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1. critical care

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critical care nursing

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1. critical care

  1. 1. CRITICAL CARE NURSING 1
  2. 2. CRITICAL  Crucial  Crisis  Emergency  Serious  Requiring immediate action  Thorough and constant observation  Total dependent (Oxford Dictionary) 2Prof. Dr. R S Mehta, BPKIHS
  3. 3. CRITICAL CARE NURSING  The care of seriously ill clients from point of injury or illness until discharge from intensive care  Deals with human responses to life threatening problems -trauma /major surgery (Mary,L.S., Deborah, G.K. & Marthe, J.M. 2005) 3Prof. Dr. R S Mehta, BPKIHS
  4. 4. CRITICAL CARE NURSE  care for clients who are very ill  provide direct one to one care  Responsible for making life-and death decision  At high risk of injury or illness from possible exposure to infections  Communication skill is of optimal importance 4Prof. Dr. R S Mehta, BPKIHS
  5. 5. CRITICALLY ILL CLIENT  At high risk for actual or potential life- threatening health problems  More ill  Required more intensive and careful nursing care 5Prof. Dr. R S Mehta, BPKIHS
  6. 6. 6
  7. 7. DEFINITIONS  CRITICAL CARE : CRITICAL CARE IS A TERM USED TO DESCRIBE AS THE CARE OF PATIENTS WHO ARE EXTREMELY ILL AND WHOSE CLINICAL CONDITION IS UNSTABLE OR POTENTIALLY UNSTABLE. 7Prof. Dr. R S Mehta, BPKIHS
  8. 8.  CRITICAL CARE UNIT : IT IS DEFINED AS THE UNIT IN WHICH COMPREHENSIVE CARE OF A CRITICALLY ILL PATIENT WHICH IS DEEMED TO RECOVERABLE STAGE IS CARRIED OUT. 8Prof. Dr. R S Mehta, BPKIHS
  9. 9.  CRITICAL CARE NURSING : IT REFERS TO THOSE COMPREHENSIVE, SPECIALIZED AND INDIVIDUALIZED NURSING CARE SERVICES WHICH ARE RENDERED TO PATIENTS WITH LIFE THREATENING CONDITIONS AND THEIR FAMILIES. 9Prof. Dr. R S Mehta, BPKIHS
  10. 10. 10 Critical Care Technology  ECG monitoring  Arterial Lines  Oxygen Saturation  Ventilation  Intracranial Pressure Monitoring  Temperature  Pulmonary Artery Catheter  IABP  Extensive use of pharmaceuticals Prof. Dr. R S Mehta, BPKIHS
  11. 11. 11 The Critical Care Nurse  “Specialty dealing with human responses to life-threatening problems”  Requires Extensive Knowledge and a Continual Desire to Learn Prof. Dr. R S Mehta, BPKIHS
  12. 12. Economic Impact of ICU (1994) * <10% of hospital beds * 30% of acute care hospital cost * >20% of hospital budget * 1% of GNP expended for ICU care With aging of the population  Demand for critical care service will increase 12Prof. Dr. R S Mehta, BPKIHS
  13. 13. Prof. Dr. R S Mehta, BPKIHS 13 Historical Background
  14. 14. World War II  Shock wards established for resuscitation  Transfusion practices in early stages  After World war-II, nursing shortage forced grouping of postoperative patients in recovery areas 14Prof. Dr. R S Mehta, BPKIHS
  15. 15. Polio epidemic  1950’s: use of mechanical ventilation (“iron lung”) for treatment of polio  Development of respiratory intensive care units  At the same time, general ICU’s developed for sick and postoperative patients 15Prof. Dr. R S Mehta, BPKIHS
  16. 16. 16 History Continued  Collaboration between nurses and physicians  1950’s & 1960’s – CV Disease most common diagnosis  1960’s – 30-40% mortality rate for MI  1965 – 1st specialized ICU – The Coronary Care Unit  Emergence of Specialized ICU’s Prof. Dr. R S Mehta, BPKIHS
  17. 17. 1957 17
  18. 18. ICU’s also treat the dying  Isaac Asimov: “Life is pleasant. Death is peaceful. It is the transition that is difficult” Isaac Asimov: Professor of Biochemistry Boston 18
  19. 19. 19 American Association of Critical-Care Nurses - AACN  1969  Educational support  Certification  Largest professional specialty nursing organization  Scholarships  Research  Publishes 2 journals  Local chapters  Political awareness  Provides standards of practice Prof. Dr. R S Mehta, BPKIHS
  20. 20. An Ideal ICU 20Prof. Dr. R S Mehta, BPKIHS
  21. 21. Multidisciplinary & Collaborative approach to ICU care  Medical & nursing directors : co-responsibility for ICU management • a team approach : doctors, nurses, R/T, pharmacist • use of standard, protocol, guideline consistent approach to all issues • dedication to coordination and communication for all aspects of ICU management • emphasis on research, education, ethical issues, patient advocacy 21Prof. Dr. R S Mehta, BPKIHS
