NCM 118 - Critical Care Nursing
A. Introduction to Critical Care
Care of clients with Threatening Conditions, Acutely ill/Multi-organ problems, High Acuity and Emergency
Critical care is a specialized field of nursing and medicine focused on the care of patients with life-threatening conditions that require comprehensive and continuous monitoring. Patients in critical care units (CCUs) often suffer from severe illnesses or injuries, such as respiratory failure, sepsis, multi-organ dysfunction, or major trauma. These patients need advanced medical interventions, close observation, and skilled nursing care to manage their complex conditions.
Critical care is not only about managing acute medical issues but also about anticipating potential complications, providing holistic care, and supporting both the patient and their families during extremely challenging times. The environment is highly dynamic, with rapid decision-making and interventions being essential to improve patient outcomes.
Definition of Critical Care
Critical care, often referred to as intensive care, involves the treatment of patients who are experiencing or are at risk of experiencing life-threatening organ dysfunction. It encompasses the use of specialized equipment, advanced medical technologies, and the expertise of a multidisciplinary team to monitor and manage the patient’s condition.
The goal of critical care is to stabilize the patient’s physiological status, prevent further deterioration, and promote recovery. This care typically occurs in a Critical Care Unit (CCU) or Intensive Care Unit (ICU), where healthcare professionals, including doctors, nurses, respiratory therapists, and pharmacists, work collaboratively to deliver high quality care.
B. Environment in the Critical Care Unit
Physical Environment (ALSA)
The physical environment of a Critical Care Unit (CCU) is designed to support the intensive monitoring and treatment of critically ill patients. Key features of this environment include:
Advanced Monitoring Systems: These systems continuously track vital signs such as heart rate, blood pressure, oxygen saturation, and respiratory rate. They are crucial for detecting early signs of deterioration.
Life-Support Equipment: Ventilators, dialysis machines, and infusion pumps are commonly used to support failing organs and deliver medications.
Sterile Environment: Maintaining a sterile environment is essential to prevent infections in immunocompromised or vulnerable patients. This includes the use of personal protective equipment (PPE), regular cleaning, and strict adherence to infection control protocols.
Accessibility: The unit is designed for easy access to patients by healthcare staff, with space for quick intervention and emergency procedures. Equipment and supplies are strategically placed to ensure immediate availability.
Psychological Environment (FPS)
The psychological environment in a CCU is just as important as the physical one, both for patients and healthcare providers. Key considerations include:
Patient Anxiety: Patients may experience fear, confusion, and anxiety due to their critical condition and the unfamiliar environment. Strategies such as clear communication, family presence, and providing a calming atmosphere can help alleviate these feelings.
Family Support: Families of critically ill patients often experience significant stress. Providing them with regular updates, involving them in care decisions, and offering emotional support can be vital in helping them cope.
Staff Well-being: Working in a CCU can be emotionally and physically taxing for healthcare providers. Ensuring a supportive work environment, providing access to mental health resources, and promoting teamwork can help mitigate burnout and maintain a high level of care.
C. Review of Hemodynamics
Hemodynamics refers to the study of blood flow and the forces involved in circulating blood throughout the body. In a critical care setting, monitoring hemodynamics is crucial for assessing cardiovascular function and guiding treatment decisions
Key components of hemodynamics include:
Blood Pressure: The force of blood against the walls of arteries, which is a critical indicator of circulatory health.
Cardiac Output: The amount of blood the heart pumps per minute, which is essential for ensuring adequate tissue perfusion.
Central Venous Pressure (CVP): The pressure in the thoracic vena cava near the right atrium, which provides insight into venous return and right heart function.
Pulmonary Artery Pressure (PAP): The pressure in the pulmonary artery, important for assessing left heart function and pulmonary circulation.
In critical care, hemodynamic monitoring may involve non-invasive methods like blood pressure cuffs or more invasive techniques such as arterial lines and pulmonary artery catheters. The data collected from these methods help guide interventions such as fluid administration, vasopressor support, and mechanical ventilation adjustments.
D. Role of the Critical Care Nurse in a Critical Care Unit Setting (PACEDE)
Critical care nurses play a pivotal role in managing patients in the CCU. Their responsibilities include:
Patient Assessment and Monitoring: Continuously assessing patients' vital signs, neurological status, and overall condition to detect any changes that require immediate intervention.
