UNIT- 9

Acute Care Nursing AND

CRITICAL CARE NURSING

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CRITICAL
 Crucial
 Crisis
 Emergency
 Serious
 Requiring immediate action
 Thorough and constant observation
 Total dependent

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 Acute care

 In an acute care patients receive short-term

medical treatment for acute illnesses or injury,
or to recover from surgery.

 In this setting, medical and nursing personnel

will administer the critical care required to help
restore a patient back to health.

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Short-Term Acute Care Setting

Short-term acute care is usually administered in

a hospital, which has all the medical care
personnel, staff, and facilities needed to
diagnose, treat and care for patients with acute
conditions like short-term injuries .

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Acute Care Hospital

 Unlike hospitals that administer health care for

chronic disease, hospice treatment, mental
illness or other conditions, acute care hospitals
are designed for short-term stays, helping to
stabilize patients from a variety of conditions.

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Facilities
 Facilities available in an acute care setting
typically include an
 Emergency room
 Operating room
 Blood bank
 Radiology department
 Pathology department
 Pharmacy and laboratory

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 Long-Term Acute Care
 Long-term acute care is administered to patients
after their acute care treatment.

 This is necessary for patients who have

medically complex needs and need specialized
care.

Long-Term Acute Care Setting

 Long-term acute care can be given in hospitals,
hospices, inpatient rehabilitation centers, in the
home and other settings.
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 DEFINITION

Critical care:
Critical care 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.

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The Critical Care Nurse
 “Specialty dealing with human responses
to life-threatening problems”

 Requires Extensive Knowledge and a

Continual Desire to Learn

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An ideal ICU

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A Good ICU
 Well organized
 coordinated care
• Full-time intensivist : Daily round
• Protocol & policies
• Bedside nurses
• No intern

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A Good ICU
 A team:
Doctors, Nurses , Pharmacists, physiotherapist,
Anesthetics and other staff
• Led by full time intensivist
Critical care trained
Available in a timely fashion (24hr/day)
• Closed units, if resources allow

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 CLASSIFICATION OF
CRITICAL CARE UNITS

LEVEL - I :
Provides monitoring, observation and
short term ventilation. nurse patient ratio
is 1:3 and the medical staff are not
present in the unit all the time.

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Level - II :
Provides observation, monitoring
and long term ventilation with
resident doctors.

The nurse-patient ratio is 1:2 and

junior medical staff is available in the
unit all the time and consultant
medical staff is available if needed.
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level - III:
Provides all aspects of intensive care
including invasive hemodynamic
monitoring and dialysis.
Nurse patient ratio is 1:1.

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 CLASSIFICATION OF
CRITICAL CARE PATIENTS
 Level O : Normal ward care

 Level 1: At risk of deteriorating , support from

critical care team

 Level 2 : More observation or intervention,

single failing organ or post operative care

 Level 3; Advanced respiratory support or basic

respiratory support ,multi organ failure
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Types of ICU
 General
 Medical Intensive Care Unit(MICU)
 Surgical Intensive Care Unit
 Medical Surgical Intensive Care Unit(MSICU)

 Specialized
 Neonatal Intensive Care Unit(NICU)
 Special Care Nursery(SCN)
 Paediatric Intensive Care Unit(PICU)
 Coronary Care Unit(CCU)
 Cardiac Surgery Intensive Care Unit(CSICU)
 Neuro Surgery Intensive Care Unit(NSICU)
 Burn Intensive Care Unit(BICU)
 Trauma Intensive Care Unit
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PRINCIPLES OF CRITICAL CARE
NURSING

ANTICIPATION :
 The first principle in critical care is Anticipation.
One has to recognize the high risk patients
and anticipate the requirements, complications
and be prepared to meet any emergency.

 Unit is properly organized in which all

necessary equipments and supplies are
mandatory for smooth running of the unit.
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 EARLY DETECTION AND
PROMPT ACTION
 The prognosis of the patient depends on
the early detection of variation, prompt and
appropriate action to prevent or combat
complication.

 Monitoring of cardiac respiratory function is

of prime importance in assessment.
 COLLABORATIVE PRACTICE :

Critical Care, which has originated as technical

sub-specialized body of knowledge has evolved
into a comprehensive discipline requiring a very
specialized body of knowledge for the physicians
and nurses working in the critical care unit fosters
a partnerships for decision making and ensures
quality and compassionate patient care.
Collaborate practice is more and more warranted
for critical care more than in any other field.