  22. 22. Team Dynamics  A multidisciplinary team to effectively attain specified objective  Physician team leader & critical care nurse manager 22Prof. Dr. R S Mehta, BPKIHS
  23. 23. Critical Care Practice Pattern  Open  Closed  transitional 23Prof. Dr. R S Mehta, BPKIHS
  24. 24. Open Units Definition : any attending physician with hospital admitting privileges can be the physician of record and direct ICU care. (All other physicians are consultants) Disadvantage :  lack of a cohesive plan  Inconsistent night coverage  Duplication of services 24Prof. Dr. R S Mehta, BPKIHS
  25. 25. Closed Units  Definition: An intensivist is the physician of record for ICU patients. (other physicians are consultants), All orders & procedures carried out by ICU staff • advantage: • improved efficiency • standardized protocol for care • disadvantage: • potential to lock out private physician • increase physician conflict 25Prof. Dr. R S Mehta, BPKIHS
  26. 26. Transitional Units Definition: intensives are locally present shared co- managed care between ICU staff and private physician ICU staff is a final common pathway for orders and procedures Advantage: reduce physician conflict, standard policies and procedures usually present Disadvantage: confusion and conflict regarding final authority & responsibilities for patient care decision 26Prof. Dr. R S Mehta, BPKIHS
  27. 27. ICU Model Care  Full-time intensivist model :  patient care is provided by an intensivist  Consultant intensivist model :  an intensivist consults for another physician to coordinate or assist in critical care, but dose not have primary responsibility for care  Multiple consultant model:  multiple specialists are involved in the patient care, (esp. R/T doctors for ventilators), but none is designated especially as the consultant intensivist  Single physician model :  primary physician provides all ICU care 27Prof. Dr. R S Mehta, BPKIHS
  28. 28. A Good ICU  Well organized trust coordinated care • Full-time intensivist: daily round • protocol & policies (eg: how to DC elective operation when bed not available) • bedside nurses (master degree) • no intern 28Prof. Dr. R S Mehta, BPKIHS
  29. 29. A Good ICU  A team: doctors, nurses, R/T, pharmacists • led by full time intensivists critical care trained available in a timely fashion (24hr/day) no competiting clinical responsibilities during duty • closed units, if resources allow 29Prof. Dr. R S Mehta, BPKIHS
  30. 30. What are the conditions considered as Critical? 1. ANY PERSON WITH LIFE THREATENING CONDITION 2. PATIENTS WITH :  ARF  AMI  CARDIAC TAMPONATE  SEVERE SHOCK 30Prof. Dr. R S Mehta, BPKIHS
  31. 31.  HEART BLOCK  ACUTE RENAL FAILURE  POLY TRAUMA, MULTIPLE ORGAN FAILURE AND ORGAN DYSFUNCTION  SEVERE BURNS 31Prof. Dr. R S Mehta, BPKIHS
  32. 32. NURSING ASSESSMENT  IT IS THE FIRST STAGE OF NURSING PROCESS IN WHICH THE NURSE SHOULD CARRY OUT A COMPLETE AND HOLISTIC NURSING ASSESS- MENT OF EVERY PATIENT’S NEEDS, REGARDLESS OF THE REASON FOR THE ENCOUNTER. 32Prof. Dr. R S Mehta, BPKIHS
  33. 33. COMPONENTS OF NURSING ASSESSMENT 1. NURSING HISTORY: Taking a nursing history prior to the physical examination allows a nurse to establish a rapport with the patient and family. Elements of the history include –  Health Status  Cause of present illness including symptoms  Current management of illness  Past medical history including family’s medical history 33Prof. Dr. R S Mehta, BPKIHS
  34. 34.  Social history  Perception of illness 2. Psychological and Social Examination-  Client’s perception  Emotional health  Physical health  Spiritual health  Intellectual health  3. Physical Examination : A nursing assessment includes physical examination, where the observation or measurement of signs, which can be observed or measured, or symptoms such as nausea or vertigo, which can be felt by the patient. 34
