Basic Principles of Critical Care

1. TOTAL NURSING CARE
Gradian Health Systems
Basic Principles of Critical Care
BASIC PRINCIPLES OF CRITICAL CARE

2. Disclaimer
Basic Principles of Critical Care Training I Total Nursing Care
Disclaimer: Gradian Health Systems cannot provide formal recommendations or indications
regarding medical care and clinical service delivery. The tables, checklists, and other clinical
documents referenced in this training have not been validated in all settings. These documents are
intended to serve as examples only. We recognize that all clinical training content and activities
must be customized to meet the needs of each facility and its clinical staff, factoring in available
resources, practitioner skill level, and other environmental considerations.
For any questions regarding the contents or applications of this training,
please contact Gradian Health Systems:
40 W 25th St, 6th Floor
New York, NY 10010 USA
+1 212-537-0340
training@gradianhealth.org

3. Module 1
Gradian Health Systems
Basics Principles of Critical Care
Basic Principles of Critical Care

4. Module 1: Basic Principles of Critical Care
MODULE OVERVIEW
Lesson 1 I Introduction to ICUs
Lesson 2 I Pain Management and Sedation
Lesson 3 I ICU Admission and Discharge
Lesson 4 I Infection Prevention and Control
Lesson 5 I Total Nursing Care
Basic Principles of Critical Care Training I Total Nursing Care

5. Components of the Gradian CCV SystemLesson 5: Total Nursing Care
Lesson Objectives
• Explain the concept of total nursing care (TNC)
• Establish the role of the nurse in the ICU admission process
Basic Principles of Critical Care Training I Total Nursing Care

6. Components of the Gradian CCV SystemLesson 5: Total Nursing Care
Key Concepts
• Total nursing care
• Patient assessment
Basic Principles of Critical Care Training I Total Nursing Care

7. Components of the Gradian CCV SystemTotal Nursing Care
Introduction
Patients admitted to the ICU have life-threatening illnesses requiring a range of
high-level interventions. Responses to that treatment can be unpredictable.
Within this context of intensive care, the nursing contribution involves:
• Meticulous observation and skilled intervention
• Provision of basic hygiene, nutrition and prevention of harm,
• Provision of emotional and psychological support to patients and families
Basic Principles of Critical Care Training I Total Nursing Care

8. Components of the Gradian CCV SystemTotal Nursing Care
Planning Patient Care
Nurses are responsible for planning patient care, which involves:
• Organizing the patient’s problem, setting priorities, and finding out actual and
potential problems or risk factors
• Developing nursing care plans
• Essential Nursing Care
• Personal hygiene
Basic Principles of Critical Care Training I Total Nursing Care

9. Components of the Gradian CCV SystemTotal Nursing Care
Planning Patient Care
Eye care
Necessary if the patient is unconscious:
• Use artificial tears
• Instill lubricating drops or ointment and close the eyelids with tape to prevent
corneal ulceration
• Raise the head of the bed to reduce scleral edema (common in ventilated
patients)
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10. Components of the Gradian CCV SystemTotal Nursing Care
Planning Patient Care
Oral care
• Perform regular oral hygiene (every 8 hours) to prevent infection
• Establish a scheduled, regular oral car regimen
• Remove plaque and cleanse mouth without causing pain / irritation
• Use non-alcohol-based mouthwash (e.g. chlorohexidine-based
mouthwash), hydrogen peroxide, or other antibacterial or antifungal
mouthwashes, as compatible with patient condition
• Should not cause pain due to additives for flavor, alcohol, or strength
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11. Components of the Gradian CCV SystemTotal Nursing Care
Planning Patient Care
Skin care
• Turn the patient every 2 hours
• Use special mattress to prevent pressure sores
• Perform daily, complete bed baths (or whenever necessary)
• Keep clothes clean, dry, and unwrinkled
• Massage and lubricate the back and over bony prominences
Basic Principles of Critical Care Training I Total Nursing Care

