Foundations of Critical Care Nursing

1. Critical Care Training
Program (CCTP)
Sam Angelo F. Estrella, RN, RGN, MSN
Critical Care and Emergency Nursing

3. Critical Care
Nursing
Conceptual Foundation of
Sam Angelo F. Estrella, RN, MSN, CEN

4. 1. Define and Discuss what is Critical Care Nursing
and its role in nursing practice
2. Expound on the Goals of Critical Care Nursing
3. Discuss the role of critical care nurse in the
management of the critically ill patients
Objectives

5. A specialty within nursing that deals with human responses to life-
threatening problems.
The roles and scope of practice for ICU nurses specifically involve providing
direct and comprehensive care for acutely or critically ill patients including
critical care treatments, oversight of life support equipment and invasive
monitoring devices, support for patient- and family-centered care in the ICU,
and overall assurance of the delivery of safe and high-quality patient care in
collaboration with the interprofessional ICU team.
(American Association of Critical Care Nurses)
Critical Care Nursing

6. In the Critical Care Units, each patient is viewed as a unique
individual with dignity and worth. The critically ill patient should
receive comfort and provided privacy in a highly technological
environment. In collaboration with other health care team members,
critical care nurses provide high level of patient care which includes
patient and family education, health promotion and rehabilitation. To
achieve this holistic care process, participation by the patient and
his/her family is always emphasized. At the forefront of critical care
science and technology, critical care nurses maintain professional
competence based on a broad base of knowledge and experience
through continuous education and evidence-based research.
Philosophy of Critical Care Nursing

7. 1. To promote optimal delivery of safe and quality care to
the critically ill patients and their families by providing
highly individualized care so that the physiological
dysfunction as well as the psychological stress in the ICU
are under control;
Goals of Critical Care Nursing

8. 2. To care for the critically ill patients with a holistic
approach, considering the patient’s biological,
psychological, cultural and spiritual dimensions
regardless of diagnosis or clinical setting;
Goals of Critical Care Nursing

9. 3. To use relevant and up-to-date knowledge, caring
attitude and clinical skills, supported by appropriate
technology for the prevention, early detection and
treatment of complications to facilitate recovery.
Goals of Critical Care Nursing

10. 4. To provide palliative care to the critically ill patients in
situations where their health status is progressing to
unavoidable death, and to help the patients and families
to go through the painful sufferings.
Goals of Critical Care Nursing

11. Critical Care Nurse Qualification
it is necessary that the health institution as employer provide newly hired
nurses with a basic critical care nurse specialty education and orientation
prior to the deployment in the critical care areas. In the Advanced
Practice Nursing level, the advanced practice nurses in the critical care,
must earn an advanced degree either at the master’s or doctorate level
in nursing.

12. ENTRY LEVEL ADVANCED LEVEL
• BSN, valid PRC license • Advanced Degree (Masters/Doctorate
Level)
• min 6 month clinical experience • Min of 2 years experience in critical care
area
• Certification of Completion in an accredited
post-grad course in critical care nursing
• Certification of post-grad course in
advanced critical care nursing
• Advanced Cardiac Life Support
• Pediatric Advanced Cardiac Life Support
• Newborn Resuscitation
• Continuous Renal Replacement Certification
• Intravenous therapy
• Stroke Nursing
• Active participation in critical care research
projects

13. Roles of a Critical
Care Nurse
02

14. 1. Care Provider
A. Direct patient care
1. Detects and interprets indicators that signify the varying conditions of
the critically ill with the assistance of advanced technology and
knowledge;
2. Plans and initiates nursing process to its full capacity in a need driven
and proactive manner;
3. Acts promptly and judiciously to prevent or halt deterioration of
patients’ condition when conditions warrant, and
4. Co-ordinates with other healthcare providers in the provision of
optimal care to achieve the best possible outcomes.

15. 1. Care Provider
B. Indirect patient care – Care of the Family
1. Understands family needs and provide information to allay fears and
anxieties and
2. Assists family to cope with the life-threatening situation and/or
patient’s impending death.

