505549557-1-Critical-Care-Introduction-Concept.ppt

CRITICAL CARE NURSING
1
1

Critical Care Unit/ICU
Critical Care Unit/ICU
 ICU is highly specialized and
ICU is highly specialized and
sophisticated area of a hospital which is
sophisticated area of a hospital which is
specifically designed, staffed, located,
specifically designed, staffed, located,
furnished and equipped, dedicated to the
furnished and equipped, dedicated to the
management of critically sick patients,
management of critically sick patients,
injuries or complications. It is department
injuries or complications. It is department
with dedicated medical, nursing and
with dedicated medical, nursing and
allied staffs.
allied staffs.
2
2

ICU…
ICU…
 An ICU is, “a specially staffed and
An ICU is, “a specially staffed and
equipped, separate and self-contained
equipped, separate and self-contained
are of hospital dedicated to the
are of hospital dedicated to the
management of patients with life-
management of patients with life-
threatening illnesses, injuries and
threatening illnesses, injuries and
complications, and monitoring of
complications, and monitoring of
potentially life-threatening conditions”.
potentially life-threatening conditions”.
3
3

HDU
HDU (High Dependency Unit)
(High Dependency Unit)
 A specifically staffed and equipped
A specifically staffed and equipped
section of an intensive care complex that
section of an intensive care complex that
provides level of care intermediate
provides level of care intermediate
between intensive care and general ward
between intensive care and general ward
care.
care.
 It must be near ICU Geographically and
It must be near ICU Geographically and
functionally, with intenvist service.
functionally, with intenvist service.
4
4

CRITICAL
CRITICAL
 Crucial
Crucial
 Crisis
Crisis
 Emergency
Emergency
 Serious
Serious
 Requiring immediate action
Requiring immediate action
 Thorough and constant observation
Thorough and constant observation
 Total dependent
Total dependent
(Oxford Dictionary)
(Oxford Dictionary)
5
5

 The care of seriously ill clients from point
The care of seriously ill clients from point
of injury or illness until discharge from
of injury or illness until discharge from
intensive care
intensive care
 Deals with human responses to life
Deals with human responses to life
threatening problems -trauma /major
threatening problems -trauma /major
surgery
surgery
(Mary,L.S., Deborah, G.K. & Marthe, J.M. 2005)
(Mary,L.S., Deborah, G.K. & Marthe, J.M. 2005)
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6

CRITICAL CARE NURSE
CRITICAL CARE NURSE
 care for clients who are very ill
care for clients who are very ill
 provide direct one to one care
provide direct one to one care
 Responsible for making life-and death decision
Responsible for making life-and death decision
 At high risk of injury or illness from possible
At high risk of injury or illness from possible
exposure to infections
exposure to infections
 Communication skill is of optimal importance
Communication skill is of optimal importance
 Specialty dealing with human responses to life-
Specialty dealing with human responses to life-
threatening problems
threatening problems
 Requires Extensive Knowledge and a Continual
Requires Extensive Knowledge and a Continual
Desire to Learn
Desire to Learn
7
7

CRITICALLY ILL CLIENT
CRITICALLY ILL CLIENT
 At high risk for actual or potential life-
At high risk for actual or potential life-
threatening health problems
threatening health problems
 More ill
More ill
 Required more intensive and careful
Required more intensive and careful
nursing care
nursing care
8
8
Prof. Dr. R S Mehta, BPKIHS

DEFINITIONS
DEFINITIONS
 CRITICAL CARE
CRITICAL CARE :
:
CRITICAL CARE IS A TERM USED
CRITICAL CARE IS A TERM USED
TO DESCRIBE AS THE CARE OF
TO DESCRIBE AS THE CARE OF
PATIENTS WHO ARE EXTREMELY
PATIENTS WHO ARE EXTREMELY
ILL AND WHOSE CLINICAL
ILL AND WHOSE CLINICAL
CONDITION IS UNSTABLE OR
CONDITION IS UNSTABLE OR
POTENTIALLY UNSTABLE.
POTENTIALLY UNSTABLE.
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10