12. Components of the Gradian CCV SystemTotal Nursing Care
Planning Patient Care
Nutrition and hydration status
• Nurses ensure the patient meets his/her energy requirements
• Metabolic needs in critically ill patients are much higher than normal – usually
increased by 25% for hospital activity and stress associated with treatment
• If gastrointestinal tract is intact, enteral nutrition is preferred and can be
provided through a feeding tube
• Many chronically ill patients, such as those with COPD, have long-standing
protein and calorie malnutrition, so initial tube feeding is started slowly
Basic Principles of Critical Care Training I Total Nursing Care

13. Components of the Gradian CCV SystemTotal Nursing Care
Planning Patient Care
Nutrition and hydration status
• Nurse observes the patient for signs of intolerance, such as diarrhea and
hyperosmolar dehydration
• If feedings tolerated, rate is gradually increased until desired rate is achieved
• If tube feedings cannot be tolerated, parenteral nutrition should be considered
• Provide the correct proportions of fats, CHO, proteins, and water through
enteral or parenteral routes
• Establish a regular bowel elimination pattern.
• Consult dietitian for metabolic needs and recommendations and administer
bowel regimen medications and adequate hydration, as ordered
Basic Principles of Critical Care Training I Total Nursing Care

14. Components of the Gradian CCV SystemTotal Nursing Care
Planning Patient Care
Promote comfort
Comfort needs include:
• Keeping the patient clean and dry
• Preventing urine scald and skin break down
• Seeing to the patient’s mental well-being
• Performing range of motion exercises
• Assessing for pain and providing proper pain management; nurse should
observe for signs associated with pain. Individually, these signs do not
indicate pain, but collectively and with recent patient history, a pain
assessment should be rendered. Provide analgesia, as appropriate, and
document efficacy after each dose.
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15. Components of the Gradian CCV SystemTotal Nursing Care
Planning Patient Care
Catheter care
• Common catheters: IV, urinary, chest tube, and gastric tube
• Nursing goal is to minimize risk of infection
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16. Components of the Gradian CCV SystemTotal Nursing Care
Planning Patient Care
IV catheter care
• Care should be performed every 48 hours, or as needed
• Catheter dressing should be removed, and the site inspected – look for signs
of phlebitis, infection, and or thrombosis
• When signs of phlebitis or thrombosis are apparent, catheter should be
removed and a new one placed at a different site
• If the catheter site looks good, then the site should be cleaned with an
iodophor or chlorhexidine solution
• When catheter site is dry, apply a small amount of Betadine or triple antibiotic
ointment to a sterile gauze pad
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17. Components of the Gradian CCV SystemTotal Nursing Care
Planning Patient Care
Urinary catheter care
• Care should be performed every 8 hours
• Includes cleaning the prepuce or vulva and surrounding area with Betadine
scrub and water rinse
• Catheter itself should be kept clean, especially in female patients where the
vulva is close to the rectum
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18. Components of the Gradian CCV SystemTotal Nursing Care
Planning Patient Care
Urinary catheter care
• Urinary catheter should be attached to a collection system
• By maintaining a closed collection system, you decrease the chance of a
urinary tract infection (UTI)
• Do not disconnect the urinary catheter from the collection system
• Drain the system every 2-4 hours rather than hourly
• Adding 3% hydrogen peroxide to the urinary collection system has been
shown to decrease the incidence of UTI; 5-10 mL of hydrogen peroxide are
added to the urinary collection system
Basic Principles of Critical Care Training I Total Nursing Care

19. Components of the Gradian CCV SystemTotal Nursing Care
Planning Patient Care
Facilitate communication
• Assess the patient's ability to communicate then ensure complete
explanations from staff members regarding any procedures to help decrease
the patient's stress
• Use verbal and nonverbal communication skills where nonverbal
communication may include sign language, gestures, or lip reading
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20. Components of the Gradian CCV SystemTotal Nursing Care
Planning Patient Care
Psychological support
• Before initiating any procedures, provide adequate information and
explanation
• Communicate with a caring and unhurried attitude
• Encourage visitor conversations with patients in a normal tone of voice and
subject matter
• Teach visitors to assist with range-of-motion and other simple care delivery
tasks to facilitate normal patterns of interaction
Basic Principles of Critical Care Training I Total Nursing Care