16. 2. Extended roles as critical care nurses
Critical care nurses have roles beyond their professional boundary. With
proper training and in accordance with established guidelines,
algorithms, and protocols that are continuously reviewed and updated,
critical care nurses also perform procedures and therapies that are
otherwise done by doctors. Such procedures and therapies are:

17.  Sampling and analyzing arterial blood gases;
 Weaning patients off ventilators;
 Adjusting intravenous analgesia / sedations;
 Performing and interpreting ECGs;
 Titrating intravenous and central line medicated infusion and
nutrition support;
 Initiating defibrillation to patient with ventricular fibrillation or
lethal ventricular tachycardia;
 Removal of pacer wire, femoral sheaths and chest tubes, and
 Other procedures deemed necessary in their respective
institutions under a clinical protocol.

18. 3. Educator
As an educator, the critical care nurse must be able to:
Provides health education to patient and family to promote
understanding and acceptance of the disease process thus facilitate
recovery and Participates in the training and coaching of novice
healthcare team members to achieve cohesiveness in the delivery of
patient care.

19. 4. Patient Advocate
The critical care nurses’ role includes being an advocate – someone who
acts or intercedes on behalf or another. Typically, the critical care nurse
may be in the best position to act as the liaison between patient and
family and other team members and departments because they are the
healthcare professionals with the most interpersonal contact with the
patients. To perform this function adequately, the nurse must be
knowledgeable about the involved in all aspects of the patient’s care and
have a positive working relationship with other team members. The
critical care nurses are expected to:
Acts in the best interests of the patient and Monitors and safeguards the
quality of care which the patient receives.

20. Critical Care Nursing
Workforce
Requirements

21. As a minimum, the critical care unit should maintain or strive to
achieve the following nursing workforce requirements:
1. Critically ill patients (clinically determined) require one registered
nurse at all times.
2. High dependency patients (clinically determined) in a critical care
unit require no less than one registered nurse for two patients at all
times.
3. Where necessary extra registered nurses may provide additional
Assistance, Coordination, Contingency (for late admission, sick
staff), Education, Supervision, and Support to a sub-set of patients
and nurses in a critical care unit. (some times referred to as
ACCESS nurse)

22. 4. A critical care unit must have a dedicated head nurse (otherwise
called Charge Nurse or similar title) to manage and lead the unit.
This person must have a recognized post-registration critical care
nursing qualification. It is also recommended the Head Nurse/Nurse
in Charge have management qualifications.
5. Each shift must have a designated nurse in charge to deputize for
the head nurse and to ensure direction and

23. 6. A critical care unit must have a dedicated nurse educator to provide
education, training and quality improvement activities for the unit
nursing staff. This person (s) must have a recognized post-
registration critical care nursing qualification.
7. Resources must be allocated to support nursing time and costs
associated with quality assurance activities, nursing and team
research initiatives, education and attendance at seminars and
conferences.

24. 8. Adequate support staff within the critical care area including:
administrative staff, support staff to assist with manual handling,
cleaning and domestic duty staff and other personnel exist to allow
nursing staff to focus on direct patient care and associated
professional requirements.
9. Appropriately skilled and qualified medical staff are appointed and
accessible to the unit for decision making and advice at all times. A
medical director is appointed to work collaboratively with the head
nurse in order to provide policy/protocol, direction and collaborative
support.

25. 10. Remuneration levels for nursing staff are such that they are
competitive with similar professions in the country and are scaled in
such away as to reward and retain qualified, experienced and
senior critical care nurses.
11. Appropriate, accessible and functional levels of equipment and
technology are available and maintained to meet the demands of
the expected patient load at any given time and nursing staff are
adequately trained and skilled in the application of such equipment
and technology.

26. 12. Adequate occupational health and safety regulations should be in
place and enforced to protect nurses from hazards of manual
handling and occupational exposure.
13. Organized and structured peer support and debriefing procedures
are in place to ensure nursing staff support and wellbeing following
critical incident exposure.

27. Conceptual Model of
Critical Care

28. Credentialing Framework
 adopted from Patricia Benner
 5 stages of skill acquisition
NOVICE ADVANCED
BEGINNER
COMPETENT PROFICIENT EXPERT

29. Maslow’s Hierarchy of Needs

30. Patients in Critical Care
have had or will likely have major physical
derangement requiring either invasive
monitoring or intensive interventions

31. Patients in Critical Care
the most common cause of one or all of
these derangements is local or systemic
infection

32. Patients with Special Needs
Critical care units must manage intersecting challenges of
maintaining:
1. Highly advanced environment
2. Ensuring staff competency
3. operating the equipment
4. providing high-quality care to facility’s sickest patients, and
5. Tending to the needs of staff member working in a very
stressful environment.