 CRITICAL CARE UNIT
CRITICAL CARE UNIT :
:
IT IS DEFINED AS THE UNIT IN
IT IS DEFINED AS THE UNIT IN
WHICH COMPREHENSIVE CARE
WHICH COMPREHENSIVE CARE
OF A CRITICALLY ILL PATIENT
OF A CRITICALLY ILL PATIENT
WHICH IS DEEMED TO
WHICH IS DEEMED TO
RECOVERABLE STAGE IS
RECOVERABLE STAGE IS
CARRIED OUT.
CARRIED OUT.
11
11

 CRITICAL CARE NURSING
CRITICAL CARE NURSING :
:
IT REFERS TO THOSE
IT REFERS TO THOSE
COMPREHENSIVE, SPECIALIZED
COMPREHENSIVE, SPECIALIZED
AND INDIVIDUALIZED NURSING
AND INDIVIDUALIZED NURSING
CARE SERVICES WHICH ARE
CARE SERVICES WHICH ARE
RENDERED TO PATIENTS WITH
RENDERED TO PATIENTS WITH
LIFE THREATENING CONDITIONS
LIFE THREATENING CONDITIONS
AND THEIR FAMILIES.
AND THEIR FAMILIES.
12
12

Economic Impact of ICU (1994)
Economic Impact of ICU (1994)
* <10% of hospital beds
* <10% of hospital beds
* 30% of acute care hospital cost
* 30% of acute care hospital cost
* >20% of hospital budget
* >20% of hospital budget
* 1% of GNP expended for ICU care
* 1% of GNP expended for ICU care
With aging of the population
With aging of the population

 Demand for critical care service will
Demand for critical care service will
increase
increase
13
13

Prof. Dr. R S Mehta, BPKIHS 14
14
Historical Background

World War II
World War II
 Shock wards
Shock wards
established for
established for
resuscitation
resuscitation
 Transfusion practices in
Transfusion practices in
early stages
early stages
 After World war-II,
After World war-II,
(1939-1945) nursing
(1939-1945) nursing
shortage forced
shortage forced
grouping of
grouping of
postoperative patients
postoperative patients
in recovery areas
in recovery areas
15
15

Polio epidemic
Polio epidemic
 1950’s: use of
1950’s: use of
mechanical ventilation
mechanical ventilation
(“iron lung”) for treatment
(“iron lung”) for treatment
of polio
of polio
 Development of
Development of
respiratory intensive care
respiratory intensive care
units
units
 At the same time, general
At the same time, general
ICU’s developed for sick
ICU’s developed for sick
and postoperative
and postoperative
patients
patients
16
16

17
17
History …
History …
 Collaboration between nurses and
Collaboration between nurses and
physicians
physicians
 1950’s & 1960’s – CV Disease most
1950’s & 1960’s – CV Disease most
common diagnosis
common diagnosis
 1960’s – 30-40% mortality rate for MI
1960’s – 30-40% mortality rate for MI
 1965 – 1
1965 – 1st
st
specialized ICU – The
specialized ICU – The
Coronary Care Unit
Coronary Care Unit
 Emergence of Specialized ICU’s
Emergence of Specialized ICU’s

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19
American Association of
American Association of
Critical-Care Nurses - AACN
Critical-Care Nurses - AACN
 1969
1969
 Educational support
Educational support
 Certification
Certification
 Largest professional
Largest professional
specialty nursing
specialty nursing
organization
organization
 Scholarships
Scholarships
 Research
Research
 Publishes 2 journals
Publishes 2 journals
 Local chapters
Local chapters
 Political awareness
Political awareness
 Provides standards
Provides standards
of practice
of practice