21. Components of the Gradian CCV SystemTotal Nursing Care
Planning Patient Care
Psychological support
• Familiarize the family with the physical surroundings of ICU
• Inform family of visiting hours and visitation policies
• Provide frequent progress reports about patient's condition
• Encourage family participation and involvement in patient care, when the
patient's condition allows, through guiding and observing the family while
participating in hygienic care, feeding, etc.
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22. Components of the Gradian CCV SystemTotal Nursing Care
Planning Patient Care
Patient evaluation
• As part of nursing care, nurse should constantly evaluate the patient's
condition
• Observe whether therapy is improving the patient's condition
• Observe and evaluate the nursing care plans
• Remember: "If you don't look, you won't see.”
Basic Principles of Critical Care Training I Total Nursing Care

23. Components of the Gradian CCV SystemTotal Nursing Care
Total Nursing Care (TNC)
Refers to providing wholly for the patient’s needs and includes:
• Safety checks
• Physical assessment
• Hemodynamic monitoring
• Breathing / ventilation
• Feeding
• Elimination
• Skin care and prevention of bed sores
• Care of invasive devices
• Psychological care
• Spiritual care
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24. Components of the Gradian CCV SystemTotal Nursing Care
Total Nursing Care
Safety checks
• Initial step of nursing care after handing over
• Activities that are carried out in the critical care setting to:
• Provide and maintain a safe environment
• Ensure availability of facilities to handle emergencies and ensure they
are ready for use
Sequence of safety checks – ABC
Basic Principles of Critical Care Training I Total Nursing Care

