dada

1. CENTRAL LUZON DOCTORS’ HOSPITAL –
EDUCATIONAL INSTITUTION, INC
Romulo Highway, San Pablo, Tarlac City
Tel No. (045) 982-5019/982-5052/982-0264 Fax No. (045) 982-0780/982-2757
DEPARTMENT OF NURSING
NCM 118 LECTURE
WRITTEN REPORT
Submitted by:
GROUP 3
BSN 4B
Bartolome, Kim Allyza
Caisip, Aezel Mari
Espiritu, Jerson
Feliciano, Jasmine Jade
Fernandez, Gabriel Niko
Gruspe, Jiremy
Gonzales Jr., Noli
Lacamura, Airah Mae
Laxamana, Analiza
Magdaraog, John Carlo
Mendoza, Irish Bernadette
Navarro, Christopher James
Ovejera, Adriane Gabriel
Robinos, Junel Rose
Roldan, John Matthew
Sagun, David
Salas, Camille
Sacalamitao, Adrianna Ymielle
Sagun, David
Valdez, Eleizza Marie
Vallejo, Therese Marie
Ventura, Bianca Gabrielle
Victoriano, Cassandra Grace
Yabut, Mae Angelore

2. Yumul, Mary Ann
INTRODUCTION TO CRITICAL CARE AND EMERGENCY SITUATIONS
A. SCOPE AND CRITICAL CARE PRACTICE
DEFINITION OF CRITICAL CARE NURSING
Critical care nursing is concerned with human responses to life-threatening problems, such
as trauma, major surgery, or complications of illness. The human response can be a physiological
or psychological phenomenon. The focus of the critical care nurse includes both the patient’s and
family’s responses to illness and involves prevention as well as cure. Because patients’ medical
needs have become increasingly complex, critical care nursing encompasses care of both acutely
and critically ill patients.
DEVELOPMENT OF CRITICAL CARE NURSING PRACTICE
In 1970, the health care system in the Philippines was greatly affected by advancements in
care and technology and the changing nature of care. These factors influenced the development of
specialty practice, particularly in critical care.
Critical care practice is a collaborative process and nurses play a vital part in it. Critical
care nurses assume the role of direct caregivers to the patient. They are expected to possess the
competency necessary to work in complex critical care areas or the intensive care unit (ICU)
environment. To be able to meet the demands of this type of care, recruitment of nurses must be
based on skill levels. The patient to nurse ratio in the ICU of most Metro Manila tertiary hospitals
is usually 1:2. However, this is not a consistent picture in other government or private hospitals
throughout the country.
Most critical care nurses in the Philippines have not been educationally prepared for critical
care practice. They have developed knowledge and skills ‘on the job’ through mentoring or
preceptoring by senior nurses. There is no difference in salary between critical care nurses and
‘ordinary’ ward nurses, and newly hired nurses can be deployed immediately in any ICU setting
to augment staffing. However, with the specialization programme as required by the Nursing Act
2002, most hospitals are trying to comply with the guidelines for hospital accreditation to have
nurses trained and educated in critical care nursing practice.
Critical care programmes are provided by only a few tertiary hospitals in Metro Manila.
These programmes are not currently reviewed or accredited by the national Critical Care Nurses
Association of the Philippines. However, development of a mechanism for accreditation of
speciality programmes is being discussed by the Professional Regulation Commission Board of
Nursing and specialty nursing organizations’. This mechanism will still have to be approved before
it can be made a requirement for critical care practice.
EDUCATION OF CRITICAL CARE NURSING PRACTICE
Critical Care Nurses are registered nurses, who are trained and qualified to practice critical
care nursing. They possess the standard critical care nursing competencies in assuming
specialized and expanded roles in caring for the critically ill patients and their family. Likewise,

3. each critical care nurse is personally responsible and committed to continuous learning and
updating of his/her knowledge and skills. The critical care nurses carry out interventions and
collaborates patient care activities to address life-threatening situations that will meet patient’s
biological, psychological, cultural and spiritual needs.
Contrary to other countries where there are several nursing degrees that allow for nursing
practice, there is only one entry point to become a nurse in the Philippines - graduating with a
bachelor’s degree and passing the national licensure examination administered by the Professional
Regulatory Board of Nursing (PRC-BON). The Philippine Nursing Act of 2002 (RA 9173)
provides guidance to enable the nurse to practice, and mandates the PRC-BON-recognized
specialty organizations and the Department of Health (DOH) to develop comprehensive nursing
specialty programs such as CCN (Article VII, Section 31). To fulfill this mandate, the specialty
organization, CCNAPI, provides training to critical care nurses. On the other hand, the DOH
provides the Nurse Certification Program where nurses are given certification on thirteen
specialties (cardiovascular nursing, renal nursing, emergency and trauma nursing, orthopedic and
rehabilitation nursing, mental health nursing, infectious disease nursing, pulmonary nursing,
maternal and child nursing, pediatric nursing, operating room nursing, anesthesia care nursing,
geriatric and gerontology nursing, public health nursing). The program uses a competency-based
determination of acquired skills in a specialty area throughout the nurses’ career. Critical care
nurses may seek certification in specific specialties based on their area of practice. Through self-
assessment, provision of necessary documents, and confirmation from accredited institutions as
learning providers, nurses can receive certification from the DOH. However, similar to trainings
of CCNAPI, the DOH Nurse Certification Program is not a specialization certification, rather,
awards certificate of competence valid for three years and will only obtain continuing professional
education (CPE) units for each accomplished module or learning package if accredited by the
PRC-BON (DOH, 2015). In addition, individual institutions such as tertiary, academic, training
hospitals, and other multispecialty organizations are also offering advanced training programs on
specific critical care focus, e.g. mechanical ventilation, advanced ECG course to name a few.
TRAINING OF NURSES FOR CRITICAL CARE SERVICES
The institution / hospital should provide training opportunities to ensure staff
competencies. This will enable the nurses working in the critical care units to cope with the
complexities and demands of the changing needs of the critically ill patients. The following
training activities should be supported by the higher level of management to maintain a high
standard of care:
 Orientation Program / Preceptorship and Mentoring Program
New recruits to the critical care units shall attend an orientation program and be given
opportunities to work under senior staff supervision. Experienced staff in the unit should be readily
available for consultation.
 In-Service Training Program