  35. 35. The techniques used may include Inspection, Palpation, auscultation and Percussion in addition to the vital signs like temperature, pulse, respiration , BP and further examination of the body systems such as the cardiovascular or musculoskeletal systems.  Documentation of Assessment: The Assessment is documented in the patient’s medical or nursing records, which may be on paper or as part of the electronic medical record which can be assessed by all members of the health care team. 35Prof. Dr. R S Mehta, BPKIHS
  36. 36. CLASSIFICATION OF CRITICAL CARE UNITS  LEVEL - I : PROVIDES MONITORING, OBSERVATION AND SHORT TERM VENTILATION. NURSE PATIENT RATIO IS 1:3 AND THE MEDICAL STAFF ARE NOT PRESENT IN THE UNIT ALL THE TIME. 36Prof. Dr. R S Mehta, BPKIHS
  37. 37. LEVEL - II : PROVIDES OBSERVATION, MONITORING AND LONG TERM VENTILATION WITH RESIDENT DOCTORS. THE NURSE-PATIENT RATIO IS 1:2 AND JUNIOR MEDICAL STAFF IS AVAILABLE IN THE UNIT ALL THE TIME AND CONSULTANT MEDICAL STAFF IS AVAILABLE IF NEEDED. 37
  38. 38.  LEVEL - III : PROVIDES ALL ASPECTS OF INTENSIVE CARE INCLUDING INVASIVE HAEMODYNAMIC MONITORING AND DIALYSIS. NURSE PATIENT RATIO IS 1:1 38Prof. Dr. R S Mehta, BPKIHS
  39. 39. CLASSIFICATION OF CRITICAL CARE PATIENTS  Level O : normal ward care  Level 1: at risk of deteriorating , support from critical care team  Level 2 : more observation or intervention, single failing organ or post operative care  Level 3; advanced respiratory support or basic respiratory support ,multiorgan failure 39Prof. Dr. R S Mehta, BPKIHS
  40. 40. HIGH DEPENDENCY CARE  Coronary care units (CCU)  Renal high dependency unit (HDU)  Post-operative recovery room  Accident and emergency departments (A&E)  Intensive care units (ICU) 40Prof. Dr. R S Mehta, BPKIHS
  41. 41. TYPES OF CRITICAL CARE UNIT  NEONATAL INTENSIVE UNIT (NICU)  SPECIAL CARE NURSERY (SCN)  PAEDIATRIC INTENSIVE CARE UNIT (PICU)  PSYCHIATRIC INTENSIVE UNIT (PICU) 41Prof. Dr. R S Mehta, BPKIHS
  42. 42.  CORONARY CARE UNIT (CCU)  CARDIAC SURGERY INTENSIVE CARE UNIT (CSICU)  CARDIOVASCULAR INTENSIVE CARE UNIT (CVICU)  MEDICAL INTENSIVE CARE UNIT (MICU)  MEDICAL SURGICAL INTENSIVE CARE UNIT (MSICU) 42Prof. Dr. R S Mehta, BPKIHS
  43. 43.  OVERNIGHT INTENSIVE RECOVERY (OIR)  NEUROSCIENCE / NEUROTRAUMA INTENSIVE CARE UNIT (NICU)  NEURO INTENSIVE CARE UNIT (NICU)  BURN INTENSIVE CARE UNIT (BNICU) 43Prof. Dr. R S Mehta, BPKIHS
  44. 44.  SURGICAL INTENSIVE CARE UNIT (SICU)  TRAUMA INTENSIVE CARE UNIT (TICU)  SHOCK TRAUMA INTENSIVE CARE UNIT (STICU)  TRAUMA – NEURO CRITICAL CARE INTENSIVE CARE UNIT (TNCC) 44Prof. Dr. R S Mehta, BPKIHS
  45. 45.  RESPIRATORY INTENSIVE CARE UNIT (RICU)  GERIATRIC INTENSIVE CARE UNIT (GICU) 45Prof. Dr. R S Mehta, BPKIHS
  46. 46. Types of ICU  General  Medical Intensive Care Unit(MICU)  Surgical Intensive Care Unit  Medical Surgical Intensive Care Unit(MSICU)  Specialized  Neonatal Intensive Care Unit(NICU)  Special Care Nursery(SCN)  Paediatric Intensive Care Unit(PICU)  Coronary Care Unit(CCU)  Cardiac Surgery Intensive Care Unit(CSICU)  Neuro Surgery Intensive Care Unit(NSICU)  Burn Intensive Care Unit(BICU)  Trauma Intensive Care Unit 46Prof. Dr. R S Mehta, BPKIHS
  47. 47. PRINCIPLES OF CRITICAL CARE NURSING ANTICIPATION : The first principle in critical care is Anticipation. One has to recognize the high risk patients and anticipate the requirements, complications and be prepared to meet any emergency. Unit is properly organized in which all necessary equipments and supplies are mandatory for smooth running of the unit. 47Prof. Dr. R S Mehta, BPKIHS
  48. 48. EARLY DETECTION AND PROMPT ACTION :  The prognosis of the patient depends on the early detection of variation, prompt and appropriate action to prevent or combat complication. Monitoring of cardiac respiratory function is of prime importance in assessment. Prof. Dr. R S Mehta, BPKIHS 48
  49. 49.  COLLABORATIVE PRACTICE : Critical Care, which has originated as technical sub-specialized body of knowledge has evolved into a comprehensive discipline requiring a very specialized body of knowledge for the physicians and nurses working in the critical care unit fosters a partnerships for decision making and ensures quality and compassionate patient care. Collaborate practice is more and more warranted for critical care more than in any other field. 49Prof. Dr. R S Mehta, BPKIHS