33. General Nursing
Protocols for Critically
Ill Patients

34. What you need to know about critical care
nursing
1. No critical care patient shall be left without the nurse
in attendance.
2. Each nurse will be responsible for the entire care of
his/her patient(s) and acts to coordinate with other
Healthcare team professionals.
3. Breaks will be arranged accordingly to meet safe
unit coverage.

35. What you need to know about critical care
nursing
4. The nurse must give full report to another staff
nurse prior to leaving patient’s bedside.
5. All critical ill patients will have continued ECG
monitoring.
6. Alarms must be left on the ECG & arterial lines at all
times, with appropriate limits set per hospital policy.
7. An ECG strip will be regularly obtained and
analyzed per hospital policy.

36. What you need to know about critical care
nursing
8. For a stable, non-acute patient without invasive
monitoring equipment, vital signs monitoring will be
done at least every hour.
9. Core temperatures will be measured on all patients
at least every 4 hrs.
10. All patients admitted for neurologic problems will
have hourly neurologic assessments performed &
documented.

37. 11. The turning of critically ill patients every 2 hours RTC should
be done unless contraindicated. Skin assessment should be done
every 4 hours & documented.
12.If turning is contraindicated, pressure points will be relieved
every 2 hours.
13. All intensive care patient will have ROM exercises every 4
hours unless contraindicated.
14. Perineal care will be done every shift and PRN for all patients.

38. 15. All critical care patients will have oral care done
every 4 hours, with inspection for oral skin sores.
16. Restraining of patients may be done after
collaboration with the restraint team per hospital
policy. Consent for restraints is only good for 24 hours.
17. All restraints will be secured to allow rapid lowering
of bedside.

39. 18. Any patient who expires and falls into the
classification of a coroner’s case or will undergo
autopsy must have all lines/attachments in place until
coroner confirms that they may be removed.
19. All routine dressing changes, IV tubing changes, &
catheter changes will be done in the night shift.
20. Routine daily baths will be done in the night shift.

40. 21. Thromboembolic stockings will be applied 4 hours, then should be
removed for 4 hours or as per doctor’s order.
22. Nursing care will be spaced out to allow periods of rest.
23. All patients who have not had a bowel movement will be checked for
impaction every 3 days.
24. Patients should be routinely oriented. Sensory stimulation mediums
should be utilized.
25. All procedures should be explained to the patient &/or family.

41. 26. Information & emotional support for the family & patient
should be provided PRN.
27. The environment will be maintained in a mechanically safe
condition.
28. Isolation techniques will be followed as per infection
control policy.
29. Safety signs will be posted as indicated.
30. Sharps and glass will be disposed to designated sharps
container.

42. 31. Any containers of body fluids must be disposed in the appropriate
biohazard container.
32. All electrical equipment will be grounded (3-prong plugs) and be
used away/protected from water/spillage.
33. Labels will be affixed to all bedside medications, IV bags,
irrigations, etc.
34. All medications will be regularly reviewed by the critical care
physicians or clinical pharmacist.
35. All orders written for non-critical care patients will be brought to the
attention of the critical care physician by the RN before being carried
out.

43. 36. Narcotics may not be kept at bedside.
37. Visiting is negotiated between the nurse and the family, with
consideration given to unit activity and institutional policy.
38. The number of visitors will be limited to 1 at a time.
39. The nurse/physician will notify the families of significant
deterioration in the patient’s condition.
40. Support will be given to family who would like children to visit
(special prep).

44. 41. A visitor’s handout will be given to one member of each patient’s
family.
42. All patients in critical care unit will be weighed on admission, daily
and recorded.
43. All patients in the critical care unit will have 2 minimum IV access.
44. All change-of-shift reports will include a review of all physicians’
orders, current lab results, MAR, & joint head-to-toe review.
45. All staff members assigned to post-acute trauma or actively
bleeding patient will wear appropriate PPE.

45. Thank you