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COMMUNICATION :

 Intra professional, inter departmental and

inter personal communication has a
significant importance in the smooth
running of unit. Collaborative practice of
communication model

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Prevention of Infection :

 Nosocomial infection cost a lot in the health care

services. Critically ill patients requiring intensive
care are at a greater risk than other patients due
to the immuno-compromised state with the
antibiotic usage and stress, invasive lines,
mechanical ventilators, prolonged stay and
severity of illness and environment of the critical
unit itself.

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 Crisis Intervention and Stress
Reduction :
 Partnerships are formulated during crisis.
Bonds between nurses, patients and
families are stronger during hospitalization.

 As patient advocates, nurses assist the

patient to express fear and identify their
grieving pattern and provide avenues for
positive coping.
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PRIME ROLE AND RESPONSIBILITIES OF
A CRITICAL CARE NURSE

 Continuous monitoring
 Keep ready emergency trolley / crash Cart
 Efficient Individualized Care.
 Counseling and information to family.
 Application of policies and procedures
 Proper records of all activities
 Maintain infection control principles.
 Keep update with advance information.

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 ORGANIZATION OF ICU

DESIGN OF ICU :
1. Should be at a geographically distinct area
within the hospital, with controlled access.
2. There should be a single entry and exit.
However, it is required to have emergency exit
points in case of emergency and disaster.
3. There should not be any through traffic of
goods or hospital staff. Supply and professional
traffic should be separated from public/visitor
traffic.
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5. Safe, easy, fast transport of a critically sick pt
should be a priority in planning its location.
Therefore, the ICU should be located in close
proximity or ER, OT, trauma ward etc.

6. Corridors, lifts and ramps should be spacious

enough to provide easy movement of bed/trolley of a
critically sick patient.

7. Close, easy proximity is also desirable to

diagnostic facilities, blood bank, pharmacy etc.
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BED STRENGTH

1. It is recommended that total bed

strength in ICU should be between 8-12
and not less than 6 or not more than 24
in any case.
2. 3-5 beds per 100 hospital beds for a
Level III ICU or 2 to 20% of the total no
of hospital beds.
3. 1 isolation bed for every ICU beds.
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BED AND ITS SPACE:

1. 150-200 sq.ft per open bed with 8 ft in

between beds

2. 225-250 sq.ft per bed if in a single room.

3. Beds should be adjustable, with side rails and

wheels.

4. Keep bed 2 ft away from head wall.

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ACCESSORIES:

1. 3 O2 outlets, 3 suction outlets (gastric, tracheal

and underwater seal), 16 power outlets per bed.

2. Storage by each bedside.

3. Hand rinse solution by each bedside.

4. Equipment shelf at the head end

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5. Hooks and devices to hang infusions/
blood bags, extended from the ceiling with
a sliding rail to position.

6. Infusion pumps to be mounted on stand

or poles.

7. Level II ICUs may require multi channel

invasive monitors.
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8. ventilators, infusion pumps, portable X ray
unit, fluid and bed warmers, portable light,
defibrillators, anesthesia machines and
difficult airway management equipments
are necessary.

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STAFFING:

Nursing staff – The major teaching tertiary

care ICU requires trained nurses in critical
care.

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Medical Staff – the best senior medical
staff to be appointed as an Intensive Care
Director or Intensivist. Less preferred are
other specialists from anaesthesia/
medicine who has clinical commitment
elsewhere. Junior staff are intensive care
trainers and trainees on deputation from
other disciplines.

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 The no of nurses ideally required for such unit is
1:1 ratio, however it might not be possible to have
such members in our set up. So 1 nurse for 2
patients is acceptable. The no of trained nurses
should also be worked out by the type of ICU, the
workload and work statistics and type of patient
load.

3. Allied Services: Respiratory services,

Nutritionist, Physiotherapist, Biomedical engineer,
technicians, computer programmer, clinical
pharmacist, social worker / counsellor and other
support staff, guards and grade IV workers.
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QUICK REFERENCE PROTOCOL FOR
MANAGING EMERGENCY IN ICU
 Quickly review the patient -
Identity,
History , Physical Exam.
 Be with the patient, ask for help.
 Place the patient in a suitable
position.
 Attach the cardiac monitor and
call for
crash cart.
 Maintain ABC Along with expert37
 Administer medication as needed.