  50. 50. COMMUNICATION :  Intra professional, inter departmental and inter personal communication has a significant importance in the smooth running of unit. Collaborative practice of communication model Prof. Dr. R S Mehta, BPKIHS 50
  51. 51.  Prevention of Infection : Nosocomial infection cost a lot in the health care services. Critically ill patients requiring intensive care are at a greater risk than other patients due to the immunocompromised state with the antibiotic usage and stress, invasive lines, mechanical ventilators, prolonged stay and severity of illness and environment of the critical unit itself. 51Prof. Dr. R S Mehta, BPKIHS
  52. 52.  Crisis Intervention and Stress Reduction : partnerships are formulated during crisis. Bonds between nurses, patients and families are stronger during hospitalization. As patient advocates, nurses assist the patient to express fear and identify their grieving patttern and provide avenues for positive coping. 52Prof. Dr. R S Mehta, BPKIHS
  53. 53. ORGANIZATION OF ICU  DESIGN OF ICU : 1. Should be at a geographically distinct area within the hospital, with controlled access. 2. There should be a single entry and exit. However, it is required to have emergency exit points in case of emergency and disaster. 3. There should not be any through traffic of goods or hospital staff. Supply and professional traffic should be separated from public/visitor traffic. 53Prof. Dr. R S Mehta, BPKIHS
  54. 54. 4. Safe, easy, fast transport of a critically sick pt should be a priority in planning its location. Therefore, the ICU should be located in close proximity or ER, OT, trauma ward etc. 5. Corridors, lifts and ramps should be spacious enough to provide easy movement of bed/trolley of a critically sick patient. 6. Close, easy proximity is also desirable to diagnostic facilities, blood bank, pharmacy etc.  BED STRENGTH: 1. It is recommended that total bed strength in ICU should be between 8-12 and not less than 6 or not more than 24 in any case. 54Prof. Dr. R S Mehta, BPKIHS
  55. 55. 2. 3-5 beds per 100 hospital beds for a Level III ICU or 2 to 20% of the total no of hospital beds. 3. 1 isolation bed for every ICU beds.  BED AND ITS SPACE: 1. 150-200 sq.ft per open bed with 8 ft in between beds. 2. 225-250 sq.ft per bed if in a single room. 3. Beds should be adjustable, no head board, with side rails and wheels. 4. Keep bed 2 ft away from head wall. 55Prof. Dr. R S Mehta, BPKIHS
  56. 56.  ACCESSORIES: 1. 3 O2 outlets, 3 suction outlets (gastric, tracheal and underwater seal), 2 compressed air outlets and 16 power outlets per bed. 2. Storage by each bedside. 3. Hand rinse solution by each bedside. 4. Equipment shelf at the head end. 5. Hooks and devices to hang infusions/ blood bags, extended from the ceiling with a sliding rail to position. 6. Infusion pumps to be mounted on stand or poles. 7. Level II ICUs may require multi channel invasive monitors. 56Prof. Dr. R S Mehta, BPKIHS
  57. 57. 8. ventilators, infusion pumps, portable X ray unit, fluid and bed warmers, portable light, defibrillators, anaesthesia machines and difficult airway management equipments are necessary.  STAFFING : 1. Medical Staff – the best senior medical staff to be appointed as an Intensive Care Director or Intensivist. Less preferred are other specialists from anaesthesia / medicine who has clinical commitment elsewhere. Junior staff are intensive care trainers and trainees on deputation from other disciplines. 2. Nursing staff – The major teaching tertiary care ICU requires trained nurses in critical care. 57
  58. 58. The no of nurses ideally required for such unit is 1:1 ratio, however it might not be possible to have such members in our set up. So 1 nurse for 2 patients is acceptable. The no of trained nurses should also be worked out by the type of ICU, the workload and work statistics and type of patient load. 3.Allied Services – Respiratory services, Nutritionist, Physiotherapist, Biomedical engineer, technicians, computer programmer, clinical pharmacist, social worker / counsellor and other support staff, guards and grade IV workers. 58Prof. Dr. R S Mehta, BPKIHS
  59. 59. CRITICAL CARE NURSE Factors to be considered in recruiting Critical Care Nurses are: 1. Intra and interpersonal factors 2. Technical Qualifications. 3. Educational background 4. Clinical Experience. 59Prof. Dr. R S Mehta, BPKIHS