4. a. Unit / hospital based training courses / workshop / seminar at hospital level
b. On-the-job training and bedside supervision
Critical Care Nursing Program (Post Graduate Specialty Program)
Critical Care Nurses Association of the Philippines, Inc. recommends that all practicing
CCN shall continuously update their knowledge, skills and behavior through active participation
in Critical Care Nursing Education or its related field.
The following are categorization of critical care nursing education:
 Post Graduate Courses
Post graduate courses are part of higher education taken after a Bachelor’s Degree that are
accredited from the Commission on Higher Education (CHED) or the Professional Regulation
Commission—Board of Nursing (PRC-BON).
It is recommended that this course has been reviewed, evaluated and endorsed to the
accrediting body by the Critical Care Nurses Association of the Philippines, Inc.
Likewise, it is further recommended that the World Federation of Critical Care Nurses
policy statement of education shall be used as a framework for designing a critical care nursing
program. (Please see Declaration of Madrid, 2005 Annex I)
 Certification Course
Certification courses provides recognition and designation earned by a professional nurse
after completing with satisfaction the requirements of the course and has earned qualification to
perform a job or task.
The certification courses should be recognized and accredited by the Professional
Regulation Commission— Board of Nursing (PRC-BON) or other authorized accrediting body.
This shall include but not limited to the following:
Advanced Cardiac Life Support
Pediatric Advanced Cardiac Life Support
Newborn Resuscitation
Continuous Renal Replacement Certification
Advanced Intravenous therapy
Stroke Nursing
 Continuing Professional Education (CPE)
Continuing Professional Education Programs is a type of education that consist of updated
knowledge and other pertinent information that will help the Critical Care Nurse to attain broader

5. understanding of criticalcare practice and its related field. The goal includes Critical Care Nurses
development of skill, behavior that will help them view the critically ill person in a holistic
dimension.
CCNAPI recommends that all practicing CCN shall ensure the they continuously update
their knowledge, skills and behavior through active participation in related critical care nursing
education and must earn at least 20 credit units per year.
The updated educational component includes but not limited to the following:
Advanced/Comprehensive Critical Assessment
Critical Care Practitioner
End-of-Life and Palliative Care
PROFESSIONAL ACTIVITIES OF CRITICAL CARE NURSING
In response to the changes and expansions within and outside the healthcare environment,
critical care nurses have broadened their roles in the practice levels. Competencies of critical care
nurses are honed and developed to achieve their roles in practice, management / leadership and
research.
Practitioner Role
The critical care nurses execute their practice roles 24-hours a day to provide high quality
care to the critically ill patient.
1. Care Provider
A. Direct patient care
- Detects and interprets indicators that signify the varying conditions of the critically ill with
the assistance of advanced technology and knowledge;
- Plans and initiates nursing process to its full capacity in a need driven and proactive
manner;
- Acts promptly and judiciously to prevent or halt deterioration of patients’ condition when
conditions warrant, and
- Co-ordinates with other healthcare providers in the provision of optimal care to achieve the
best possible outcomes.
B. Indirect patient care – Care of the Family
- Understands family needs and provide information to allay fears and anxieties and
- Assists family to cope with the life-threatening situation and/or patient’s impending death.

6. 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:
a. Sampling and analyzing arterial blood gases;
b. Weaning patients off ventilators;
c. Adjusting intravenous analgesia / sedations;
d. Performing and interpreting ECGs;
e. Titrating intravenous and central line medicated infusion and nutrition support;
f. Initiating defibrillation to patient with ventricular fibrillation or lethal ventricular
tachycardia;
g. Removal of pacer wire, femoral sheaths and chest tubes, and
h. Other procedures deemed necessary in their respective institutions under a clinical
protocol.
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.
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:
o Acts in the best interests of the patient and
o Monitors and safeguards the quality of care which the patient receives.
Management and Leadership Role
The critical care nurse in her management and leadership role will be able to assume the
following responsibilities:

7. o Performance of management and leadership skills in providing safe and quality
care;
o Accountability for safe critical care nursing practice;
o Delivery of effective health programs and services to critically-ill patients in the
acute setting;
o Management of the critical care nursing unit or acute care setting;
o Taking the lead and supervision of nursing support staff, and
o Utilization of appropriate mechanism for collaboration, networking, linkage –
building and referrals.
Role in Research
The critical care nurse’s role in research will entail the following responsibilities:
o Engage self in nursing or other health – related research with or under the
supervision of an experienced researcher;
o Utilization of guidelines in the evaluation of research study or report
o Application of the research process in improving patient care infusing concepts of
quality improvement in partnership with other team-players.
ADVANCED PRACTICE LEVEL
The development of the Advanced Practice Nursing is the future direction in the
Philippines and to be bench marked with other countries. For now, a thorough study of Advanced
Practice in critical care is being undertaken to align with the PRC- BON initiative on specialization
framework.
The current global healthcare environment demands critical care nurses to have advanced
knowledge and skills to provide the highest possible level of care to the critically ill patients.
CCNAPI supports the following descriptions of advanced practice roles.
Expanded Roles
A. Nurse Specialist / Clinical Nurse Specialist
The education and preparation of the critical care nurse practitioner is provided by the
respective hospitals. CCNAPI recommends that a graduate study or a master’s degree program
should support the development of critical care nursing specialization goes beyond the basic
baccalaureate nursing degree. Advanced educational preparation refers to the critical care nursing
educational program run by the university offering Advanced Nursing Studies or other recognized
advanced critical care program offered in the Philippines and overseas.
A registered nurse who is a nursing degree holder, should have more than 3 years of
uninterrupted practice experience in the critical care field. He/she can function as a critical care
nurse specialist when he/she has attained advanced education and expertise in caring patients with

