Conceptual Foundation and Critical

Care Nursing

BSN YEAR-IV SEMESTER-VII

BY:
Mr. TAUQEER AHMED
LECTURER-FUCN
Dated:
 Objectives
By the end of the session students will be able to:

⚫ Define principles of critical care and emergency nursing.

⚫ Describe the scope of practice of critical care and emergency
nursing.
⚫ Identify role of nurse in critical care nursing.
⚫ Explore holistic and interdisciplinary approach.
⚫ Identify the standards of healthy work environment
in critical care.
⚫ Psychosocial implications in the care of critically ill patient
and family
⚫ Contemporary issues in critical care area
⚫ Complementary therapies
 History of Critical Care & ICU’s
⚫ 1850s- Florence Nightingale
⚫ 1923- Dr. Walter opened a special three-bed unit for the more critically
ill
⚫ 1930’s –Dr Martin, introduction of Recovery Rooms
⚫ 1960 almost all hospitals had a recovery unit with OR
⚫ WWII & Korean War – shock units and concepts of triage and
specialty nursing
⚫ 1950’s –opening of respiratory units , beginning of Critical Care Units
⚫ 1958, Dr Max Harry & Dr Hebert opened a four-bed shock ward
⚫ Collaboration between nurses and physicians
⚫ 1950’s & 1960’s – CV Disease most common diagnosis
⚫ 1960’s – 30-40% mortality rate for MI
⚫ 1965 – 1st specialized ICU – The Coronary Care Unit

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Emergence of Specialized ICU’s
ICU, 20 years ago!.
 Definitions
Critical Care :
⚫It is a term used to describe as the care of patients who
are extremely ill and whose clinical condition is
unstable or potentially unstable

Critical Care Unit :

⚫ It is defined as the unit in which comprehensive
care of a critically ill patient which is deemed to
recoverable stage is carried out.
 Critical Care Now
1. Mechanical ventilators are much smaller, more mobile, and
more user-friendly.
2. The development of portable ultrasound units.
3. patient management becoming less invasive whenever possible,
less interventional, and more humane.
4. Units are generally much less strict and more friendly and
welcoming for the patient and family than in the past.
5. Improved communication with patients and their
families
6. A multidisciplinary approach
7. In large hospital-wide infection prevention schemes

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 Critical Care is Provided in:

⚫ Accident & Emergency Units

⚫ High Dependency Units
⚫ Intensive Care Units (ICU)
⚫ Coronary Care Units (CCU)
⚫ Recovery
⚫ Anaesthetic Rooms
⚫ Operating Theatres
 Critical Care Now
⚫ Nursing shortage
⚫ Half of patients in ICU’s >65
⚫ In US – critical care beds account for 8% of all hospital beds,
20% of patients spends time in a critical care unit

GOAL:
Provide high quality, holistic care

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 Principles of Critical Care Nursing

1. Anticipation
2. Early detection and prompt action
3. Collaborative practice
4. Communication
5. Prevention of infection : Nosocomial infection
6. Crisis intervention and stress reduction
Scope of Critical Care & Emergency Nursing
CCRN:
Critical Care Certification by AACN
Requires: Clinical hours working in an ICU
Successful completion of an exam
Requires continuing education and clinical
hours for recertification

Advanced practice
Critical Care nurseNurse Specialist
Clinical Five Roles (CCNS):
of a CCNS:
Licensed by the State
1. Patient & staff educator. 4.Researcher
2. Expert practitioner 5.Administrator
3. Consultant

Acute Care Nurse Practitioner (ACNP):

Advanced practice nurse
Licensed by the State
Provides comprehensive care to select critically ill patients
1
0
 Critical Care Nurse
• Help the client to obtain necessary
Care Provider care and supporting the basic needs

Comprehensive• Comprehensive direct care to the

patient and family
• Based on patient’s needs and severity
Educator
of the condition

• Coordinates the care provided by

Manager various health care

• Protects the patient’s rights

Advocate
 The Critical Care Nursing
1. Specialized and individualized nursing care services:
Patient life threatening conditions and their
families.
2. Requires Extensive Knowledge and a continual desire to
learn.
3. Provides comprehensive care to select critically ill
patients.
4. Constant and rapid assessment: close monitoring and
respond to treatment.
5. Communication skill is of optimal importance.
6. Observing mental state of family state.
7. Maintaining a spiritual attitude.
AACN: Critical Care Nurse’s Role Responsibilities
1. Support and respect for the patient's autonomy and informed
decision making
2. Intervening when it is questionable about whose interest is
served
3. Helping the patient to obtain the necessary care
4. Respecting the values, beliefs, and rights of the patient
5. Educating the patient/surrogate in decision making
6. Representing the patient's right to choose
7. Supporting decisions of patient/surrogate or transferring care to
an equally qualified critical care nurse
8. Negotiating for patients who cannot speak for themselves and
who require emergency intervention
9. Monitoring and ensuring quality care
10. Acting as liaison between the patient/significant others and
others health care team
 Levels of Care
• Patients whose needs can be met through the normal
ward care in an acute hospital
Level 0