25. Components of the Gradian CCV SystemTotal Nursing Care
ABCs of Safety Checks
Airway
• Ensure airway is secure – tape, position, and cuff pressures
• Check oxygen delivery device – tracheostomy, ETT, etc.
• Oxygen delivery units should be complete (i.e., humidifiers w/ distilled water)
• If intubated, check the tube size and ensure it is secured
• Bacterial filter should be dated, changed daily and as needed
• Age specific airway adjuncts should be available (e.g. oral/ nasal airway -
appropriate size, catheter mount, etc.)
• Check that suction unit is working and suction tubing is protected
• Ensure appropriate suction catheters are by the bedside
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26. Components of the Gradian CCV SystemTotal Nursing Care
ABCs of Safety Checks
Breathing
• How is the breathing pattern?
• What is the rate?
• What is the mode of ventilation?
• What are the ventilator settings?
• What are the ventilator orders?
• Are the orders tallying with the actual settings on the vent?
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27. Components of the Gradian CCV SystemTotal Nursing Care
ABCs of Safety Checks
Circulation
• Check the heart rate and all invasive monitoring
• Ensure CVC and cannula dressings are labeled, dated, and signed
• Ensure all drips infusing are within time; all infusing drugs must be calculated
and tallied with order on treatment sheet
• All solutions by the bedside labeled, dated, and not expired; ensure no
unlabeled drugs by the bedside
• Sharps containers must not be more than ¾ full
• Any drugs by the bedside must have date, time of reconstitution, dose and
diluents amount.
• Check alarms; ensure alarm limits are set appropriately
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28. Components of the Gradian CCV SystemTotal Nursing Care
ABCs of Safety Checks
Alarms
• Help nurses stay informed of patient condition
• Can cause sleep deprivation, if not set appropriately, and can cause noise of
up to 80 decibels
• Source of stress for both staff and patients
• For a clinical alarm to be effective, it must be triggered by a problem which
adversely affects the patient
• Nurses must identify the source and meaning of the alarm and correct the
problem in time
• Studies show that up to 90% of all alarms in the ICU are false positive; rate of
significant alarms is as low as 10%
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29. Components of the Gradian CCV SystemTotal Nursing Care
ABCs of Safety Checks
Types of alarms
High Priority Alarms
Indicate a critical situation requiring immediate response
Medium Priority Alarms
Indicate a dangerous situation requiring urgent, but not immediate, response
Low Priority Alarms
Require attention but not immediately
Advisory Alarms
Indicate a technical problem (e.g. lead disconnection or patient syringe pump)
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30. Components of the Gradian CCV SystemTotal Nursing Care
Total Nursing Care
Physical assessment
The approach required to manage critically ill patients differs from that used in
less severely ill patients. For critically ill patients, immediate resuscitation and
stabilization of the patient’s condition takes precedence. Care is best determined
by using the nursing process where all steps and phases are adhered to. Patient
assessment and developing appropriate nursing diagnosis helps in planning
care. Making a diagnosis depends on history taking and physical examination.
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31. Components of the Gradian CCV SystemTotal Nursing Care
Total Nursing Care
Physical examination
• Part of a general health assessment
• Used to gather data about the patient
• Focuses on functional abilities and responses to illness / stressor
• Purpose:
• Establish baseline data
• Identify nursing diagnoses, collaborative problems, or wellness
diagnoses
• Monitor the status of an identified problem
• Screen for health problems
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32. Components of the Gradian CCV SystemTotal Nursing Care
Total Nursing Care
Physical examination types
Comprehensive
Interview plus complete head-to-toe examination
Focused
“Focused” on presenting problem
Ongoing
Performed as needed to assess status; evaluate patient outcomes
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33. Components of the Gradian CCV SystemTotal Nursing Care
Organizing the examination
Head-to-toe
• Starts at the head and progresses down the body
• System-related data found throughout
Body systems
• Gathers system-related data all at once
• May be done in a predetermined order that mimics head-to-toe
• Neurological
• Cardiovascular
• Respiratory
• Gastrointestinal
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34. Components of the Gradian CCV SystemTotal Nursing Care
Organizing the examination
Preparing yourself
• Theoretical knowledge
• Self-knowledge (skill and comfort level, willingness to seek help, etc.)
• Knowledge of patient situation (purpose of exam, patient diagnosis)
Preparing the environment
• Privacy is key (draping, use of curtains)
• Noise control (TV / radio off)
• Enable visualization (adequate lighting or flashlight, if needed)
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35. Components of the Gradian CCV SystemTotal Nursing Care
Organizing the examination
Preparing the patient
• Promote patient comfort:
• Develop rapport
• Explain the procedure
• Respect cultural differences
• Use proper positioning
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36. Components of the Gradian CCV SystemTotal Nursing Care
Physical Assessment Skills
There are four major skills needed:
• Inspection
• Palpation
• Percussion
• Auscultation
Inspection
• Use of sight to gather data
• Used throughout physical examination
• Tools to enhance inspection – otoscope, ophthalmoscope, penlight
• Examples: Skin color, gait, general appearance, behavior
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37. Components of the Gradian CCV SystemTotal Nursing Care
Physical Assessment Skills
Palpation
• Use of touch to gather data
• Begin with light pressure, moving to deep palpation
• Use caution with deep palpation
• Parts of the hands used:
• Fingertips: tactile discrimination
• Dorsum: temperature determination
• Palm: general area of pulsation
• Grasping (fingers and thumb): mass evaluation
• Examples: edema, moisture, anatomical landmarks, masses
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38. Components of the Gradian CCV SystemTotal Nursing Care
Physical Assessment Skills
Percussion
• Tapping on skin to elicit sound
• Useful for assessing abdomen, lungs, and underlying structures
• Examples: Distended bladder
Auscultation
• Use of hearing to gather assessment data
• Direct auscultation: listening without an instrument
• Indirect auscultation: use of a stethoscope to listen
• Diaphragm - high-pitched sounds; bell – low-pitched sounds
• Examples: heart sounds, lung sounds
Basic Principles of Critical Care Training I Total Nursing Care

39. Components of the Gradian CCV SystemTotal Nursing Care
Physical Assessment
Documentation
After a complete head to toe examination:
• Documents should be signed at the end of each entry (name, designation,
signature)
• All new entries should have patient’s names entered at the beginning
• Data should be comprehensive; targeting critical data
Basic Principles of Critical Care Training I Total Nursing Care

40. Components of the Gradian CCV SystemTotal Nursing Care
Physical Assessment
Documentation: Do’s and Don’t’s
• DO check that you have the correct chart before you begin writing
• DO make sure your documentation reflects the nursing process and your
professional capability
• DO write legibly
• DO chart the time you gave a medication, administration route and the
patient’s response
• DO record each phone call to a physician including the exact time, message
and response
• DO chart patient care at the time you provided it (e.g. urine output, PAC etc.)
Basic Principles of Critical Care Training I Total Nursing Care