  60. 60.  Continuous monitoring  Keep ready emergency trolley / crash Cart  Efficient Individualized Care.  Counseling and information to family.  Application of policies and procedures  Proper records of all activities  Maintain infection control principles.  Keep update with advance information. 60
  61. 61. QUICK REFERENCE PROTOCOL FOR MANAGING EMERGENCY IN ICU  Quickly review the patient - Identity, History , Physical Exam.  Be with the patient, ask for help.  Place the patient in a suitable position.  Attach the cardiac monitor and call for crash cart.  Maintain ABC Along with expert team  Introduce IV, CV line 61Prof. Dr. R S Mehta, BPKIHS
  62. 62.  Administer medication as needed.  Carry on Investigations - ABG, ECG, Urea, Creatinine, Blood Sugar, Cardiac enzymes.  Maintain Fluid and Electrolytes .  Record right things at right time rightly. 62Prof. Dr. R S Mehta, BPKIHS
  63. 63. Core Competencies  Patient Care  Medical Knowledge  Professionalism & Ethics  Interpersonal Communication Skills  Practice-based Learning and Improvement  Systems-based Practice 63Prof. Dr. R S Mehta, BPKIHS
  64. 64. MonthlyEvaluations ProcedureLogBooks InTrainingExams EvaluationofACCPBoard ReviewLectures ErrorReporting TaumaMAn FCCS THCI QIPROJECTS Patient Care X X X X X X X X Medical Knowledge X X X X X X X Practice Based Learning and Improvement X X X X Interpersonal and Communication Skills X X X Professionalism X X X X Systems-Based Practice X X X X 64Prof. Dr. R S Mehta, BPKIHS
  65. 65. 65 Family Need of the Critical Care Patient  Information – major source of anxiety and litigation (legal issues)  Reassurance – can reassure care is being given  Convenience – access to the patient Prof. Dr. R S Mehta, BPKIHS
  66. 66. Job description  Patient care  Multidisciplinary rounds  Bed allocation/triage  Infection control  Protocol development  Quality control/assurance  Education  Residents, fellows, med students, nurses, respiratory therapists, nurse practitioners  Research  Quality assurance projects  Clinical trials  Database-driven projects 66Prof. Dr. R S Mehta, BPKIHS
  67. 67. General Concept, Setting and Principle of Critical Care Nursing 67Prof. Dr. R S Mehta, BPKIHS
  68. 68. Who are critically ill patient? 68Prof. Dr. R S Mehta, BPKIHS
  69. 69. Critical illness are grouped by the system of the body; A. Cardiac System 1. Acute myocardial infarction with complications 2. Cardiogenic shock 3. Complex arrhythmias requiring close monitoring and intervention 4. Acute congestive heart failure with respiratory failure and/or requiring hemodynamic support 5. Hypertensive emergencies 6. Unstable angina, particularly with dysrhythmias, hemodynamic instability, or persistent chest pain 8. Cardiac tamponade or constriction with hemodynamic instability 9. Dissecting aortic aneurysms 10. Complete heart block 69 Prof. Dr. R S Mehta, BPKIHS
  70. 70. B. Pulmonary System . 1. Acute respiratory failure requiring ventilatory support 2. Pulmonary emboli with hemodynamic instability 3. Massive hemoptysis C. Neurologic disorder 1. Intracranial hemorrhage 2. Meningitis with altered mental status or respiratory compromise 3. Central nervous system or neuromuscular disorders with deteriorating neurologic or pulmonary function 4. Status epilepticus 5. Severe head injured patients 70Prof. Dr. R S Mehta, BPKIHS
  71. 71. D. Drug Ingestion and Drug Overdose 1. Hemodynamically unstable drug ingestion 2. Drug ingestion with significantly altered mental status with inadequate airway protection 3. Seizures following drug ingestion E. Gastrointestinal Disorders 1. Life threatening gastrointestinal bleeding including hypotension, angina, continued bleeding, or with comorbid conditions 2. Hepatic failure 3. Severe pancreatitis 71Prof. Dr. R S Mehta, BPKIHS
  72. 72. F. Endocrine 1. Diabetic ketoacidosis complicated by hemodynamic instability, altered mental status, respiratory insufficiency, or severe acidosis 2. Severe hypercalcemia with altered mental status, requiring hemodynamic monitoring 3. Hypo or hypernatremia with seizures, altered mental status 4. Hypo or hypermagnesemia with hemodynamic compromise or dysrhythmias 5. Hypo or hyperkalemia with dysrhythmias or muscular weakness 6. Hypophosphatemia with muscular weakness 72Prof. Dr. R S Mehta, BPKIHS
