and to permit transfer for those who are not that stable

For sexually assaulted

under reported → fear of stigma, keep secret, unable to prove it happen, minimizing what happen, concern for retribution, fear of police response, protecting someone, unsure if it was criminal

Sexual Assault Nurse Examiner (SANE)

→ emotional support, evaluate injuries, forensic exams, collects evidence for sexual assault

not require certification but better outcomes = from Association of Forensic Nurses (IAFN): minimum of 45 CE hrs for q3y

Law enforcement: available right after evidence, foreignsic photography to properly document injuries

Time is important for collection of forensic evidence, vital to conviction of perpetrator,

Private room + emotional support, obtain consent before all steps, do not change clothes or void prior to the exam

Assess possible exposure to HIV → tx w/ postexposure prophylaxis (PEP) ~ 72hrs

evaluated for STIs and emergency contraception (ulipristal acetate/ 30mg once up to 120hrs after unprotected intercourse)

discharging sexual assault

• bathing, food/drink, grooming supplies, phone, replacement clothing (since those are for forensic exam)

• determine safety issure prior to home

• verbal/ written instructions + follow-up appt

• information of medications, law enforcement agencies, support services

Role of nurses

if experiencing circulatory or cardiac problems:

→ hx:

• cehst pain, SOB, HR/rhythm, BP, pain in legs, syncope, meds, family CV hx, smoking or recreational drug, diet and exercise

→ physical assessment:

• perfusion in hands/feet

• BP = both arms + laying

• carotid + JVP

• color of mucous membranes

• listen to heart and palpate all pulses

interprofessional communication:

must deal with accomplish care in a short time, working with rotating members of the care team, weak interpersonal relationships due to members not being familiar with each other’s experience, and personal factors such as lack of confidence

other communication that streghts interpersonal:

• asking for help,

• providing updates on lab or radiology results,

• checking to see how other members are doing

• giving positive feedback.

communicating w/ family:

due to low communication of ED (since life-saving) family has lot of anxiety

giving written information that describe ED experience, informational TV screen

breaking bad news: nurse (empathy/support) + HCP (technical)

first say what happen first, then say how they were transported or treated

never given false hope

media in ED:

staff nurses are not expected to have responsibility w/ info sharing in news media

communication policies are in Disaster Plan and describe process on how to communicate w/ authorities, public, equipment, vendors, and other health care facilities

challenge of misinformation: refrain from sharing info in ED → remember HIPAA

violence in the ED

more than 50% of nurses face verbal or physical assault

stress and anxiety leads pt and family to lash out at staff

or those w/ pain, drug/alcohol, mental illness, long wait times, fear of dx

risk reduction → redesign more space, private rooms, security officers, caregivers to see each other, safety glass partition, video and audio monitoring, duress alarms

human trafficking

multiple illnesses: fractures, bruises, headaches, weight loss, infections, sexually transmitted diseases, and depression

chemical emergency

PPE: hair net, face shield, googles, N95 mask, Isolation gown, gloves, shoe cover

nurse should be aware of what types of chemicals in community and locate them in material safety data sheet (MSDS)

Decontamination process:

• “Hot zone” contaminated pts

• pts are triaged and placed in a holding area

• pt remove discard contaminated clothing → shower dry → provided w/ clean clothes

• → “Cold zone”

• evaluated for discharged

During disasters

mass casualties: natural disasters, terror attacks, mass shootings, and bombings

pre-disaster → planning, / actual disaster → response to disaster → recovery + evaluation period

pre disaster: risk assessment:

→ disaster drills, other activities

response phase → activation of plan, command post, lines of communication

triage, identify areas for shelter

recovery: continued provision of pt affected by disaster, continue w/ triaging, assist w/ transport + transfer of pts

monitoring mental health of those in the disaster and helping reuniting w/ family members

smoking inhalation:

• evidence of burns in mouth, face, nose

• stridor or wheezing

• expectorant containing charcoal-like material

• continuous coughing

• O2 less than 95%

severe burns → shock due to fluid shift → High BP/ low BP

if higher TBSA of 15% → IV fluid resuscitation = LR + pain manage

• mechanical ventilation, GI intubation, indwelling catheter

Assess:

considerations

Where did the disaster occur? What kind of disaster is it?

