The document discusses various aspects of critical care nursing. It begins by defining a critical care unit as a facility equipped to provide life support treatment to critically ill patients. It describes the role of critical care nurses in monitoring patients on life support equipment. Key aspects of patient care discussed include feeding/fluids, analgesia, sedation, thromboembolism prophylaxis, head elevation, ulcer prophylaxis, glycemic control, spontaneous breathing trials, bowel care, indwelling catheter removal, and drug de-escalation. The document emphasizes the importance of these aspects of care and outlines the roles and responsibilities of nurses in ensuring patients receive appropriate treatment and monitoring.

1. FAST HUGS BID
By PINKY RATHEE
M.Sc. Nursing

2. Critical care unit
 Critical care unit is defined as specially designed and equipped facility,
staffed by skilled personnel to provide effective and safe care for
patients with life threatening or potentially life threatening health
problems.

3.  Using advanced therapeutic, monitoring and diagnostic technology,
the objective of critical care is to maintain organ system functioning
and improve the patient’s condition such that his or her underlying
injury or illness can then be treated.

4.  A critical care unit is a continuously busy ward in which critically ill
patients are on life support treatment under intensive monitoring.
Doctors, nurses and technicians vigilantly work on the patients and
handle the life support equipment, pipeline and monitors.

5. Critically ill patients
 Critically ill patient has life threatening or potentially life threatening
health problems that requires continuous monitoring and intervention
to prevent complication and to restore health.

6. This could be as a result of injury or surgery or disease leading
to a single or multiple organ failure. They include patients in:-
Haemorrhage Shock

7. Complications of surgery, those requiring specialized care
and monitoring after major surgical procedures:-
Coma Heart attack
Acute
Respiratory
Problems

8. Critical Care Nursing
 Critical care nursing is the field of
nursing with a focus on the
utmost care of the critically ill or
unstable patients following
extensive injury, surgery or life
threatening diseases. These
specialists generally take care of
critically ill patients who require
mechanical ventilation by way of
endotracheal intubation.

9. Critical care nurses can be found working in a wide variety
of environments and specialties, such as:-
 General intensive care units
 Medical intensive care units
 Surgical intensive care units
 Trauma intensive care units
 Cardiothoracic intensive care units
 Coronary care units
 Burns unit
 Pediatrics and some trauma centre emergency departments.

10.  In the intensive care unit patients are constantly looked after and
monitored by skilful team, which includes consultants,
physiotherapists, dieticians and nurses, each of them with
specialized knowledge and skills.

11. ICU nurses play a vital role in the patient’s care, including
the following:-
 Monitoring of regular laboratory investigations.
 Changing the patient’s treatment in line with test results.
 Giving the medications to the patient as per physicians order.
 Recording the patient’s vital signs.
 Suctioning with aseptic techniques.
 Changing patient’s position every 2 hourly to prevent bed sores.
 Giving oral care, eye care, nail care, foot care, hair care, back care
and sponge bath to the patient.
 Changing a patient’s surgical stockings, which help circulation when
he or she is inactive (lying still) for a long time.

12. Critical care unit admission criteria
 Respiratory arrest
 Respiratory rate >25 or
<8/min.
 Oxygen saturation <90%
despite oxygen
administration.
Respiratory System

13. Cardiac System
 Cardiac arrest
 Heart rate >125 or <50 beats/min.
 Systolic blood pressure <90 or
>200mmHg, or a sustained fall of
more than 40mmHg from the
patient’s normal value.

14. Neurology
 Fall of Glasgow Coma Scale
score >2 points.
 Sustained alteration or sudden
fall in level of consciousness.
 Patient looks unwell.
Urology
Urine output <50 ml total over 4 hours.

15. Priority of care
 The ABCDE approach is used in
assessing and treating all critically ill
patients.
 Follow a systematic approach, based on
Circulation, Airway, Breathing, Disability
and Exposure (CABDE) to assess and
treat the critically ill patient in circulatory
compromised state.