 Carry on Investigations - ABG, ECG,

Urea, Creatinine, Blood Sugar,
Cardiac enzymes.

 Maintain Fluid and Electrolytes.

 Record right things at right time

rightly.

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Core Competencies
 Patient Care
 Medical Knowledge
 Professionalism & Ethics
 Interpersonal Communication Skills
 Practice - based Learning and
Improvement
 Systems-based Practice

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Nursing Care
Protocols

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Critical Care
Considerations
 F=Feeding/fluid
 A=Analgesics
 S=Sedation
 T=Thrombolytic agents
 H=Head elevation
 U=Ulcer – bed sore
 G=Glucose monitoring

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Feeding and Fluids
 It includes
 Enteral feeding
o Oro - gastric and Naso - gastric feeding
o Churn diet
o Dairy and poultry products (Milk, egg,
youghort)
o High protein liquid diet
o Medications
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 Oral feeding
o Hospital diet
o Bland diet
o Normal diet
o Liquid intake

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 Transparenteral diet
o Oliclinomel
Includes:-
• Amino acid solution with electrolyte (5.5%) volume
800 ml
• Amino acid 44 gram
• Na acetate
• Na glycerophosphate
• KCl
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 MgCl2
 Sodium
 Magnesium
 PO4
 Acetate
 Chloride
 Glucose 20% solution with CaCl2
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 Overall volume of TPN = 2000 ml
 Osmolarity = 75 mOsm/L
 pH = 6
 Amino acid = 44 gram
 Total calorie = 1,215 Kcal

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 Fluids
 IV fluids like NS, RL, 5% D, 10% D, DNS

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 Analgesics
 Fentanyl
o It works 600 times more effectively than
Morphine and reduces the pain and increases
the pain threshold
o Used in moderate and severe pain
o In ICU 50 – 100 µg per Kg
o Antidote Naloxone 0.05 mg/ Kg

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Morphine
o Reduces pain
o Chiefly used in MI
o 2-4 mg dissolved in 10 ml NS
o Antidote: Naloxone
o Supplied by hospital.

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 Acetaminophen and NSAIDs
o Often more effective than opioids in reducing
pain from pleural or pericardial rubs, a pain that
responds poorly to opioids.
o Particularly effective in reducing muscular and
skeletal pain.
o Tab form: 500mg OD

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Sedatives

Benzodiazepines
1. Midazolam
o Short acting sedatives and hypnotics
o In intubated patients
o Dose 0.01- 0.05 mg/Kg for several hours

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Benzodiazepines
Diazepam
• Adult dose = 0.2 – 0.5 mg / Kg
• Not given in MI patients

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 Dissociative Anesthesia

 Ketamine
 Adult dose= 1 – 3 mg/kg IV

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Propofol
o Arousal is rapid 10- 15 min
o Used in neuro cases and those with
increased ICP, during tracheostomy
procedure

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Inotropes
 Dopamine
 Dobutamine
 Nor- adrenaline

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Thrombolytic agents
 TEDS compressive stocking
 SCD (Systematic Compressive Device)
 LMWX
 Heparin flush

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Head elevation
 Head is elevated to 30 degree.

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Ulcer
 Two hourly position change
 Back care in each shift
 Oxygen therapy
 Each shift dressing of pressure sore
 Air mattresses

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Glucose Monitoring
 RBS as prescribed
 Insulin therapy
 Careful monitoring of signs of
Hypoglycemia
(Trembling, clammy skin, palpitations,
anxiety, sweating, hunger, and irritability)

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Infection control
 Hand washing before, during and after the procedure
 Sterility maintenance during procedures
 Use of disinfectants
 Weekly high wash
 Monthly culture test of health personnel, equipments
and infrastructures
 Regular inspection by infection control team
 Each shift CVP dressing

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Specific Equipment's
used in ICU and CCU
 Ventilators
 Infusion pumps
 Cardiac monitors
 Defibrillator
 ABG machine
 ECG machine

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Thank you…!!!

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