An Ideal ICU
An Ideal ICU
20
20

Multidisciplinary & Collaborative
Multidisciplinary & Collaborative
approach to ICU care
approach to ICU care
 Medical & nursing directors :
Medical & nursing directors :
co-responsibility for ICU management
co-responsibility for ICU management
•
• a team approach :
a team approach :
doctors, nurses, R/T, pharmacist
doctors, nurses, R/T, pharmacist
•
• use of standard, protocol, guideline
use of standard, protocol, guideline
consistent approach to all issues
consistent approach to all issues
•
• dedication to coordination and communication
dedication to coordination and communication
for all aspects of ICU management
for all aspects of ICU management
•
• emphasis on research, education, ethical
emphasis on research, education, ethical
issues, patient advocacy
issues, patient advocacy
21
21

ICU Model Care
ICU Model Care
 Full-time intensivist model :
Full-time intensivist model :
 patient care is provided by an intensivist
patient care is provided by an intensivist
 Consultant intensivist model :
Consultant intensivist model :
 an intensivist consults for another physician to
an intensivist consults for another physician to
coordinate or assist in critical care, but dose not
coordinate or assist in critical care, but dose not
have primary responsibility for care
have primary responsibility for care
 Multiple consultant model:
Multiple consultant model:
 multiple specialists are involved in the patient care,
multiple specialists are involved in the patient care,
(esp. R/T doctors for ventilators), but none is
(esp. R/T doctors for ventilators), but none is
designated especially as the consultant intensivist
designated especially as the consultant intensivist
 Single physician model :
Single physician model :
 primary physician provides all ICU care
primary physician provides all ICU care
22
22

A Good ICU
A Good ICU
 Well organized: trust & coordinated care
Well organized: trust & coordinated care
•
• Full-time intensivist: daily round, critical care
Full-time intensivist: daily round, critical care
trained, available in a timely fashion (24hr/day)
trained, available in a timely fashion (24hr/day)
•
• protocol & policies
protocol & policies
•
• bedside nurses: adequate (master degree)
bedside nurses: adequate (master degree)

 no intern
no intern
 Team of: doctors, nurses, R/T, pharmacists
Team of: doctors, nurses, R/T, pharmacists
•
• closed units, if resources allow
closed units, if resources allow
23
23

HIGH DEPENDENCY CARE
HIGH DEPENDENCY CARE
 Coronary care units (CCU)
Coronary care units (CCU)
 Renal high dependency unit (HDU)
Renal high dependency unit (HDU)
 Post-operative recovery room
Post-operative recovery room
 Accident and emergency departments
Accident and emergency departments
(A&E)
(A&E)
 Intensive care units (ICU)
Intensive care units (ICU)
24
24

CLASSIFICATION OF
CLASSIFICATION OF
CRITICAL CARE
CRITICAL CARE
 Level 1:
Level 1: at risk of deteriorating , support
at risk of deteriorating , support
from critical care team
from critical care team
 Level 2 :
Level 2 : more observation or
more observation or
intervention, single failing organ or post
intervention, single failing organ or post
operative care
operative care
 Level 3;
Level 3; advanced respiratory support or
advanced respiratory support or
basic respiratory support ,multiorgan
basic respiratory support ,multiorgan
failure
failure
25
25

Level-I
Level-I
 Usually found in District hospital, Small
Usually found in District hospital, Small
nursing homes, and small hospitals.
nursing homes, and small hospitals.
 Provides immediate and short term cardio-
Provides immediate and short term cardio-
respiratory support
respiratory support
 Provides Short term invasive ventilator
Provides Short term invasive ventilator
service
service
 Nurse Patient ration= 1:2
Nurse Patient ration= 1:2
 ABG-desirable
ABG-desirable
26

Level -II
Level -II
 Large general hospitals, zonal hospitals,
Large general hospitals, zonal hospitals,
Nursing homes with specialty services.
Nursing homes with specialty services.
 Bed strength 6-12
Bed strength 6-12
 Long term ventilation ability
Long term ventilation ability
 Blood bank service available
Blood bank service available
 Multisystem life support available
Multisystem life support available
 CT MRI desirable
CT MRI desirable
27