8. critical problems. He/she is also eligible to be certified by the PRC- Board of Nursing as a Clinical
Nurse Specialist.
The critical care nurse specialist is responsible for building up nursing competencies in the
ICU entity. He / She contributes to continuous improvement in critical care nursing through staff
and clients education and uphold quality nursing guidelines on patient care through clinical
research and refinement of ICU Standards.
B. Acute Care Nurse Practitioner
Acute Care Nurse Practitioner (ACNP) in the critical care unit takes lead in developing
evidence-based practices to meet changing clinical needs and facilitates patient care processes
across professional and organizational boundaries. The qualification of Acute Care Nurse
Practitioner (ACNP) includes: should have the recommended number of post registration
(licensed experience) nursing experience which are spent in the critical field, exhibiting in –depth
professional knowledge and skills. An Acute Care Nurse Practitioner (ACNP) is a holder of: a)
clinical master’s degree in a clinical nursing specialty (Medical-Surgical) such as Critical Care
Nursing or b) master’s degree in nursing or related discipline such as management together with
recognized critical care training qualifications. The Acute Care Nurse Practitioner executes the
nursing team leader’s responsibilities as designated in the position of Advanced Nurse Practitioner.
C. Outcome Specialist
Outcome management has been introduced into the healthcare system to ensure
achievement of quality and cost-effectiveness in the delivery of patient care. Some critical care
units have adopted clinical pathways (e.g., Critical Pathways, Protocols, Algorithms and Orders)
in the management of specific diseases such as Acute Myocardial Infarction and Cardio-thoracic
Surgeries. Qualified nurse experts are involved in the development and implementation of patient
outcomes management.
CRITICAL CARE BODY OF KNOWLEDGE
Critical Care
- is the direct delivery of medical care for a critically ill or injured patient (Department of
Health and Human Services, 2008).
o To be considered critical, an illness or injury must acutely impair one or more vital
organ systems to such a degree that there is a high probability of life threatening
deterioration.
- Critical care involves highly complex decision-making and is usually, but not always,
provided in a critical care area such as a coronary care unit, an intensive care unit, or an
emergency department.

9. Critical Care Nursing
- is concerned with human responses to life-threatening problems, such as trauma, major
surgery, or complications of illness. The human response can be a physiological or
psychological phenomenon. The focus of the critical care nurse includes both the patient’s
and family’s responses to illness and involves prevention as well as cure.
o Because patients’ medical needs have become increasingly complex, critical care
nursing encompasses care of both acutely and critically ill patients.
Critical Nurse Characteristics:
o Systematically evaluates the quality and effectiveness of nursing practice
o Evaluates own practice in relation to professional practice standards, guidelines, statutes,
rules, and regulations
o Acquires and maintains current knowledge and competency in patient care
o Contributes to the professional development of peers and other healthcare providers
o Acts ethically in all areas of practice
o Uses skilled communication to collaborate with the healthcare team to provide care in a
safe, healing, humane, and caring environment
o Uses clinical inquiry and integrates research findings into practice
o Considers factors related to safety, effectiveness, cost, and impact in planning and
delivering care
o Provides leadership in the practice setting for the profession
Critical Care Competencies (AACN’s Synergy Model for Patient Care):
o Clinical Inquiry
o Clinical Judgment
o Caring Practices
o Advocacy and Moral Agency
o Systems Thinking
o Facilitator of Learning
o Response to Diversity
o Collaboration
Clinical Inquiry
- Critical care nurse should be engaged in the “ongoing process of questioning and
evaluating practice and providing informed practice.”
- Provide care based on the best available evidence rather than on tradition.
- An expert critical care nurse might be able to evaluate research and develop
- evidence-based protocols for nursing practice in her agency, whereas a competent nurse
might follow evidence-based agency policies and protocols.

10. - Critical care nurses (both novice and expert) can develop the mindset that questioning
practice is an issue of safety.
- A safe practitioner is one who wonders, “Why do we do things this way?” or “Why am I
being asked to provide this specific type of care to this patient at this moment?”
Clinical Judgment
- “Clinical reasoning which includes clinical decision-making, critical thinking, and a global
grasp of the situation, coupled with nursing skills acquired through a process of integrating
formal and experiential knowledge.”
- Able to collect and interpret basic data and then follow pathways and algorithms when
providing care.
- When unsure about how to respond, often defers to the expertise of other nurses.
- An expert nurse is able to use past experience, recognize patterns of patient problems, and
“see the big picture.”
o Her previous experience coupled with the ability to see the “big picture” often
allows her to anticipate possible untoward events and develop interventions to
prevent them.
Caring Practices
- “Nursing activities that create a compassionate, supportive, and therapeutic environment
for patients and staff, with the aim of promoting comfort and preventing unnecessary
suffering.”
- A caring critical care nurse can make an enormous difference in the critical care experience
for a frightened patient and family.
- Able to anticipate patient/ family changes and needs, varying caring approach to meet their
needs.
Advocacy and Moral Agency
- “The nurse promotes, advocates for, and protects the rights, health, and safety of the
patient”
- AACN states that “Foremost, the critical care nurse is a patient advocate and defines
advocacy as ‘respecting and supporting the basic rights and beliefs of the critically ill
patient.’
- A nurse might want to consider the following:
o What types of issues (including end-of-life issues) might arise in the clinical setting
for which the patient may need an advocate?
o What is owed to the patient, and what are the duties of the nurse in those
circumstances?