16. Undertake a complete initial assessment; reassess
regularly.
Always treat life-threatening problems first, before
proceeding to the next part of the assessment.
Always evaluate the effects of treatment or other
interventions.
Recognize the circumstances when additional help
is required; request it early and utilize all members
of the multidisciplinary team. This will enable
assessment, monitoring, intravenous (IV) access,
etc. to be undertaken simultaneously.

17. FAST HUGS BID
F - Feeding/fluids
A - Analgesia
S - Sedation
T - Thromboprophylaxis
H - Head up position
U - Ulcer prophylaxis
G - Glycemic control
S - Spontaneous breathing trial
B - Bowel care
I - Indwelling catheter removal
D - Drug de-escalation

18. FAST HUGS BID
 FAST HUGS BID principle followed for care of
critically ill patients, as checklist is a simple
strategy which is used for identifying and
checking the significant aspects in the general
care of ICU patients.
 It is a systematic approach to patient cares which is used repeatedly
throughout work shifts and prevent errors of omission in basic domains
of intensive care unit management that might otherwise be forgotten in
the setting of more urgent care requirements.

19. Need of FAST HUGS BID principle:-
 Improves quality of patient care.
 Increases safety and efficacy of patient’s
care.
 Improves quality of care, helps not to forget
general aspects of patients care.
 it encourages teamwork.

20.  It helps in preparation for patient rounds,
helps to prevent and identify medication
errors, and promote patient safety.

21.  F - Feeding/fluids
 A - Analgesia
 S - Sedation
 T - Thromboprophylaxis
 H - Head up position
 U - Ulcer prophylaxis
 G - Glycemic control
 S - Spontaneous breathing trial
 B - Bowel care
 I - Indwelling catheter removal
 D - Drug de-escalation
 F - Feeding/fluids
 A - Analgesia
 S - Sensorium
 T - Thromboprophylaxis.
 H - Head up position
 U - Ulcer prophylaxis
 G - Glycemic control
 S - Supplement O2
 B - Bowel care
 I - Indwelling catheter removal
 D - Drug de-escalation
Medical intensive care unit Surgical intensive care unit

22. FEEDING/FLUIDS
ISSUES-
 Malnutrition can lead to impaired immune function
leading to-
Increased
susceptibility to
infection,
Poor wound
healing, loss of
muscle mass,
Bacterial
overgrowth in the
GI tract,
Increased chances
for decubitus
ulcers and
Prolonged ICU
and hospital
length of stay.

23. NEED- to meet the nutritive demands of the patients of ICU.
Two methods are available for ensuring adequate nutritional intake these
are enteral or parental nutrition.
 Initial oral or enteral feeding
(preferred to parenteral
feedings) as soon as possible,
typically within the first 24-48
hours after stabilization. Enteral
feeding options include
nasogastric or orogastric tubes
(NG/OG).
 Parenteral nutrition should be
considered if a patient has not
been able to receive enteral
nutrition for at least 7 days.
Parental nutrition can be delivered
via central venous access using
Total Parental Nutrition solutions
(TPN). Fast I/V infusion of TPN can
lead to hyperglycemia.

24. NURSES ROLE-
Can the patient be fed-
 Does the patient require further resuscitation or procedures?
Routes (if the gut works, use it)
 Oral- Is a diet ordered?
 Tube feeding- Are tube feeds continuous or intermittent?
 Intravenous- Does the patient have a central line?
What nutrient contributions are coming from medications?
 Medications in 5% Dextrose I/V fluid.
 Lipid containing medications (propofol).

25. ANALGESIA
ISSUES-
 Excessive analgesia should be avoided because it can lead to
complications such as prolonged endotracheal intubation.

26. NEED- ANALGESIA AND SEDATION ADMINISTRATION OPTIMIZES PATIENT
COMFORT AND MINIMIZES THE ACUTE STRESS RESPONSE
(HYPERMETABOLISM, INCREASED OXYGEN CONSUMPTION).CRITICALLY ILL
PATIENTS FEEL PAIN FROM-
Illness
Devices
(endotracheal tube,
lines etc.)
Procedures
(turning,
suctioning, and
dressing changes)

27. NURSES ROLE-
Pain should be assessed regularly with-
 Visual Analogue Scale (VAS),
 Critical Care Pain Observation Tool (CCPOT)
 When the patient is unable to co-ordinate the Patient controlled
analgesia (PCA) mechanism, bolus analgesia should be
administered by the nursing staff, titrated to the patients request for
pain relief. In exceptional circumstances an infusion of narcotic can
be used as per physician’s order.
 Pre-elective analgesia should be considered for invasive or
potentially painful clinical procedures.