41. Components of the Gradian CCV SystemTotal Nursing Care
Physical Assessment
Documentation: Do’s and Don’t’s
• DON’T chart a symptom without also charting what you did about it
• DON’T alter a patient’s record - this is a criminal offence
• DON’T use shorthand or abbreviations that aren’t widely accepted
• DON’T write imprecise descriptions such as ‘bed soaked’ or ‘large amount’
• DON’T chart what someone else heard, said, felt unless the information is
critical and in that case use quotations and attribute the remarks appropriately
• DON’T chart care ahead of time – something may happen, and you may be
not be able to give the care you’ve charted – charting care that you haven’t
done is considered fraud
Basic Principles of Critical Care Training I Total Nursing Care

42. Components of the Gradian CCV SystemTotal Nursing Care
Skin Care
General guidelines
Intact, healthy skin is the body’s first line of defense. Nurses need to ensure that
skin care measures prevent injury and irritation. Avoid jewelry, long sharp nails,
harsh rubbing, and use of rough towels.
The degree to which the skin protects the underlying tissues from injury depends
on the general health of the cells, the amount of subcutaneous tissue and the
dryness of the skin
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43. Components of the Gradian CCV SystemTotal Nursing Care
Skin Care
General guidelines
Moisture in contact with the skin for more than a short time can result in
increased bacterial growth and irritation:
• Dry the skin well – pay particular attention to the skin folds (axillae, groin,
beneath the breast and between toes)
• Body odors are caused by resident skin bacteria acting on body secretions –
cleanliness is the best deodorant
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44. Components of the Gradian CCV SystemTotal Nursing Care
Skin Care
General guidelines
Skin sensitivity to irritation and injury varies among individuals and in accordance
with their health:
• Nurses need to ascertain whether the client has any sensitivity and what
agents are appropriate to use
• Agents used for skin care have selective action and purposes (e.g. soap,
detergents, skin creams, lotion, powder, deodorant antiperspirant)
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45. Components of the Gradian CCV SystemTotal Nursing Care
Skin Care
Purpose of bathing
• Cleanliness of the skin
• Acts as skin conditioner
• Helps relax a restless person
• Promotes circulation by stimulating the skin’s peripheral nerves and
underlying tissues
• Stimulates rate and depth of respiration
• Promotes comfort through muscle relaxation and skin stimulation
• Improves self-image (grooming)
• Serves as musculoskeletal exercises
Basic Principles of Critical Care Training I Total Nursing Care

46. Components of the Gradian CCV SystemTotal Nursing Care
Skin Care
Categories of bathing
Cleaning bath
• Given purposely for hygiene purposes
• Water should be comfortable and feel comfortably warm to the client
• Water for should be changed when it becomes dirty or cold
Therapeutic bath
• Given for physical effects such as soothing irritated skin or treating an area
(e.g. perineum, burns)
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47. Components of the Gradian CCV SystemTotal Nursing Care
Hair Care
• Hair is exposed to dirt & oil as the skin
• Should be washed to keep it clean
Nail Care
• Nails continue to grow throughout life and change very little until people are
old
• Record and report any abnormality
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48. Components of the Gradian CCV SystemTotal Nursing Care
Oral Care
Patients’ oral care is key component of nursing care. It is central to patient’s
comfort and wellbeing. Effective mouth care can improve quality of life and
prevent serious infections:
• Perform oral care every 8 hours or as needed
• Wash hands and wear gloves
• Remove dentures to clean them
• Poor oral hygiene may:
• Affect communication, nutritional intake, and sense of taste
• Cause pain and infections
• Lead to unnecessary prolonged hospitalization
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49. Components of the Gradian CCV SystemTotal Nursing Care
Pressure Area Care
Prevention is key:
• Use of sheepskin
• Turn patient every 2 hours
• Massage pressure areas
• Use ripple mattress
• Use pillows
• Avoid folds on linen
• Avoid patient staying for long hours with soiled linen
• Provide appropriate nutrition
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50. Components of the Gradian CCV SystemTotal Nursing Care
Pressure Area Care: Waterlow Score
The Waterlow score gives an estimated risk for the development of a pressure
sore in a given patient. It was developed in 1985 by clinical nurse teacher Judy
Waterlow.
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51. Components of the Gradian CCV SystemTotal Nursing Care
Pressure Area Care: Waterlow Score
Basic Principles of Critical Care Training I Total Nursing Care