11. o If she encountered one of those situations, how would the nurse be able to determine
what the patient or family desires or what would be in the patient’s best interests?
o Would the nurse be able to differentiate her needs and desires from those of the
patient?
o How certain could she be?
o How would the nurse act for her patient or empower her patient and his family to
communicate their needs and desires to the rest of the healthcare team?
o How would the nurse respond if she thought that the quality of a patient’s care was
being jeopardized?
o How would the nurse ensure that the discussion was a mutual exploration of
concerns and not a confrontation?
Systems of Thinking
- “Managing the existing environmental and system resources for the benefit of patients and
their families.”
- For a vulnerable patient and family, being in an unfamiliar and overwhelming healthcare
system can be intimidating, even frightening. Having a nurse who knows how the system
works and explains it to the patient and family, or who helps the patient and family obtain
what they need, can make the difference between an experience that is overpowering for
the family and one that the patient and family believe they can endure
- An expert nurse know how to negotiate and navigate for the patient throughout the
healthcare system to obtain the necessary or desired care.
Facilitator of Learning
- Nurses should be able to facilitate both informal and formal learning for patients, families,
and members of the healthcare team.
- An expert nurse would be able to “creatively modify or develop patient/family educational
programs and integrate family/patient education throughout the delivery of care.”
Response to Diversity
- Defines response to diversity as “sensitivity to recognize, appreciate, and incorporate
diversity into the provision of care.”
- An expert nurse would anticipate the needs of the patient and family based on their cultural,
spiritual, or personal values, and would tailor the delivery of care to incorporate these
values.
Collaboration
- defines collaboration in its Synergy Model as “working with others in a way that promotes
each person’s contributions toward achieving optimal and realistic patient/family goals.”
- an expert nurse might facilitate the active involvement and contributions of others in
meetings and role model leadership and accountability during the meetings

12. Professional Organizations:
 American Association of Critical-Care Nurses (AACN)
o The nursing organization most closely associated with critical care nurses
o It is the world's largest specialty nursing organization and was created in 1969. The
top priority of the organization is education of critical care nurses.
o AACN is at the forefront of setting professional standards of care for critical care
nursing.
 AACN publishes numerous materials, evidence-based practice summaries,
and practice alerts related to the specialty.
o The organization also publishes Practice Alerts, which present succinct, evidence-
based practices that are to be applied at the bedside. The organization also sponsors
the Beacon Award for Excellence.
 Society of Critical Care Medicine (SCCM).
- was founded in 1970 by a group of physicians, and it has grown to more than 15,000
members in over 100 countries
- It is a multidisciplinary, multispecialty, international organization.
- Its mission is to secure the highest quality, cost-efficient care for all critically ill patients
- 10 Numerous publications and educational opportunities provide cutting-edge critical care
information to critical care practitioners.
ETHICO-LEGAL CONSIDERATIONS IN CRITICAL CARE
Definition
- Critical care nurses are often confronted with ethical and legal dilemmas related to
informed consent, withholding or withdrawing life-sustaining treatment, organ and tissue
transplantation, confidentiality, and increasingly, justice in the distribution of healthcare
resources.
- One of the primary concerns in critical care is whether a patient’s values and beliefs about
treatment can be overridden by the technological imperative, or the strong tendency to use
technology because it is available.
- Although many ethical dilemmas are not unique to critical care, they occur with greater
frequency in critical care settings. Therefore, it is crucial that critical care nurses examine
the nature and scope of their ethical and legal obligations to patients.
The Code of Ethics
Consists of nine provision statements.

13. - The first three describe fundamental values and commitments of the nurse
- The next three describe the boundaries of duty and loyalty
- and the last three describe duties beyond individual patient encounters.
Nurses in all practice arenas, including critical care, must be knowledgeable about the
provisions of the code and must incorporate its basic tenets into their clinical practice. The code is
a powerful tool that shapes and evaluates individual practice as well as the nursing profession.
However, situation may arise in which the code provides only limited direction.
Nurses’ ethical obligation to serve as advocates for their patients is derived from the unique
nature of the nurse patient relationship. Critical care nurses assume a significant caregiving role
that is characterized by intimate, extended contact with persons who are often the most
physiologically and psychologically vulnerable and with their families.
Critical care nurses have a moral and professional responsibility to act as advocates on their
patients’ behalf because of their unique relationship with their patients and their specialized
nursing knowledge.
ETHICAL DECISION MAKING
As reflected in the ANA code of ethics, one of the primary ethical obligations of
professional nurses is protection of their patients’ basic rights. This obligation requires nurses to
recognize ethical dilemmas that actually or potentially threaten patients’ rights and to participate
in the resolution of those dilemmas.
An ethical dilemma is a difficult problem or situation in which conflicts arise during the
process of making morally justifiable decisions. In identifying a situation as an ethical dilemma,
certain criteria must be met. More than one solution must exist, and there is no clear “right” or
“wrong.”
Each solution must carry equal weight and must be ethically defensible. Whether to give
the one available critical care bed to a patient with cancer who is experiencing hypotension after
chemotherapy or to a patient in the emergency department who has an acute myocardial infarction
is an example of an ethical dilemma. The conflicting issue in this example is which patient should
be given the bed, based on the moral allocation of limited resources.
Several warning signs can assist the critical care nurse in recognizing an ethical dilemma.
If these warning signs occur, the critical care nurse must reassess the situation and determine
whether an ethical dilemma exists and what additional actions are needed:
• Is the situation emotionally charged?
• Has the patient’s condition changed significantly?