30. SEDATION
ISSUES- Adverse effects associated with over-sedating a patient:-
Respiratory
depression and
Hypotension
Prolonged ventilation
and associated risk of
nosocomial infection.
Prolonged stay with
unnecessary use of
resource, and
increased risk of
complications.

31. NEED- Sedation in critically ill patients is principally used to-
Control
agitation to
enable
effective care.
Facilitate
ventilation or
minimise
patient-
ventilator dys-
synchrony.
Prevent
accidental
extubation or
removal of
vascular
access
catheters.
Control intra-
cranial
pressure &
reduce
metabolic rate
(oxygen
consumption).

32. NURSES ROLE
 Ensure intubated patients have
adequate depth of sedation
with calm, comfortable and
collaborative level.
 Evaluate depth of sedation- by
Glasgow Coma Scale (GCS).
 Richmond Agitation and
Sedation Scale (RASS) for
intubated patients

34. THROMBOEMBOLISM PROPHYLAXIS
ISSUES- prolonged stay of intubated or bed
ridden patients in ICU can leads to
thromboembolism.
 If a clot were to “embolize,” this means it
has- Broken loose.

35. NEED- Due to the life-threatening nature of deep vein
thrombosis (DVT) and pulmonary embolism (PE),
thromboembolism prophylaxis should be implemented as soon
as possible within the first 24 hours following admission as it
increases the risk of venous thromboembolism (VTE).

36. NURSES ROLE
 Should heparin be held for a procedure?
 Are serial assessments of appropriate hematology labs being done?
 Ensure all patients have appropriate thromboembolic prophylactic agents
unless contraindicated.
 Graduated compression stockings or intermittent pneumatic compression
devices (IPC).
 Thigh length elasticised compression stockings (ECS)
 Sequential compression devices (SCD)
 Pharmacological agents such as: Clexane, Low dose Heparin.
 Many neurosurgeons and neurocritical care specialists prefer the subclavian
vein over the Internal Jugular vein due to the lower risk of CVC-associated
thrombosis, which carries an additional and unnecessary risk in a patient
with increased intracranial pressure (ICP).

37. HEAD OF BED ELEVATION
ISSUES- aspiration, Ventilator Associated Pneumonia (VAP).
NEED- Elevating the head of bed to 30-45 degree angle reduces the
occurrence of gastro-intestinal reflux, prevents chances of aspiration during
enteral feeding and nosocomial pneumonia in mechanically ventilated
patients or Ventilator Associated Pneumonia (VAP).

38. Nosocomial infection is also called Hospital Acquired
Infection, can be defined as the infection which appears
after 48 hours or more within 30 days of discharge.
NURSES ROLE-Ensuring head of bed is elevated at least 30 to 45
degree (head injured patients should have HOB elevated to 30° as
tolerated), unless it is contraindicated.

39. ULCER PROPHYLAXIS
ISSUES- Critically ill patients develop stress related mucosal damage,
potentially leading to clinically significant bleeding. Incidence of overt
gastrointestinal bleeding ranges from 1.5 to 8.5% and may reach 15%
in patients without prophylaxis.

40. NURSES ROLE-
Ensure patient is receiving a form of stress ulcer prophylaxis (histamine-2
receptor blockers, proton pump inhibitors, sucralfate).
NEED-to prevent gastrointestinal bleeding and to prevent stress ulcers in ICU
patients.
American Society of Health System Pharmacists recommended criteria-
Major criteria
•Mechanical ventilator >48 hours & Prior ulcer
•Coagulopathy (platelets<50,000 , INR>1.5, PTT>2min.)
•Traumatic brain injury, spinal cord or burn injury.
Minor criteria
•Sepsis
•More than 1 week stay in an intensive care unit (ICU).
•Occult GI bleeding for 6 or more days.
•Glucocorticoid therapy
•Others– organ transplant or failure, anticoagulant & antiplatelet therapy.