  73. 73. G. Surgical 1. Post-operative patients requiring hemodynamic monitoring/ventilatory support or extensive nursing care H. Miscellaneous 1. Septic shock with hemodynamic instability 2. Hemodynamic monitoring 3. Environmental injuries (lightning, near drowning, hypo/hyperthermia) 73Prof. Dr. R S Mehta, BPKIHS
  74. 74. Admission Criteria in ICU  The ICU admission decision may be based on several models utilizing prioritization, diagnosis, and objective parameters models. A. Prioritization Model This system defines those that will benefit most from the ICU (Priority 1) to those that will not benefit at all (Priority 4) from ICU admission. 74Prof. Dr. R S Mehta, BPKIHS
  75. 75. Priority 1:  These are critically ill, unstable patients in need of intensive treatment and monitoring that cannot be provided outside of the ICU. Usually, these treatments include ventilator support, continuous vasoactive drug infusions. Examples of these patients may include post-operative or acute respiratory failure patients requiring mechanical ventilatory support and shock or hemodynamically unstable patients receiving invasive monitoring and/or vasoactive drugs. Prof. Dr. R S Mehta, BPKIHS 75
  76. 76. Priority 2:  These patients require intensive monitoring and may potentially need immediate intervention. Examples include patients with chronic comorbid conditions who develop acute severe medical or surgical illness. Prof. Dr. R S Mehta, BPKIHS 76
  77. 77.  Priority 3: These unstable patients are critically ill but have a reduced likelihood of recovery because of underlying disease or nature of their acute illness. Examples include patients with metastatic malignancy complicated by infection, cardiac tamponade, or airway obstruction. Priority 4: These are patients who are generally not appropriate for ICU admission. Admission of these patients should be on an individual basis, under unusual circumstances and at the discretion of the ICU Director. These patients can be placed in the following categories: 77Prof. Dr. R S Mehta, BPKIHS
  78. 78. B. Diagnosis Model This model uses specific conditions or diseases to determine appropriateness of ICU admission. (described above in critically ill patient) 78Prof. Dr. R S Mehta, BPKIHS
  79. 79. C. Objective Parameters Model Vital Signs • Pulse < 40 or > 150 beats/minute • Systolic arterial pressure < 80 mm Hg or 20 mm Hg below the patient's usual pressure • Mean arterial pressure < 60 mm Hg • Diastolic arterial pressure > 120 mm Hg • Respiratory rate > 35 breaths/minute Laboratory Values (newly discovered) • Serum sodium < 110 mEq/L or > 170 mEq/L • Serum potassium < 2.0 mEq/L or > 7.0 mEq/L • PaO2 < 50 mm Hg pH < 7.1 or > 7.7 • Serum glucose > 800 mg/dl • Serum calcium > 15 mg/dl • Toxic level of drug or other chemical substance in a hemodynamically or neurologically compromised patient 79Prof. Dr. R S Mehta, BPKIHS
  80. 80.  Radiography/Ultrasonography/Tomography (newly discovered)  Cerebral vascular hemorrhage, contusion or subarachnoid hemorrhage with altered mental status or focal neurological signs  Ruptured viscera, bladder, liver, esophageal varices or uterus with hemodynamic instability  Dissecting aortic aneurysm  Electrocardiogram  Myocardial infarction with complex arrhythmias, hemodynamic instability or congestive heart failure  Sustained ventricular tachycardia or ventricular fibrillation  Complete heart block with hemodynamic instability 80Prof. Dr. R S Mehta, BPKIHS
  81. 81.  Physical Findings (acute onset)  Unequal pupils in an unconscious patient  Burns covering > 10% BSA  Anuria  Airway obstruction  Coma  Continuous seizures  Cyanosis  Cardiac tamponade 81Prof. Dr. R S Mehta, BPKIHS