•Patients at risk of their condition deteriorating. Whose

needs can be met on an acute ward with additional advice
Level 1 and support from the critical care team

• Patients requiring more detailed observations or

intervention, including support for a single failing organ
Level 2 or in the post-operative period

• Patients requiring advanced respiratory support alone

or basic respiratory support with at lest 2 organ systems
Level 3 (multi-organ failure)
 Conditions Considered As Critical
⚫ Any person with life threatening condition patients with:
⚫ ARF
⚫AMI
⚫ Cardiac Tamponade
⚫Severe Shock
⚫Heart block
⚫Poly Trauma
⚫Multiple Organ Failure
⚫Organ dysfunction
⚫ Severe Burns
 Critical Care Technology

⚫ ECG monitoring ⚫ Pulmonary

⚫ Arterial Lines Artery Catheter
⚫ Oxygen Saturation ⚫ Intra Aortic
⚫ Ventilation Balloon Pump
(IABP)
⚫ Intracranial Pressure
⚫ Extensive use of
Monitoring
pharmaceuticals

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 The Critical Care Patient
⚫ Physiologically Unstable

⚫ At Risk for Serious Complications

⚫ Require Intensive and complicated nursing

support and/or advanced technology

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 GOALS OF CRITICAL
CARE
⚫ Towards the survival of the critical ill patients and
restoring quality of life

⚫ Restoring optimal physiological, psychological, social

and spiritual potential

⚫ Helping the families of the critically ill patients in

coping with crises
 Care of the Critically Ill

⚫ Assessment ⚫ Communication
⚫ Airway management ⚫ Sleep
⚫ Breathing support ⚫ Sensory disturbances
⚫ Fluid management ⚫ Social Isolation
⚫ Nutrition ⚫ Loss of Privacy
⚫ Positioning ⚫ Loss of Dignity
⚫ Hygiene ⚫ Loss of control
⚫ Comfort
Common Problems of Critical Care Patients
1. Nutrition
⚫Address it early
⚫Goal: Prevent or correct nutritional deficiencies
⚫Parenteral
⚫Enteral

2. Anxiety
⚫70-80% of patients
⚫Indicators – agitation, increased BP, increased HR,
verbalization, restlessness
⚫Treatment
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 Common Problems of Critical Care Patients (cont’)

3. Pain
⚫70% reported moderate to severe pain
⚫5th vital sign
⚫Leads to anxiety, agitation, increased myocardial
oxygen consumption, delays wound healing

4. Impaired Communication
⚫Patient on the ventilator
⚫Use of medications
⚫Nursing Interventions

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 Common Problems of Critical Care Patients (cont’)

5. Sensory-Perceptual Problems
⚫“ICU Psychosis”– Really Delirium
⚫15-40% of patients
⚫Psychomotor behavior
⚫Alterations in sleep

6. Sleep Deprivation factors

⚫Poor sleep/wake cycles
⚫Lack of REM sleep
⚫Treatment

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American Association of
Critical Care Nursing
(AACN)’s Healthy Work
Environments Initiative
Sr Healthy Work Environments Require
1. Skilled Nurses must be as proficient in communication
communication skills as they are in clinical skills.
2. True collaboration Nurses must be persistent in pursuing and
fostering collaboration.
3. Effective decision Nurses must be valued and committed partners
making in making policy, directing and evaluating
clinical care and leading organizational
operations.
4. Appropriate Staffing must ensure the effective match
staffing between patient needs and nurse competencies
5. Meaningful Nurses must be recognized and must recognize
recognition others for the value each brings to the work of
the organization.
6. Authentic Nurse leaders must fully embrace the imperative
of a healthy work environment, authentically
live it and engage others in its achievement.
 Are There Challenges?
Challenges: Healthy Work Environments

1. Link to patient safety not universally recognized

2. Relationship issues seen as “soft”
3. Hierarchy and power structures
4. Difficult to measure improvements
5. Tradition
 Question

Which of these statements are true as it pertains to families

where you practice? Select all that apply.