Level - III
Level - III
 Recommended for tertiary level hospital or
Recommended for tertiary level hospital or
specialty and super-specialty hospitals
specialty and super-specialty hospitals
 Centre of excellence
Centre of excellence
 Provide comprehensive critical care
Provide comprehensive critical care
 Preferably closed ICU, Headed by intenvist
Preferably closed ICU, Headed by intenvist
 Protocol and policies are observed
Protocol and policies are observed
 All required equipments and supplies available
All required equipments and supplies available
28

Types of ICU
Types of ICU
 General
General
 Medical Intensive Care Unit(MICU)
Medical Intensive Care Unit(MICU)
 Surgical Intensive Care Unit
Surgical Intensive Care Unit
 Medical Surgical Intensive Care Unit(MSICU)
Medical Surgical Intensive Care Unit(MSICU)
 Specialized
Specialized
 Neonatal Intensive Care Unit(NICU)
Neonatal Intensive Care Unit(NICU)
 Special Care Nursery(SCN)
Special Care Nursery(SCN)
 Paediatric Intensive Care Unit(PICU)
Paediatric Intensive Care Unit(PICU)
 Coronary Care Unit(CCU)
Coronary Care Unit(CCU)
 Cardiac Surgery Intensive Care Unit(CSICU)
Cardiac Surgery Intensive Care Unit(CSICU)
 Neuro Surgery Intensive Care Unit(NSICU)
Neuro Surgery Intensive Care Unit(NSICU)
 Burn Intensive Care Unit(BICU)
Burn Intensive Care Unit(BICU)
 Trauma Intensive Care Unit
Trauma Intensive Care Unit
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29

PRINCIPLES OF CRITICAL
PRINCIPLES OF CRITICAL
CARE NURSING
CARE NURSING
ANTICIPATION :
ANTICIPATION :
 The first principle in critical care is
The first principle in critical care is
Anticipation. One has to recognize the
Anticipation. One has to recognize the
high risk patients and anticipate the
high risk patients and anticipate the
requirements, complications and be
requirements, complications and be
prepared to meet any emergency.
prepared to meet any emergency.
 Unit is properly organized in which all
Unit is properly organized in which all
necessary equipments and supplies are
necessary equipments and supplies are
mandatory for smooth running of the unit.
mandatory for smooth running of the unit.
30
30

EARLY DETECTION AND
EARLY DETECTION AND
PROMPT ACTION :
PROMPT ACTION :
 The prognosis of the patient depends on
The prognosis of the patient depends on
the early detection of variation, prompt
the early detection of variation, prompt
and appropriate action to prevent or
and appropriate action to prevent or
combat complication.
combat complication.
 Monitoring of cardiac respiratory function
Monitoring of cardiac respiratory function
is of prime importance in assessment.
is of prime importance in assessment.
31

 COLLABORATIVE PRACTICE
COLLABORATIVE PRACTICE :
:
Critical Care, which has originated as technical
Critical Care, which has originated as technical
sub-specialized body of knowledge has evolved
sub-specialized body of knowledge has evolved
into a comprehensive discipline requiring a very
into a comprehensive discipline requiring a very
specialized body of knowledge for the physicians
specialized body of knowledge for the physicians
and nurses working in the critical care unit fosters
and nurses working in the critical care unit fosters
a partnerships for decision making and ensures
a partnerships for decision making and ensures
quality and compassionate patient care.
quality and compassionate patient care.
Collaborate practice is more and more warranted
Collaborate practice is more and more warranted
for critical care more than in any other field.
for critical care more than in any other field.
32
32

COMMUNICATION :
COMMUNICATION :
 Intra professional, inter departmental and
Intra professional, inter departmental and
inter personal communication has a
inter personal communication has a
significant importance in the smooth
significant importance in the smooth
running of unit. Collaborative practice of
running of unit. Collaborative practice of
communication model
communication model
33