14. • Is there confusion or conflict about the facts?
• Is there increased hesitancy about the right course of action?
One helpful way to approach ethical decision making is to use a systematic, structured process,
such as the one depicted
This model provides a framework for evaluating the related ethical principles and the
potential outcomes, as well as relevant facts concerning the contextual factors and the patient’s
physiological and personal factors. Using this approach, the patient, family, and healthcare team
members evaluate choices and identify the option that promotes the patient’s best interests.
Ethical decision making includes implementing the decision and evaluating the short-term
and long-term outcomes. Evaluation provides meaningful feedback about decisions and actions in
specific instances, as well as the effectiveness of the decision-making process. The final stage in
the decision-making process is assessing whether the decision in a specific case can be applied to
other dilemmas in similar circumstances. In other words, is this decision useful in similar cases.
ETHICAL PRINCIPLES
- As reflected in the decision-making model, relevant ethical principles should be considered
when a moral dilemma exists. Principles facilitate moral decisions by guiding the decision-
making process, but they may conflict with each other and may force a choice among the
competing principles based on their relative weight in the situation.
Principlism is a widely applied ethical approach based on four fundamental moral principles to
contemporary ethical dilemmas: respect for autonomy, beneficence, nonmaleficence, and justice.

15. Principle of autonomy
- States that all persons should be free to govern their lives to the greatest degree possible.
- The autonomy principle implies a strong sense of self-determination and an acceptance
of responsibility for one’s own choices and actions.
- To respect autonomy of others means to respect their freedom of choice and to allow
them to make their own decisions.
Principle of beneficence
- The duty to provide benefits to others when in a position to do so, and to help balance
harms and benefits.
- Care should not be given if it is futile in terms of improving comfort or the medical
outcome.
Principle of non-maleficence
- is the explicit duty not to inflict harm on others intentionally.
- The principle of justice requires that health care resources be distributed fairly and
equitably among groups of people.
Principle of justice
- Particularly relevant to critical care because most healthcare resources, including
technology and pharmaceuticals, are expended in this practice setting
Principle of veracity
- States that persons are obligated to tell the truth in their communication with others.
Principle of fidelity
- Requires that one has a moral duty to be faithful to the commitments made to others.
These two principles, along with confidentiality, are the key to the nurse-patient
relationship
SITUATIONS WHERE ETHICS CONSULTATION MAY BE CONSIDERED
- Disagreement or conflict exists on whether to pursue aggressive life-sustaining
treatment in a seriously ill patient, such as cardiopulmonary resuscitation, or emphasize
comfort/palliative care.
- Family demands to provide life-sustaining treatment, such as mechanical ventilation or
tube feeding, that the physician and nurses consider futile.

16. - Competing family members are present and want to make critical decisions on behalf
of the patient.
- A seriously ill patient is incapacitated and does not have a surrogate decision maker or
an advance directive.
Informed Consent
- Many complex dilemmas in critical care nursing concern informed consent. Consent
problems arise because patients are experiencing acute, life-threatening illnesses that
interfere with their ability to make decisions about treatment or participation in a
clinical research study. The doctrine of informed consent is based on the principle of
autonomy; competent adults have the right to self-determination or to make decisions
regarding their acceptance or rejection of treatment.
Elements of Informed Consent
- Three primary elements must be present for a person’s consent or decline of medical
treatment or research participation to be considered valid: competence, voluntariness,
and disclosure of information.
1. Competence (or capacity) refers to a person’s ability to understand information
regarding a proposed medical or nursing treatment. Competence is a legal term and
is determined in court. Healthcare providers evaluate mental capacity. The ability
of patients to understand relevant information is an essential prerequisite to their
participation in the decision-making process and should be carefully evaluated as
part of the informed consent process.
2. Consent must be given voluntarily, without coercion or fraud, for the consent to be
legally binding. This includes freedom from pressure from family members,
healthcare providers, and payers. Persons who consent should base their decision
on sufficient knowledge. Basic information considered necessary for decision
making includes the following:
 A diagnosis of the patient’s specific health problem and condition
 The nature, duration, and purpose of the proposed treatment or
procedures
 The probable outcome of any medical or nursing intervention
 The benefits of medical or nursing interventions
 The potential risks that are generally considered common or hazardous
 Alternative treatments and their feasibility

17.  Short-term and long-term prognoses if the proposed treatment or
treatments are not provided
3. Disclosure of information. Informed consent is not a form. It is a process that
entails the exchange of information between the health care provider and the patient
or patient’s proxy. Frequently, critical care nurses are asked to witness the consent
process for procedures and tests. Critical care nurses should serve as advocates for
the patient and ensure that the informed consent process has been completed per
legal standards and institutional policy. Critical care nurses may provide additional
patient education to support decision making, but the process of obtaining informed
consent is a physician obligation.
Decisions Regarding Life-Sustaining Treatment
- Care of persons who are terminally ill or in a persistent vegetative state raises profound
questions about the constitutional rights of persons or surrogates to make decisions
related to death or life-sustaining care, as well as the rights of the state to intervene in
treatment decisions.
1. Cardiopulmonary Resuscitation Decisions
- The goals of emergency cardiovascular care are to preserve life, restore health, relieve
suffering, limit disability, and reverse clinical death. Frequently, ethical questions arise
about the use of CPR and emergency cardiac care because such treatment may conflict
with a patient’s desires or best interests. The critical care nurse should be guided by
scientifically proven data, patient preferences, and ethical and cultural norms.
- The American Heart Association has developed guidelines to assist practitioners in
making the difficult decision to provide or withhold emergency cardiovascular care.
The generally accepted position is that resuscitation should cease if the physician
determines that efforts are futile or hopeless. Futility constitutes sufficient reason for
either withholding or ceasing extraordinary treatments.
- Withholding or stopping extraordinary resuscitation efforts is ethically and legally
appropriate if patients or surrogates have previously made their preferences known
through advance directives. It is also acceptable if the physician determines that
resuscitation is futile or has discussed the situation with the patient, family, and/or
surrogate as appropriate, and there is mutual agreement not to resuscitate in the event
of cardiopulmonary arrest. For the nurse not to initiate the resuscitation, a do not
resuscitate (DNR) order must be written. Most physicians also write supporting
documentation regarding the order in the progress notes, such as conversations held
with the patient and family members.