How many individuals might there be?

How many facilities can help clients who experienced the disaster?

Competencies

Knowledge of and role in the clinical facility disaster plan

Immediate action to disaster alert when not working at the facility

Performing rapid physical and psychological assessments using ABCDE tool

Performing triage during a disaster

Analysis:

Considerations

How many staff members will be needed?

How many beds are available?

Where can clients be transferred?

Competencies

Registering clients and documenting during a disaster

Managing clients who require specialized care, such as those who have burn injuries, traumatic injuries, or chemical injuries

Managing clients of different ages

Planning:

Considerations

What protocols, procedures and policies will be needed?

What are the manifestations of the potential diseases the nurse may encounter, such as biologic agents, smallpox, and anthrax, and how do they manage them?

Competencies

Identifying resources needed for client care such as need for PPE and wound dressing

Identifying appropriate disposition of clients (those who have died, those who can be discharged, those who need further care)

Identifying how communications will be handled with family members, the media, and the community

Implementation:

Considerations

The nurse implements the facility’s disaster plans.

The nurse organizes and assigns staff appropriately, following established protocols for triaging and treating clients.

Competencies

Providing care for various populations:

Older adults, infants, children, young adults, clients who are pregnant, individuals who have disabilities

Addressing legal aspects of care such as caring for a minor when their guardian is not present

Reporting using SBAR

Communicating with agencies outside of the facility

Evaluate Outcomes:

Considerations

The nurse evaluates the effectiveness of the implemented plan to determine if the established outcomes were met.

Competencies

Following the initial disaster, the nurse participates in debriefing.

Disaster preparation

hazard vulnerability analysis

requires every hospital to have an Emergency Operations Plan (EOP)

→ importance of preparation and training, resource planning, and the need for experienced staff members who can coordinate the incident command center

→ high level of interdisciplinary communication, possess excellent triage skills, and provide seamless transitions of care’

triage: Simple Triage Algorithm and Rapid Assessment (START) and Sort, Assess, Life-saving Interventions, Treatment, and Transportation (SALT) algorithm.

SALT:

sort → pt unresponsive first, then those who can wave but not walk are next → those who can walk and be alert

assess →

green: lacerations, contusions, sprain, strains

yellow: fracture, open wound, deep laceration

red: neuro injury, shock, major burns, CPR is applied and hemorrhage is controlled

black: those who died or not expected to live

resources for those who will be nbenifited the most

max care for max pt

communicate public health messages on how to take care of themselves

determine level of care based on facility

base triage on legal framework

gain community trust by transparency, honesty, and inclusitivity

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State of emergency:

• emergency when Stanfford Act and National emergency act

• or state emergency → state gains the ability to empower government officials to activate authorities and resource

→ Federal financial, personnel, logistical, and technical resources will be mobilized.

→ Emergency portions of the Social Security Act and statutory immunity or liability protection will be activated under the Public Readiness and Emergency Preparedness Act (PREP Act).

→ Regulatory demands for individuals, organizations, and state and local governments will be relaxed.

Resource allocation

• Prepare: stockpile.

• Substitute:.

• Adapt: not equivalent but sufficient, such as using an anesthesia machine in place of a ventilator.

• Conserve: Use less of a resource by decreasing dose or changing method of use →discontinuing elective surgical procedures.

• Reuse: ex reusing N95 face masks by sanitizing them after use rather than discarding them.

• Reallocate: Restrict or prioritize resources to those clients with a greater chance of survival or greater need.

Bystander Assistance Program:

→ CPR programs

STOP the BLEED: direct pressure, bandages, tourniquet