  82. 82. Team of Critical Care Unit  Physicians. The Most Responsible Physician (MRP) is the physician in charge of the patient’s care during the current hospitalization. He or she communicates with other members of the team on a daily basis.  Nurses Intensive Care nurses are the minute-to-minute critical care providers. They not only help to provide, but also coordinate most aspects of care delivery. They have received specialized training in caring for critically ill patients.  Respiratory Therapists Respiratory therapists have special training and experience in caring for patients with breathing problems. They work closely with the physician to develop a plan to support a patient’s breathing. They set up, monitor and maintain the breathing machines (mechanical ventilators), and they adjust these machines minute by minute and hour by hour to best meet the patient's needs. 82
  83. 83.  Pharmacists Pharmacists consult with the physician in selecting the right medicines at the correct dose for patients and also in monitoring drug levels in the body. Pharmacists also help to decrease medication side effects and provide valuable information to the team members.  Physical Therapist They help prevent disabilities and facilitate rehabilitation as soon as possible.  Dieticians Dieticians calculate the nutritional needs of the critically ill patient and consult with the physician to provide the patient with the best possible diet, whether orally or through a feeding tube.  Medical Radiation Technologist  Medical Laboratory Technologist 83Prof. Dr. R S Mehta, BPKIHS
  84. 84.  Trauma Coordinator The Trauma Coordinator reviews the plan of care for each trauma patient and in consultation with the ICU Care Team, makes suggestions regarding patient needs. She also works closely with the patient and family, and provides teaching and information to the patient and family about the patient’s progress and expected outcomes.  Social Worker Social workers provide professional assistance with the needs of patients and families. They can help to assess and determine what resources patients and families might be lacking, providing them with information on agencies to assist with various needs and generally assisting with other family difficulties.  Clinical Educator Clinical Educators are nurses who provide ongoing education for ICU nurses on new practices, protocols and on new equipment. They are up-to-date with the best practices in ICU and communicate with the Manager and with ICU nurses about all aspects of nursing practice and education. As an important part of their role, they provide a comprehensive orientation to nurses new to the ICU Care Team as well as providing continuing advice, support and education for all nurses in ICU. 84
  85. 85.  Ward Clerk ICU Ward Clerks help with communication by answering the phones, processing physician orders and coordinating some of the patient activities in the ICU.  Pastoral Care Chaplains are available to minister to the spiritual needs of patients and families. Manager Nurse Managers are nurses with additional experience and education, who are responsible for the day to day operations of the ICU. In addition to managing the ICU nursing staff, the ICU Nurse Manager is responsible for the ICU budget and nursing practices. Nurse Managers are responsible for ensuring that the care in the ICU is safe. She/he hires ICU nurses and ensures that all nursing staff members meet the standards established for their performance. She is also there to assist family members with their needs. 85Prof. Dr. R S Mehta, BPKIHS
  86. 86. Thank you 86Prof. Dr. R S Mehta, BPKIHS
  87. 87. ICU & CCU Service of BPKIHS Nursing Care and Protocols 87Prof. Dr. R S Mehta, BPKIHS
  88. 88. Critical Care Considerations  F=Feeding/fluid  A=Analgesics  S=Sedation  T=Thrombolytic agents  H=Head elevation  U=Ulcer – bed sore  G=Glucose monitoring 88Prof. Dr. R S Mehta, BPKIHS
  89. 89. Feeding and Fluids  It includes  Enteral feeding o Oro - gastric and Naso - gastric feeding o Churn diet o Dairy and poultry products (Milk, egg, youghort) o High protein liquid diet o Medications 89Prof. Dr. R S Mehta, BPKIHS
  90. 90.  Oral feeding o Hospital diet o Bland diet o Normal diet o Liquid intake 90Prof. Dr. R S Mehta, BPKIHS
  91. 91.  Transparenteral diet o Oliclinomel Includes:- • Amino acid solution with electrolyte (5.5%) volume 800 ml • Amino acid 44 gram • Na acetate • Na glycerophosphate • KCl 91Prof. Dr. R S Mehta, BPKIHS
  92. 92.  MgCl2  Sodium  Magnesium  PO4  Acetate  Chloride  Glucose 20% solution with CaCl2 92Prof. Dr. R S Mehta, BPKIHS