18. 2. Withholding or Withdrawing Life Support
- Withholding life support, withdrawing life support, or both, can range from not
initiating hemodialysis (withholding) to terminal weaning from mechanical ventilation
(withdrawing). Decisions are made based on consideration of all factors in the ethical
decision-making model. In all instances of withholding and withdrawing life support,
comfort measures are maintained, including management of pain, pulmonary
secretions, and other symptoms as needed.
- Most decisions regarding withdrawing and withholding of life support are not made in
the courts. They are made based on open communication with the patient, family, and
surrogate, as appropriate. An ethical decision-making approach is used to decide on the
best actions to take or not take in the situation. If ethical or legal questions arise, ethics
consultation services, ethics committees, and risk managers can provide assistance. The
value of clearly stating in writing one’s end-of-life issues before becoming critically ill
(advance directive) is key to avoiding having treatment given or not given against one’s
wishes.
End-of-Life Issues
Patient Self-Determination
Act In response to public concern about end-of-life decisions and the overall lack of
consistent hospital policies, the United States Congress enacted the Patient Self-Determination.
This act requires that all healthcare facilities that receive Medicare and Medicaid funding inform
their patients about their right to initiate an advance directive and the right to consent to or refuse
medical treatment.
Discussions regarding advance directives and end-of-life wishes should be made as early
as possible, preferably before death is imminent. The ideal time to discuss advance directives is
when a person is relatively healthy, not in the critical care or hospital setting. This allows more
time for discussion, processing, and decision making. Nurses in every practice setting should
assess patients regarding their perceptions of quality of life and end-of-life wishes in a caring and
culturally sensitive way, and should document the patient’s wishes. Patients should be strongly
encouraged to complete advance directives, including living wills and durable power of attorney,
to ensure that their wishes will be followed if they are terminally ill or in a persistent vegetative
state.
Advance Directives
An advance directive is a communication that specifies a person’s preference about
medical treatment should that person become incapacitated. Several types of advance directives
exist, including DNR orders, allow-a-natural-death orders, living wills, health care proxies, and

19. other types of legal documents. It is important for nurses to know whether a patient has an advance
directive and that the directive be followed.
The living will provide a mechanism by which individuals can authorize the withholding
of specific treatments if they become incapacitated. Although living wills provide direction to
caregivers, in some states, living wills are not legally binding and are seen as advisory. When
completing a living will, individuals can add special instructions about end-of-life wishes.
Individuals can change their directive at any time.
The durable power of attorney for health care is more protective of patients’ interests
regarding medical treatment than is the living will. With a durable power of attorney for health
care, patients legally designate an agent whom they trust, such as a family member or friend, to
make decisions on their behalf should they become incapacitated. This person is called the health
care surrogate or proxy. A durable power of attorney for health care allows the surrogate to make
decisions whenever the patient is incapacitated, not just at the time of terminal illness. Some legal
commentators recommend the joint use of a living will and a durable power of attorney to give
added protection to a person’s preferences about medical treatment.
Ethical Concerns Surrounding Organ and Tissue Transplantation
Organ and tissue transplantation involve numerous and complex ethical issues. The first
consideration is given to the rights and privileges of all moral agents involved: the donor, the
recipient, the family or surrogate, and all other recipients and donors. Important ethical principles
that are useful in ethical decision-making regarding transplantation include respect for persons and
their autonomous choices, beneficence and non-maleficence, justice, and fidelity. Three of the
most controversial issues in transplantation are the moral value that should be placed on the human
body part, the just distribution of a human body part, and the complex problems inherent in
applying the concept of brain death to clinical situations.
TRIAGING
TRIAGE
- Triage means sorting the patients to determine which patients need specialized care for
actual or potential injuries.
- is the process of sorting patients as they present to the ED for care. The triage nurse must
quickly identify those patients who need to be seen immediately and those patients who
are safe to wait for care. This important decision needs to be based on a brief patient
assessment that enables the triage nurse to assign an acuity rating.
- Trauma is classified as minor or major depending on the severity of injury.
o Minor trauma refers to a single-system injury that does not pose a threat to life or
limb and can be appropriately treated in a basic emergency facility.

20. o Major trauma refers to serious multiple-system injuries that require immediate
intervention to prevent disability, loss of limb, or death
- Based on the emergency provider’s assessment, the patient is categorized, by color, as to
the type of care needed:
1) red indicates emergent, life-threatening injuries;
2) yellow means urgent major illness requiring care within an hour;
3) green indicates non urgent injuries that the patient can self-treat; and
4) black signifies the patient is dead or near death.
- Patients receive treatment based on the assessment of greatest chances for survival matched
to resources available for medical intervention.
STEPS OF TRIAGING:
Once the trauma patient has arrived, the primary RN and trauma team listen to the report
from the EMS professionals as they begin the triage process. EMS professionals will include time
of injury, mechanism of injury, vital patient assessment information, and interventions
implemented. In addition, prior medical history, information about allergies, and medication lists
may be obtained to improve individualized care.
The core steps in management of all trauma patients have two components: the primary
and secondary surveys. The first step in the management of all trauma patients is the primary
survey.
During each assessment step, the appropriate intervention is implemented prior to
continuing the assessment.
The primary survey consists of:
A. Airway and cervical spine immobilization
 The airway is assessed first; simply asking a patient her name will indicate if she
can speak.
o If the airway is not patent, it is opened while maintaining cervical
precautions.
 The cervical spine should be stabilized by being manually held until
a hard cervical collar is placed
 Once the mouth is open, the nurse assesses it for loose teeth, foreign objects,
swelling, vomitus, or blood. The team also assesses the trauma patient for the
following conditions that indicate that the patient’s airway may be in jeopardy:
apnea, a Glasgow Score less than 8, or injuries near the mouth, face, neck, and
thoracic cavity.

