1. critical care introduction concept

CRITICAL
 Crucial
 Crisis
 Emergency
 Serious
 Requiring immediate action
 Thorough and constant observation
 Total dependent
(Oxford Dictionary)
2
Prof. 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)
3

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
 Specialty dealing with human responses to life-
threatening problems
 Requires Extensive Knowledge and a Continual
Desire to Learn
4

CRITICALLY ILL CLIENT
 At high risk for actual or potential life-
threatening health problems
 More ill
 Required more intensive and careful
nursing care
5

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.
7

 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.
8

 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.
9

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
10

Prof. Dr. R S Mehta, BPKIHS 11
Historical Background

World War II
 Shock wards
established for
resuscitation
 Transfusion practices in
early stages
 After World war-II,
(1939-1945) nursing
shortage forced
grouping of
postoperative patients
in recovery areas
12

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
13

14
History …
 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

16
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
17

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
18

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
19

A Good ICU
 Well organized: trust & coordinated care
• Full-time intensivist: daily round, critical care
trained, available in a timely fashion (24hr/day)
• protocol & policies
• bedside nurses: adequate (master degree)
 no intern
 Team of: doctors, nurses, R/T, pharmacists
• closed units, if resources allow
20

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)
21

CLASSIFICATION OF
CRITICAL CARE
 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 22

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
23

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.
24

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.
26

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.
28

 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.
29

ICU & CCU Service of
BPKIHS
Nursing Care and Protocols
30

Critical Care
Considerations
 F=Feeding/fluid
 A=Analgesics
 S=Sedation
 T=Thrombolytic agents
 H=Head elevation
 U=Ulcer – bed sore
 G=Glucose monitoring
31

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
32

 Oral feeding
o Hospital diet
o Bland diet
o Normal diet
o Liquid intake
33

 Transparenteral diet
o Oliclinomel
Includes:-
• Amino acid solution with electrolyte (5.5%) volume
800 ml
• Amino acid 44 gram
• Na acetate
• Na glycerophosphate
• KCl
34

 MgCl2
 Sodium
 Magnesium
 PO4
 Acetate
 Chloride
 Glucose 20% solution with CaCl2
35

Overall volume of TPN = 2000 ml
 Osmolarity = 75 mOsm/L
 pH = 6
 Amino acid = 44 gram
 Total calorie = 1,215 Kcal
36

 Fluids
 IV fluids like NS, RL, 5% D, 10% D, DNS
37

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
38

 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.
39

 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
40

Sedatives
 Benzodiazepines
1. Midazolam
oShort acting sedatives and hypnotics
oIn intubated patients
oDose 0.01- 0.05 mg/Kg for several hours
41

Benzodiazepines…
2. Diazepam
• Adult dose = 0.2 – 0.5 mg/ Kg
• Not given in MI patients
42

Dissociative Anaesthesia
 Ketamine
 Adult dose= 1 – 3 mg/kg IV
43

Propofol
o Arousal is rapid 10- 15 min
o Used in neuro cases and those with
increased ICP, during tracheostomy
procedure
44

Inotropes
 Dopamine
 Dobutamine
 Nor- adrenaline
45

Thrombolytic agents
 Compressive stocking
 SCD (Systematic Compressive Device)
 LMWX
 Heparin flush
46

Head elevation
 Head is elevated to 30 degree.
47

Ulcer
 Two hourly position change
 Back care in each shift
 Oxygen therapy
 Each shift dressing of pressure sore
 Air mattresses
48

Glucose monitoring
 RBS as prescribed
 Insulin therapy
 Careful monitoring of signs of
Hypoglycemia
(trembling, clammy skin, palpitations,
anxiety, sweating, hunger, and irritability)
49

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
50

Specific equipments used in
ICU and CCU
 Ventilators
 Infusion pumps
 Cardiac monitors
 Defibrillator
 ABG machine
 ECG machine
51

Drugs used in CCU
 Aspirin
 Clopidogrel
 Nitroglycerine
 Atorvastatins
 LMWX
 Morphine
52

Sedation score in ICU is
done by RASS
53
(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
54

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
55

“It may seem a
strange principle to
articulate as the very
first requirement in a
Hospital that it should
do the sick no harm.”
[1859]
56

A
• AIRWAY
• ACIDOSIS
• AORTIC
DISSECTION
• ALCOHOL
B • BREATHING
C
• CIRCULATION
• COMPRESSION
• COOLING
D
• DISABILITY
• DEFIBRILLATION
• TRENDELENBURG
POSITION
E
• EXPOSURE
• EFFUSION
• EMBOLISM
• ECG
Pain Management Must

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