 Prevention of Infection :
Prevention of Infection :
 Nosocomial infection cost a lot in the health
Nosocomial infection cost a lot in the health
care services.
care services.
 Critically ill patients requiring intensive care
Critically ill patients requiring intensive care
are at a greater risk than other patients due
are at a greater risk than other patients due
to the immunocompromised state with the
to the immunocompromised state with the
antibiotic usage and stress, invasive lines,
antibiotic usage and stress, invasive lines,
mechanical ventilators, prolonged stay and
mechanical ventilators, prolonged stay and
severity of illness and environment of the
severity of illness and environment of the
critical unit itself.
critical unit itself.
34
34

 Crisis Intervention and Stress
Crisis Intervention and Stress
Reduction :
Reduction :
 partnerships are formulated during crisis.
partnerships are formulated during crisis.
Bonds between nurses, patients and
Bonds between nurses, patients and
families are stronger during hospitalization.
families are stronger during hospitalization.
 As patient advocates, nurses assist the
As patient advocates, nurses assist the
patient to express fear and identify their
patient to express fear and identify their
grieving patttern and provide avenues for
grieving patttern and provide avenues for
positive coping.
positive coping.
35
35

ICU & CCU Service of
ICU & CCU Service of
BPKIHS
BPKIHS
Nursing Care and Protocols
Nursing Care and Protocols
36
36

Critical Care
Critical Care
Considerations
Considerations
 F=
F=Feeding/fluid
Feeding/fluid
 A=
A=Analgesics
Analgesics
 S=
S=Sedation
Sedation
 T=
T=Thrombolytic agents
Thrombolytic agents
 H=
H=Head elevation
Head elevation
 U=
U=Ulcer – bed sore
Ulcer – bed sore
 G=
G=Glucose monitoring
Glucose monitoring
37
37

Feeding and Fluids
Feeding and Fluids
 It includes
It includes
 Enteral feeding
Enteral feeding
o Oro - gastric and Naso - gastric feeding
Oro - gastric and Naso - gastric feeding
o Churn diet
Churn diet
o Dairy and poultry products (Milk, egg,
Dairy and poultry products (Milk, egg,
youghort)
youghort)
o High protein liquid diet
High protein liquid diet
o Medications
Medications
38
38

 Oral feeding
Oral feeding
o Hospital diet
Hospital diet
o Bland diet
Bland diet
o Normal diet
Normal diet
o Liquid intake
Liquid intake
39
39

 Transparenteral diet
Transparenteral diet
o Oliclinomel
Oliclinomel
Includes:-
Includes:-
• Amino acid solution with electrolyte (5.5%) volume
Amino acid solution with electrolyte (5.5%) volume
800 ml
800 ml
• Amino acid 44 gram
Amino acid 44 gram
• Na acetate
Na acetate
• Na glycerophosphate
Na glycerophosphate
• KCl
KCl
40
40

 MgCl
MgCl2
2
 Sodium
Sodium
 Magnesium
Magnesium
 PO
PO4
4
 Acetate
Acetate
 Chloride
Chloride
 Glucose 20% solution with CaCl
Glucose 20% solution with CaCl2
2
41
41

Overall volume of TPN = 2000 ml
Overall volume of TPN = 2000 ml
 Osmolarity = 75 mOsm/L
Osmolarity = 75 mOsm/L
 pH = 6
pH = 6
 Amino acid = 44 gram
Amino acid = 44 gram
 Total calorie = 1,215 Kcal
Total calorie = 1,215 Kcal
42
42

 Fluids
Fluids
 IV fluids like NS, RL, 5% D, 10% D, DNS
IV fluids like NS, RL, 5% D, 10% D, DNS
43
43

Analgesics
Analgesics
 Fentanyl
Fentanyl
o It works 600 times more effectively than
It works 600 times more effectively than
Morphine and reduces the pain and
Morphine and reduces the pain and
increases the pain threshold
increases the pain threshold
o Used in moderate and severe pain
Used in moderate and severe pain
o In ICU 50 – 100 µg per Kg
In ICU 50 – 100 µg per Kg
o Antidote Naloxone 0.05 mg/ Kg
Antidote Naloxone 0.05 mg/ Kg
44
44