21.  If the airway is compromised, or the injury will increase the difficulty of
maintaining an open airway, the team may decide to intubate, placing an
endotracheal tube in the airway to administer oxygen in a controlled manner.
 Until the patient is ready to be intubated, oxygen is administered via non-rebreather
mask, or manual ventilation via a bag/valve mask may be utilized.
 Rapid Sequence Intubation (RSI) is a method of preparing and administering
medications in a specific order to prepare the patient for intubation.
o It is designed to promote patient comfort and enhance ease of intubation.
o Medications are administered in the following order: anesthetizing agents
(short half-life), depolarizing or re-polarizing agents, and long-term
anesthetic agents with pain management.
B. Breathing
 The key to trauma management is to address the issue interfering with effective breathing
prior to continuing the algorithm.
 Breathing assessment begins with determining if the patient is breathing spontaneously.
o If breathing is present, is it effective?
 The nurse should visually assess for symmetrical chest rise and fall as well
as the rate and depth of ventilation.
o If breathing is ineffective, even in severe chest wall injuries, noninvasive
ventilation has been shown to be effective
o If breathing is absent or noninvasive ventilation is ineffective, immediate intubation
is indicated.
 Continuing the assessment, the nurse auscultates lung sounds and notes the depth of
respirations, presence of adventitious sounds, and symmetry of sounds.
o The nurse then assesses the work of breathing: Is the patient using accessory
muscles and/or abdominal muscles?
o What position facilitates the patient’s breathing?
o When the nurse observes the patient’s neck, he should identify if the jugular veins
are distended and the position of the patient’s trachea.
 All of this information contributes to a thorough breathing assessment. The patient’s
oxygen saturation and ABGs should be monitored because thoracic trauma often results in
hypoxia, hypercarbia, and acidosis.
C. Circulation
- The circulation assessment includes:
o Observing the patient’s central and peripheral color.
o Palpating for carotid, brachial, radial, femoral, popliteal, and pedal pulses
o The central pulses (carotid and femoral) are palpated first. If the patient exhibits
these pulses, then his systolic blood pressure is usually at least 60 to 80 mmHg

22. systolic. If the patient has more peripheral pulses, such as radial and pedal, the
blood pressure is usually higher than 80.
o The nurse notes the quality and rate of the pulse, the skin color of the patient, and
the temperature and degrees of diaphoresis.
o The patient is inspected for any external bleeding and whether or not it is controlled
or needs external pressure.
o A blood pressure may be obtained manually, especially if pulses are weak or not
palpable.
o The nurse inspects the neck veins for distention or collapse and auscultates for
heart sounds.
- Nursing Actions
o A lack of pulse should be confirmed then immediately responded to with CPR and
resuscitation efforts.
o Any bleeding that is not controlled should have pressure applied at the bleeding
site. The extremity is elevated, if possible, and pressure is applied to the arterial
pressure point medial to the injury.
o Two large-bore intravenous catheters (size 14 gauge or 16 gauge) are started with
infusions of an isotonic solution.
 If intravenous access cannot be obtained rapidly, then an intraosseous
needle may be inserted.
 Intraosseous infusion (IO) is the process of administering medications and
other solutions into a catheter placed directly into the bone marrow (2
Figure 9-9). An intraosseous needle allows for immediate volume
replacement since it can usually be inserted in less than 1 minute.
D. Disability
- A brief neurological assessment is necessary to determine level of consciousness.
- it is important to assess the pupils for size, shape, equality, and reactivity to light.
- The AVPU scale is a mnemonic used to rapidly determine level of consciousness.
- The patient is assigned a value based on his response when the nurse speaks to him. He
receives a(n):
o A—if he responds to verbal stimuli and is alert,
o V—if he responds to verbal stimuli,
o P—if he does not respond to a verbal stimulus but does respond to painful stimuli,
o U—if he is unresponsive and does not respond to any stimulus.
- it is important to continue to monitor the patient’s ABCs.
- If the patient is unresponsive or has a decreased level of consciousness, the nurse should
conduct a further investigation during the secondary assessment to attempt to find the cause
for the decreased level of consciousness.

23. - If the patient exhibits active signs and symptoms of brain herniation or one pupil is
suddenly dilated, the nurse might consider hyperventilating the patient while awaiting
further treatment.
- In addition, the nurse rapidly assesses the patient for spontaneous movement of the
extremities.
- If the patient is awake and responsive, the presence of paraplegia or quadriplegia usually
indicates spinal cord injury.
E. Expose
- Expose the patient to assess for any unseen injuries. E also stands for environment; keep
the patient covered to prevent heat loss.
- The trauma patient is prone to hypothermia due to the clothing being removed, blood and
body fluids on the skin, and the uncovering of the patient for assessment.
- Hypothermia must be prevented—or reversed, if present.
o The temperature of the trauma room should have been increased to 99°F upon
notification from EMS of the trauma patient’s arrival.
- The nurse should consider using a Bair hugger, a device that forces warm air into an
inflatable mattress placed over the patient to warm the body and that warms the fluids
administered to the patient.
- The patient should be kept dry and breezes in the room avoided.
- The abdominal cavity may be assessed during the secondary survey either as part of E,
exposure, or H, head-to-toe assessment.
o Abdominal assessment is essential because unrecognized abdominal injury can
cause preventable death.
o Therefore, the nurse carefully assesses for blood loss, absent bowel sounds,
abdominal tenderness, and specific patterns of pain that are linked to the various
abdominal injuries.
This format of assessment is ongoing throughout patient care, ensuring that the priorities of
assessment and continuous intervention are effective.
The secondary survey consists of:
F. Full set of vital signs
- F represents ascertaining a record of a full set of vital signs including temperature (and if
there is chest trauma, the blood pressure should be taken in both arms).
- Family reassurance and presence also falls under the letter F.
G. Give comfort measures
- When a trauma patient arrives in the ED, analgesics are usually delayed until the patient
has been assessed (pain management falls under G in the ABCs).