  93. 93. Overall volume of TPN = 2000 ml  Osmolarity = 75 mOsm/L  pH = 6  Amino acid = 44 gram  Total calorie = 1,215 Kcal 93Prof. Dr. R S Mehta, BPKIHS
  94. 94.  Fluids  IV fluids like NS, RL, 5% D, 10% D, DNS 94Prof. Dr. R S Mehta, BPKIHS
  95. 95. Analgesics  Fentanyl o It works 600 times more effectively than Morphine and reduces the pain and increases the pain threshold o Used in moderate and severe pain o In ICU 50 – 100 µg per Kg o Antidote Naloxone 0.05 mg/ Kg 95Prof. Dr. R S Mehta, BPKIHS
  96. 96.  Morphine o Reduces pain o Chiefly used in MI o 2-4 mg dissolved in 10 ml NS o Antidote: Naloxone o Supplied by hospital. 96Prof. Dr. R S Mehta, BPKIHS
  97. 97.  Acetaminophen and NSAIDs o Often more effective than opioids in reducing pain from pleural or pericardial rubs, a pain that responds poorly to opioids. o particularly effective in reducing muscular and skeletal pain o Tab form: 500mg OD 97Prof. Dr. R S Mehta, BPKIHS
  98. 98. Sedatives  Benzodiazepines 1. Midazolam oShort acting sedatives and hypnotics oIn intubated patients oDose 0.01- 0.05 mg/Kg for several hours 98Prof. Dr. R S Mehta, BPKIHS
  99. 99. Benzodiazepines… 2. Diazepam • Adult dose = 0.2 – 0.5 mg/ Kg • Not given in MI patients 99Prof. Dr. R S Mehta, BPKIHS
  100. 100. Dissociative Anaesthesia  Ketamine  Adult dose= 1 – 3 mg/kg IV 100Prof. Dr. R S Mehta, BPKIHS
  101. 101. Propofol o Arousal is rapid 10- 15 min o Used in neuro cases and those with increased ICP, during tracheostomy procedure 101Prof. Dr. R S Mehta, BPKIHS
  102. 102. Inotropes  Dopamine  Dobutamine  Nor- adrenaline 102Prof. Dr. R S Mehta, BPKIHS
  103. 103. Thrombolytic agents  TEDS compressive stocking  SCD (Systematic Compressive Device)  LMWX  Heparin flush 103Prof. Dr. R S Mehta, BPKIHS
  104. 104. Head elevation  Head is elevated to 30 degree. 104Prof. Dr. R S Mehta, BPKIHS
  105. 105. Ulcer  Two hourly position change  Back care in each shift  Oxygen therapy  Each shift dressing of pressure sore  Air mattresses 105Prof. Dr. R S Mehta, BPKIHS
  106. 106. Glucose monitoring  RBS as prescribed  Insulin therapy  Careful monitoring of signs of Hypoglycemia (trembling, clammy skin, palpitations, anxiety, sweating, hunger, and irritability) 106Prof. Dr. R S Mehta, BPKIHS
  107. 107. Infection control  Hand washing before, during and after the procedure  Sterility maintenance during procedures  Use of disinfectants  Weekly high wash  Monthly culture test of health personnel, equipments and infrastructures  Regular inspection by infection control team  Each shift CVP dressing 107Prof. Dr. R S Mehta, BPKIHS
  108. 108. Specific equipments used in ICU and CCU  Ventilators  Infusion pumps  Cardiac monitors  Defibrillator  ABG machine  ECG machine 108Prof. Dr. R S Mehta, BPKIHS
  109. 109. Drugs used in CCU  Aspirin  Clopidogrel  Nitroglycerine  Atorvastatins  LMWX  Morphine 109Prof. Dr. R S Mehta, BPKIHS
  110. 110. Sedation score in ICU is done by RASS 110Prof. Dr. R S Mehta, BPKIHS (Richmond Agitation Sedation Scale = RASS)
  111. 111. RASS (Richmond Agitation Sedation Scale) Number Characteristics Definition Intervention +4 Combative Violent, immediate danger to staff Restrain and sedate +3 Very agitated Aggressive, pull or remove tubes Restrain and sedate +2 Agitated Frequent non purposeful movement, fights ventilator Restrain and sedate +1 Restless Anxious movement but not aggressive or vigorous Sedate 0 Alert and calm 111Prof. Dr. R S Mehta, BPKIHS
  112. 112. Number Characteristics Definition Intervention -1 Drowsy Not fully alert but has sustained awakening, eye contact to voice (>10 sec) Verbal stimulation -2 Light sedation Briefly awakens, eye contact to voice (<10sec) Verbal stimulation -3 Moderate sedation Moderate or eye opening to voice but no eye contact Verbal stimulation -4 Deep sedation No response to voice but movement or eye opening to physical stimuli Physical stimulation -5 No response No response to voice or physical stimuli Physical stimulation 112Prof. Dr. R S Mehta, BPKIHS
  113. 113. “It may seem a strange principle to enunciate (articulate) as the very first requirement in a Hospital that it should do the sick no harm.” [1859] 113Prof. Dr. R S Mehta, BPKIHS
  114. 114. Thank you…!!! 114Prof. Dr. R S Mehta, BPKIHS

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