 Morphine
Morphine
o Reduces pain
Reduces pain
o Chiefly used in MI
Chiefly used in MI
o 2-4 mg dissolved in 10 ml NS
2-4 mg dissolved in 10 ml NS
o Antidote: Naloxone
Antidote: Naloxone
o Supplied by hospital.
Supplied by hospital.
45
45

 Acetaminophen and NSAIDs
Acetaminophen and NSAIDs
o Often more effective than opioids in reducing
Often more effective than opioids in reducing
pain from pleural or pericardial rubs, a pain that
pain from pleural or pericardial rubs, a pain that
responds poorly to opioids.
responds poorly to opioids.
o particularly effective in reducing muscular and
particularly effective in reducing muscular and
skeletal pain
skeletal pain
o Tab form: 500mg OD
Tab form: 500mg OD
46
46

Sedatives
Sedatives
47
47

Benzodiazepines…
Benzodiazepines…
2.
2. Diazepam
Diazepam
• Adult dose = 0.2 – 0.5 mg/ Kg
Adult dose = 0.2 – 0.5 mg/ Kg
• Not given in MI patients
Not given in MI patients
48
48

49
49

Propofol
Propofol
o Arousal is rapid 10- 15 min
Arousal is rapid 10- 15 min
o Used in neuro cases and those with
Used in neuro cases and those with
increased ICP, during tracheostomy
increased ICP, during tracheostomy
procedure
procedure
50
50

Inotropes
Inotropes
 Dopamine
Dopamine
 Dobutamine
Dobutamine
 Nor- adrenaline
Nor- adrenaline
51
51

Thrombolytic agents
Thrombolytic agents
 Compressive stocking
Compressive stocking
 SCD (Systematic Compressive Device)
SCD (Systematic Compressive Device)
 LMWX
LMWX
 Heparin flush
Heparin flush
52
52

Head elevation
Head elevation
 Head is elevated to 30 degree.
Head is elevated to 30 degree.
53
53

Ulcer
Ulcer
 Two hourly position change
Two hourly position change
 Back care in each shift
Back care in each shift
 Oxygen therapy
Oxygen therapy
 Each shift dressing of pressure sore
Each shift dressing of pressure sore
 Air mattresses
Air mattresses
54
54

Glucose monitoring
Glucose monitoring
 RBS as prescribed
RBS as prescribed
 Insulin therapy
Insulin therapy
 Careful monitoring of signs of
Careful monitoring of signs of
Hypoglycemia
Hypoglycemia
(trembling, clammy skin, palpitations,
(trembling, clammy skin, palpitations,
anxiety, sweating, hunger, and irritability)
anxiety, sweating, hunger, and irritability)
55
55

Infection control
Infection control
 Hand washing before, during and after the procedure
Hand washing before, during and after the procedure
 Sterility maintenance during procedures
Sterility maintenance during procedures
 Use of disinfectants
Use of disinfectants
 Weekly high wash
Weekly high wash
 Monthly culture test of health personnel, equipments
Monthly culture test of health personnel, equipments
and infrastructures
and infrastructures
 Regular inspection by infection control team
Regular inspection by infection control team
 Each shift CVP dressing
Each shift CVP dressing
56
56

Specific equipments used in
Specific equipments used in
ICU
ICU and CCU
and CCU
 Ventilators
Ventilators
 Infusion pumps
Infusion pumps
 Cardiac monitors
Cardiac monitors
 Defibrillator
Defibrillator
 ABG machine
ABG machine
 ECG machine
ECG machine
57
57

Drugs used in CCU
Drugs used in CCU
 Aspirin
Aspirin
 Clopidogrel
Clopidogrel
 Nitroglycerine
Nitroglycerine
 Atorvastatins
Atorvastatins
 LMWX
LMWX
 Morphine
Morphine
58
58

Sedation score in ICU is
Sedation score in ICU is
done by RASS
done by RASS
59
59
(Richmond Agitation Sedation Scale = RASS)

RASS
RASS
(Richmond Agitation Sedation Scale)
(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
60
60

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
61
61

“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]
62
62

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