24. - Once the patient has been assessed and is stabilized, many institutions recommend the use
of IV fentanyl in incremental doses to manage the pain.
- As pain medication is provided, the nurse must closely assess the patient’s RR and pattern
as well as the patient’s blood pressure.
o However, if the patient is unstable, pain management must be provided very
carefully and often is delayed until the patient has stabilized.
- In trauma situations, Morse and Proctor have found that nurses can effectively comfort
their patients in three ways:
1. By retaining contact with the patient, usually a firm palmar touch that reassures the
patient that someone is there
2. By assuming an “en face” position—looking directly into the patient’s eyes and
demanding the patient’s attention
3. By using comfort talk—short rhythmic phrases that are addressed clearly to the patient;
some are clearly comforting (such as “We’re almost done”) whereas others are clearly
directive (such as “Lie still and we’ll be done soon”)
H. History and head to toe assessment
- The healthcare team must obtain information about the nature of the traumatic injury as
well as the patient’s health history. In order to provide appropriate care, the nurse might
consider the following questions:
o What is the mechanism of injury?
o What are the injuries, general condition of the patient, and the level of
consciousness?
o What were the vital signs prior to arrival at the accepting facility?
o What initial treatments did the patient receive and how did the patient respond?
o What is the patient’s past medical history?
I. Inspect posterior surfaces
- Most patients will arrive on a long backboard. It is important to log roll the patient and
inspect the posterior surfaces, controlling any bleeding and documenting findings.
After completion of the primary and secondary surveys, the trauma patient is stabilized then
admitted to the hospital or transferred to another facility better equipped to manage the patient’s
specific traumatic injuries and needs.

25. TYPES OF TRIAGE
The most common types of triage include ED triage, inpatient (ICU) triage, incident
(multicasualty) triage, military (battlefield) triage, and disaster (mass casualty) triage.
o ED TRIAGE - ED triage systems are typically designed to identify the most urgent (or
potentially most serious) cases to ensure that they receive priority treatment, followed by
the less urgent cases on a first-come, first-served basis. In routine ED triage, resources are
available to treat every patient, although those who are less severely ill or injured must wait
longer. Some patients choose to leave the ED rather than continue waiting for treatment.
o ICU TRIAGE- When a patient requires hospitalization, additional decisions must be made
about what level of hospital care the patient should receive. In the optimal situation with
abundant hospital resources, the patient can immediately receive any and all services that
reason suggests may be beneficial. In the more common situation of relative scarcity of at
least some hospital based resources, decisions must be made about who will receive
priority access to those services. If these decisions are based on assessment of the patient’s
condition and are made according to some system or plan, they are triage decisions. The
most common inpatient triage decisions in US hospitals involve access to intensive care.
o INCIDENT TRIAGE - This type of triage is designed to respond to an incident that
creates multiple casualties, as, for example, a multiple-motor vehicle crash, a major
residential fire, or a commercial airliner crash. In such events, many injured patients,
including some with severe injuries, place significant stress on, but typically do not
overwhelm, a local emergency medical system. Emergency caregivers at the scene and in
the ED triage patients to identify the most critically injured for priority transportation and
treatment.
o MILITARY TRIAGE - As noted, military physicians were the first to implement formal
systems of triage to determine treatment priorities for wounded soldiers. Military triage has
several distinctive features. The triage officers and treating professionals are typically
members of a military service, and the patients are usually, but not always, also military
personnel. As military personnel, these health care professionals and patients may have
obligations, allegiances, and expectations that are not shared by other healthcare
professionals or by the general public.
o DISASTER TRIAGE- In its policy titled “Disaster Medical Services,” the American
College of Emergency Physicians offers the following description of a medical disaster:
“A medical disaster occurs when the destructive effects of natural or man-made forces
overwhelm the ability of a given area or community to meet the demand for health care.”
As this description suggests, disaster triage can be roughly distinguished from incident
triage by the trigger event’s magnitude of destruction. Because a medical disaster creates

26. demands that overwhelm the capacity of the local health care system, at least some
demands cannot be satisfied, and triage can be used to determine who will receive treatment
and who will not.

27. References:
American Association of Critical-Care Nurses. AACN standards for establishing and sustaining
healthy work environments: a journey to excellence. American Journal of Critical Care.
2005; 14(3):187-197
Graham P. Critical care education: experience with a community based consortium approach.
Critical Care Nursing Quarterly. 2006; 29(3):207-217.
Farlex. (n.d.). Triaging. The Free Dictionary. Retrieved from
https://www.thefreedictionary.com/triaging
Iserson, K. V., & Moskop, J. C. (2007). Triage in medicine, part I: Concept, history, and types.
Annals of Emergency Medicine, 49(3), 275–281.
https://doi.org/10.1016/j.annemergmed.2006.05.019
Kagan, J. (2022, May 11). What is triage? Investopedia. Retrieved September 11, 2022, from
https://www.investopedia.com/terms/t/triage.asp
Perrin, K. O., & MacLeod, C. E. (2018). Understanding the essentials of critical care nursing.
Pearson.
Sole et al., 2011, Introduction to Critical Care Nursing, Sixth edition
Sole, M. L., Klein, D. G., & Moseley, M. J. (2021). Introduction to critical care nursing. Elsevier.