52. Components of the Gradian CCV SystemTotal Nursing Care
Pressure Area Care: Waterlow Score
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53. Components of the Gradian CCV SystemTotal Nursing Care
Care of Invasive Devices
A sample guide for the care of
invasive devices. Each
institution has its own
protocols.
Basic Principles of Critical Care Training I Total Nursing Care
Device Period of stay
ETT 14 days
Tracheostomy As per surgeon’s instructions
CVC 14 days
Arterial Line 14 days
Peripheral Line 3 days
NG Tube 14 days
Urinary Catheter (foleys) 14 days
Urinary catheter (silicon) 3 months
Giving set (blood) Single use
Giving set (fluids) 3 days
Humidifier 24 hours or as needed
Catheter mount 24 hours or as needed
Ventilator tubing 4 days or as needed
3-way stop cocks 3 days
Pressure monitoring lines 4 days
IV 3,000 dressings As needed
Suction bottle Contents should not exceed ¾ full

54. Components of the Gradian CCV SystemTotal Nursing Care
FASTHUGS BID
In 2005, Jean Louis Vincent popularized the FAST HUGS mnemonic for recalling
the key issues to review when looking after a critically ill patient. This was
subsequently updated to ‘FAST HUGS BID‘ by Vincent and Hatton:
“Give your patient a fast hug (at least) once a day”
Vincent JL Crit Care Med 2005
Basic Principles of Critical Care Training I Total Nursing Care
Vincent WR 3rd, Hatton KW. Critically ill patients need “FASTHUGS
BID” (an updated mnemonic). Crit Care Med. 2009 Jul;37(7):2326-7;

55. Components of the Gradian CCV SystemTotal Nursing Care
FASTHUGS BID
Feeding / fluids
Analgesia
Sedation
Thromboprophylaxis
Head up position
Ulcer prophylaxis
Glycemic control
Spontaneous breathing trial
Bowel care
Indwelling catheter removal
De-escalation of antibiotics
Basic Principles of Critical Care Training I Total Nursing Care
Vincent WR 3rd, Hatton KW. Critically ill patients need “FASTHUGS BID”
(an updated mnemonic). Crit Care Med. 2009 Jul;37(7):2326-7;

56. Components of the Gradian CCV SystemTotal Nursing Care
Other modifications: FAST HUGS IN BED Please
Fluid therapy and feeding
Analgesia, antiemetics and ADT (AAA)
Sedation and Spontaneous breathing trial
Thromboprophylaxis
Head up position (30 degrees) if intubated
Ulcer prophylaxis
Glucose control
Skin/ eye care and suctioning
Indwelling catheter
Nasogastric tube
Bowel cares
Environment (e.g. temperature control, appropriate surroundings in delirium)
De-escalation (e.g. end of life issues, treatments no longer needed)
Psychosocial support (for patient, family and staff)
Basic Principles of Critical Care Training I Total Nursing Care
FAST HUGS IN BED Please! • LITFL • CCC. Retrieved July
27, 2020, from https://litfl.com/fast-hugs-in-bed-please/

57. Components of the Gradian CCV SystemTotal Nursing Care
FAST HUG BID
A mental checklist that highlights key aspects in the general care of critically ill
patients. It is used in the ICU to aid healthcare professionals to:
• Prepare for patient rounds
• Help identify and prevent medication errors
• Promote patient safety
• Maximize therapeutic interventions
FAST HUG helps provide safe, efficient and effective care to ICU patients. It
allows ICU team members (i.e. physician, nurse, pharmacist, etc.) to prioritize
the vast amounts of available data that must be collected, organized, and
analyzed prior to patient care.
Basic Principles of Critical Care Training I Total Nursing Care