Administering Medications and Treatments: Critical care nurses administer complex medication regimens, manage life-support equipment, and perform procedures such as inserting intravenous lines or catheters.
Communication: They serve as a critical link between the patient, their family, and the healthcare team, ensuring that all parties are informed about the patient’s condition and care plan.
Emergency Response: In the event of a sudden deterioration, critical care nurses are trained to respond quickly, initiate emergency protocols, and provide life-saving interventions
Documentation and Reporting: Accurate documentation of patient status, interventions, and outcomes is essential for continuity of care and legal compliance.
Education and Support: Educating patients and families about the condition, treatment options, and post-CCU care is a key part of the role, as is providing emotional support during a challenging time. Critical care nurses must possess a high level of expertise, strong critical thinking skills, and the ability to work effectively under pressure to ensure the best possible outcomes for their patients.
Additional Notes
A. Code Management
Blue - Cardiac (-)(-) or Respiratory arrest (+)(-)
White - seizure, fall, patient desaturation
Violet - violent patient/relatives/staff in hospital
Pink - baby switching
Orange - radioactive spill
B. SBAR Communication
Situation
Background
Assessment
Recommendation
Remember:
The nurse who performed CPR becomes the medication nurse and stand near IV line to administer drugs.
If patient was revived, the doctor informs relatives to transfer the patient to ICU
If the relatives did not consent, require a PDN (private duty nurse) to allow patient in the ward only.
C. 5 Qualities of a Good CPR (DRRPA)
- Correct depth of compression
- Proper rate of compression
- Full chest recoil
- Minimal pause
- Adequate ventilation
HEMODYNAMICS
Preload
Preload refers to the VOLUME of blood in the ventricles at the end of diastole, influencing stroke volume and cardiac output. Assessing preload is essential for determining fluid status and guiding fluid resuscitation efforts in critically ill patients.
What measures preload?
Central Venous Pressure (CVP) or Right Atrium (RA) monitoring device
What lowers preload?
Nitroglycerin (vasodilators)
Diuretics (ex. furosemide)
Morphine (opioid analgesics that reduce fluid overload by decreasing venous return)
Afterload
Afterload refers to the RESISTANCE the heart must overcome to eject blood during systole, which can be influenced by vascular tone and total blood volume.
What measures afterload?
Systemic Vascular Resistance (SVR) or invasive devices
Increased resistance lead to hypertension
What lowers hypertension?
Vasodilators like
ACE (-pril) inhibitors will prevent conversion of angiotensin I and angiotensin II that causes constriction
Angiotensin-2 receptor blockers (ARBs-artan) help your heart pump better, and open up (dilate) and relax your blood vessels so blood can flow better throughout your body.
Beta blockers (-olol) lower the workload on your heart, help your heart pump better, help manage your blood pressure, lower your risk of a heart attack, help prevent stress hormones from making your heart failure worse and keep your heart rhythm normal.
Digoxin for Atrial fibrillation
Decreased resistance lead to shocks like anaphylactic and neurogenic.
What increase afterload?
Vasoconstrictors like norepinephrine, epinephrine, dopamine, and phenylephrine
Cardiac output and cardiac index
Cardiac output refers to the amount of blood pumped in Liters/min (SV x HR). Cardiac index measures the needed cardiac output in a patient’s system.
Normal cardiac output: 4.8 or 5-6L/min
Normal cardiac index: 2.5-4L/min
AHA
American Heart Association (AHA) uses CAB (compressions, airway, breathing)
RESPIRATORY ARREST
Mechanical ventilation
Low pressure alarm
cuff leak
displacement
High pressure alarm (2PBs CK)
Pulmonary edema
Pneumothorax
Broncho spams and Biting
Secretion
Cough
Kink
Nursing responsibilities:
Manual resuscitation bag and reintubation equipment in bedside
LOC, Vital signs, ABGs
Suction oral secretions
Reposition ET tube every 24 hours to prevent skin breakdown
Frequent oral care
BLOOD TRANSFUSION
Verifications:
2 RNs
Head/supervisor
Doctor
S/Sx of any reaction:
Common
Pruritus
Rash
Difficulty breathing
Headache
Specific
Febrile (mild/itchy)
Anaphylactic (fever/hives/hypotension)
Circulatory (heavy fluid/SOB/wheezing)
Hemolytic (lower back pain/low BP)