A. Families are considered an important part of the patient care

team.
B. Families are encouraged to visit daily.
C. Families are coached to be active participants in achieving
patient goals.
D. An interprofessional approach is used to support
families.
 Family Needs
⚫ Families experience stress and Critical Care Family Needs
anxiety when a loved one is Inventory (CCFNI) identified
admitted to the ICU. five concept areas:
⚫ In 1979 Molter conducted a study ⚫ Proximity
to identify specific needs of ⚫ Assurance
significant others. The top five ⚫ Information
needs were to:
⚫ Support
1. have hope
⚫ Comfort (Leske, 1992)
2. feel that the hospital staff
cares for the patient
3. be near the patient
4. be informed of any change in
the patient status
5. know the staff (Molter, 1979)
 Advantages to Family Engagement

For patients:
⚫ Decreases anxiety, confusion and agitation (Hupcey, 1999)
⚫ Reduces cardiovascular complications (Fumigalli, Boncinelli, Lo Nostro, et al., 2006)
⚫ Decreases the ICU Length of stay (Davidson, Powers, Hedayat, et al. 2007)
⚫ Makes the patient feel more secure
⚫ Increases patient satisfaction
⚫ Promotes quality and safety
 Family Contributions
⚫ “Active presence” to ⚫ Facilitators” to maintain
facilitate communication and meaningful relationships
what is known about the
patient’s condition ⚫ “Coaches” to provide
⚫ “Protector” creates sense of encourage and inner
safety by having a family strength
member at the bedside to
watch over and advocate for
⚫ “Voluntary caregiver”
them
assists in providing actual
⚫ “Historian” provides
care (McAdam, Arai, and Puntillo, 2008)
information about patient’s
medical history and personal
preferences
 Family Contributions to Patient
Recovery
As part of the care team, families can assist with:

⚫ Being present during patient’s treatment

⚫ Delirium assessment and interventions

⚫ Early mobilization
 Engaging The
⚫ Provide education
Family
⚫What to expect
⚫Family roles
⚫ Model caring behaviors
⚫ Support
⚫ Encouragement Google images,
2015

Consequences of Unmet Needs

⚫ Anxiety and Fear (Simon, Phillip, Badalamenti, and Ohlert, Krumberger , 1997)
⚫ Depression
⚫ Post traumatic stress syndrome
⚫ Concerns that not everything possible was being done
(Meyers, Eichhorn, Guzzetta, 2000)
 Clinical Practice Guidelines for Support
of The Family
⚫ A shared decision- ⚫ Open visitation
making model
⚫ Early and repeated care ⚫ Family-friendly signage
conferences
⚫ Family support before,
⚫ Honoring cultural during, and after a death
requests
⚫ Staff education and
⚫ Spiritual support debriefing
(ACCM Task Force of the
SCCM, 2007)
⚫ Family presence at rounds
and during resuscitation
 Engaging Families in The
ICU
In summary:
• Family engagement and
empowerment is fostered by
the culture of the unit.
• A multidisciplinary approach
is necessary to support family
engagement.
• Families can be included in many
aspects of patient care and that
benefits both patient and family.
•
Complementary &Alternative Medicine
(CAM)
⚫ Complementary medicine – therapies used together with
conventional medicine
⚫ Alternative medicine – used in place of conventional
medicine
⚫ Conventional medicine is practiced by holders of M.D. or some
other degrees and by allied health professionals

Major Domains of CAM

⚫ Biologically based practices
⚫ Energy medicine
⚫ Manipulative and body-based practices
⚫ Mind-body medicine
Table 23.1 Popular Complementary Treatments

Table
23.1
 Content For Alternative
Therapies
⚫ I. Systems of Health Care ⚫ IV. Biologic Based
⚫Traditional Chinese Therapies
Medicine ⚫ Aromatherapy
⚫Native American ⚫ Herbal
medicine preparations
⚫Homeopathy ⚫ V. Energy
⚫ II. Mind-Body Therapies
Therapies ⚫Healing touch
⚫A. Journaling ⚫Therapeutic
⚫B. Imagery touch
⚫C. Meditation ⚫Reiki
⚫ III. Manipulative
Therapies
1/11/2017
⚫D. Massage
 Mind - Body Manipulative Therapies
⚫ Biofeedback: Some of the ⚫ Yoga
processes that can be controlled ⚫ “life forces in correct
include brainwaves, muscle tone, balance and flow
skin conductance, heart rate and ⚫ Concentration, strength,
pain perception flexibility, symbolic
movements
⚫ Journaling
⚫ Breathing, movement
⚫ Provides a vehicle &
for expressing posture
feelings ⚫ Tai Chi
⚫ Hypnosis ⚫ Promotes the flow of qi
⚫ Advanced training is or
Necessary energy throughout the
⚫ Humor
body
⚫ Used in cardiac rehab
⚫ Uses the power of
programs, can lower BP
smiles and
 Message of the day

The mistakes are all there,

waiting to be made.
Chess master Savielly Tartakower (1887-1956)