41. GLYCAEMIC CONTROL
ISSUES- Insulin deficiency is associated with Diabetic
ketoacidosis. Hyperglycemia and hypoglycemia can
increase mortality, length of stay, and infection in ICU
patients.
Decreased wound healing
Increased infection risk
Increased risk of
polyneuropathy
NEED- Glycemic control is
necessary in critically ill
patients to decrease the
incidence of complications
such as:-

42. NURSES ROLE- Ensure adequate pharmacologic
glucose control. When blood glucose levels are
150mg/dl or greater, continuous insulin infusions to
maintain blood glucose between 140 and 180 mg/dl
should be considered in the acutely ill patient.
Are glucose levels at goal? (MICU patients
goals <180mg/dl)
Prior history of diabetes (Type I, Type II)
Evaluate change in diet; will insulin need to
be modified?

43. Spontaneous Breathing Trial/
Supplement Oxygen
ISSUES- prolonged days of intubated patients.
NEED- An artificial airway, an endotracheal tube, is used
in Positive Pressure type of ventilation. Patients who is
intubated and on endotracheal tube or tracheostomy
tube, spontaneous breathing trial by putting the patient
on Synchronized Intermittent Mandatory Ventilator
(SIMV) mode for weaning procedure, reduces
prolonged length of ICU stay. When patient need
further ventilator care or if planned for extubation, a trial
of TP’s is given before weaning.

44. NURSES ROLE-
 Monitor saturation level of patients and assess for signs of cyanosis.
 Oxygen support by face mask/nasal prongs according to the saturation
of oxygen of patient.

45. Bowel Care
ISSUES-
 Diarrhea can lead to electrolyte imbalances,
dehydration, hemorrhoidal irritation with
resultant anemia and delirium.
 Constipation can lead to patient discomfort,
feeding intolerance, and delirium.
NEED- Evaluation and maintenance of appropriate bowel function is
necessary to prevent further complications.
 Optimal bowel care regimen is recommended for the wellbeing of the
patient.

46. NURSES ROLE-
 Expose and observe the abdomen, look for distension
 Auscultate for presence of bowel sounds - if present, note pitch.
 Palpate for tenderness, tightness/rigidity
 Document passing flatus, bowels open and quantity/nature of faeces.
Inform the ICU Medical Officer if there
are any of the following signs:
 Increasing tenderness, distension/
rigidity.
 Decreased/ high pitch bowel sounds
or absent sounds.
 Blood or mucous present in stool.

47. Indwelling Catheter Removal
ISSUES- Nosocomial infections or complications like-
CAUTI- Catheter
Associated
Urinary Tract
Infection
CLABSI- Central
Line Association
Bloodstream
Infection.

48. NEED- Removal of Foleys cath, periphery inserted central catheter
(PICC), CVC- central venous catheter, Arterial line, epidural, Foleys), as
soon as possible is recommended to prevent Nosocomial infections.
NURSES ROLE-
Day of indwelling catheter should be checked to prevent nosocomial
infection. Site should be assessed for any abnormal sign like redness,
swelling etc. Foleys catheter should be changed after 7 days.

49. Drug De-Escalation
NEED- De-escalation therapy is defined as changing from the broad
spectrum antibiotic to an agent with a narrow focus based on culture
data; changing the focus from multiple antibiotics to a single drug
when the suspected organism is detected by culture to reduce
overload of antibiotics dosages.
ISSUES- higher amount of dose, and
antibiotic usage.

50. NURSES ROLE-
 Watching out for
discontinuation of antibiotics
or changing into a less
narrow spectrum antibiotics is
of utmost importance
because as antibiotics use
promotes development of
resistance.

51. Conclusion
FAST HUGS BID principle followed for care of critically ill patients, as
checklist is a simple strategy which is used for identifying and checking
the significant aspects in the general care of ICU patients.
It encourages teamwork and help in improving the quality of care
received by ICU patients.
It ensures safe, effective and efficient care.
It provides structure to important ICU- related interventions in an
effort to reduce errors of omission and increase compliance with
evidence-based practices to improve outcomes of effective nursing
care.