1. critical care

CRITICAL
 Crucial
 Crisis
 Emergency
 Serious
 Requiring immediate action
 Thorough and constant observation
 Total dependent
(Oxford Dictionary)
2Prof. Dr. R S Mehta, BPKIHS

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)

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

CRITICALLY ILL CLIENT
 At high risk for actual or potential life-
threatening health problems
 More ill
 Required more intensive and careful
nursing care

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.

 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.

 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.

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
The Critical Care Nurse
 “Specialty dealing with human responses
to life-threatening problems”
 Requires Extensive Knowledge and a
Continual Desire to Learn

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

Prof. Dr. R S Mehta, BPKIHS 13
Historical Background

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

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

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

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
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

An Ideal ICU

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

Team Dynamics
 A multidisciplinary team to effectively
attain specified objective
 Physician team leader & critical care
nurse manager

Critical Care Practice
Pattern
 Open
 Closed
 transitional

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

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

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

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

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

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

What are the conditions
considered as Critical?
1. ANY PERSON WITH LIFE
THREATENING CONDITION
2. PATIENTS WITH :
 ARF
 AMI
 CARDIAC TAMPONATE
 SEVERE SHOCK

 HEART BLOCK
 ACUTE RENAL FAILURE
 POLY TRAUMA, MULTIPLE
ORGAN FAILURE AND ORGAN
DYSFUNCTION
 SEVERE BURNS

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.

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

 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

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.

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

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

 LEVEL - III :
PROVIDES ALL ASPECTS OF
INTENSIVE CARE INCLUDING
INVASIVE HAEMODYNAMIC
MONITORING AND DIALYSIS.
NURSE PATIENT RATIO IS 1:1

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

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)

TYPES OF CRITICAL CARE
UNIT
 NEONATAL INTENSIVE UNIT
(NICU)
 SPECIAL CARE NURSERY (SCN)
 PAEDIATRIC INTENSIVE CARE
UNIT (PICU)
 PSYCHIATRIC INTENSIVE UNIT
(PICU)

 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)

 OVERNIGHT INTENSIVE
RECOVERY (OIR)
 NEUROSCIENCE /
NEUROTRAUMA INTENSIVE
CARE UNIT (NICU)
 NEURO INTENSIVE CARE UNIT
(NICU)
 BURN INTENSIVE CARE UNIT
(BNICU)

 SURGICAL INTENSIVE CARE UNIT
(SICU)
 TRAUMA INTENSIVE CARE UNIT
(TICU)
 SHOCK TRAUMA INTENSIVE
CARE UNIT (STICU)
 TRAUMA – NEURO CRITICAL
CARE INTENSIVE CARE UNIT
(TNCC)

 RESPIRATORY INTENSIVE CARE
UNIT (RICU)
 GERIATRIC INTENSIVE CARE
UNIT (GICU)

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

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.

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.

 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.

COMMUNICATION :
 Intra professional, inter departmental and
inter personal communication has a
significant importance in the smooth
running of unit. Collaborative practice of
communication model

 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.

 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.

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

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.

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.

 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

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

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.

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.

 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

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

 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.

Core Competencies
 Patient Care
 Medical Knowledge
 Professionalism & Ethics
 Interpersonal Communication Skills
 Practice-based Learning and
Improvement
 Systems-based Practice

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

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

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

General Concept, Setting and
Principle of Critical Care Nursing

Who are critically ill patient?

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

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

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

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

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)

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.

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.

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.

 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:

B. Diagnosis Model
This model uses specific conditions or
diseases to determine appropriateness of
ICU admission.
(described above in critically ill patient)

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

 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

 Physical Findings (acute onset)
 Unequal pupils in an unconscious patient
 Burns covering > 10% BSA
 Anuria
 Airway obstruction
 Coma
 Continuous seizures
 Cyanosis
 Cardiac tamponade

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

 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

 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

 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.

Thank you

ICU & CCU Service of
BPKIHS
Nursing Care and Protocols

Critical Care
Considerations
 F=Feeding/fluid
 A=Analgesics
 S=Sedation
 T=Thrombolytic agents
 H=Head elevation
 U=Ulcer – bed sore
 G=Glucose monitoring

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

 Oral feeding
o Hospital diet
o Bland diet
o Normal diet
o Liquid intake

 Transparenteral diet
o Oliclinomel
Includes:-
• Amino acid solution with electrolyte (5.5%) volume
800 ml
• Amino acid 44 gram
• Na acetate
• Na glycerophosphate
• KCl

 MgCl2
 Sodium
 Magnesium
 PO4
 Acetate
 Chloride
 Glucose 20% solution with CaCl2

Overall volume of TPN = 2000 ml
 Osmolarity = 75 mOsm/L
 pH = 6
 Amino acid = 44 gram
 Total calorie = 1,215 Kcal

 Fluids
 IV fluids like NS, RL, 5% D, 10% D, DNS

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

 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.

 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

Sedatives
 Benzodiazepines
1. Midazolam
oShort acting sedatives and hypnotics
oIn intubated patients
oDose 0.01- 0.05 mg/Kg for several hours

Benzodiazepines…
2. Diazepam
• Adult dose = 0.2 – 0.5 mg/ Kg
• Not given in MI patients

Dissociative Anaesthesia
 Ketamine
 Adult dose= 1 – 3 mg/kg IV

Propofol
o Arousal is rapid 10- 15 min
o Used in neuro cases and those with
increased ICP, during tracheostomy
procedure

Inotropes
 Dopamine
 Dobutamine
 Nor- adrenaline

Thrombolytic agents
 TEDS compressive stocking
 SCD (Systematic Compressive Device)
 LMWX
 Heparin flush

Head elevation
 Head is elevated to 30 degree.

Ulcer
 Two hourly position change
 Back care in each shift
 Oxygen therapy
 Each shift dressing of pressure sore
 Air mattresses

Glucose monitoring
 RBS as prescribed
 Insulin therapy
 Careful monitoring of signs of
Hypoglycemia
(trembling, clammy skin, palpitations,
anxiety, sweating, hunger, and irritability)

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

Specific equipments used in
ICU and CCU
 Ventilators
 Infusion pumps
 Cardiac monitors
 Defibrillator
 ABG machine
 ECG machine

Drugs used in CCU
 Aspirin
 Clopidogrel
 Nitroglycerine
 Atorvastatins
 LMWX
 Morphine

Sedation score in ICU is
done by RASS
(Richmond Agitation Sedation Scale = RASS)

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

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

“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]

Thank you…!!!

1. critical care

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