critical care unit the 9th unit of medical surgical nursing 2

CRITICAL
CARE UNIT
PRESENTATION BY :-
SNEHA MAITI
ROLL NO :- 53
BSC (N) 3RD
YEAR [4YDC]
GOVERNMENT COLLEGE OF
NURSING
HYDERABAD

The critical care unit (CCU) is
a specialized hospital ward
that provides intensive,
around-the-clock treatment
and monitoring for patients
with life-threatening
conditions. It is staffed by
highly trained medical
professionals who are
dedicated to delivering the
highest level of care.

CRITICAL CARE
• Critical Care also known as intensive care , is a
multidisciplinary and interprofessional speciality
dedicated to the comprehensive management of
patients having , or at risk of developing , acute , life -
threatening organ dysfunction
• Critical Care uses an array of gadgets that provide
support of failing organ systems , particularly the lungs
, cardiovascular system and kidneys.

CRITICAL CARE UNIT
• Critical Care Unit is a specially designed and equipped
facility staffed by skilled personnel to provide effective and
safe care for dependent patients with a life threatening
problems requiring continuous monitoring and advanced
treatment.
- BRUNNERS AND SUDDARTH

Critical Care Unit (CCU) is a specialized
section of a hospital that provides
comprehensive and continuous care for
persons who are critically ill and who can
benefit from the treatment.
- BT BASAVANTHAPPA

Critical care unit is a unique , high placed
environment in which the most
sophisticated medical , nursing and
technical interventions are integrated to
combat the life threatening illnesses.
- JAVED ANSARI

Compassion
Communication
Consideration
Comfort
Carefulness
Consistency
Closure
7 ‘Cs’
OF
CRITICAL
CARE
CHARACTERISTICS

HISTORICAL PERSPECTIVE
• The concept of critical care was introduced by Florence
Nightingale in the 1800s
• During the Crimean war , she created a space adjacent to the
nurses station and pooled all the soldiers with severe injuries,
thereby enabling the nurses to monitor and care for them
intensively
• After World War II : Modern medicines , concept of triage and
speciality nursing came into existence

HISTORICAL PERSPECTIVE
•Late 1950’s –
beginning of Critical
care units
•1965 – 1st
specialized ICU –
(The Coronary Care
Unit )

PRINCIPLES OF CRITICAL CARE NURSING
PRINCIPLES
ANTICIPATORY
NURSING CARE
COMPREHENSIVE
&
SUPPORTIVE CARE
ETHICAL PRINCIPLES
COLLABORATIVE
PRACTICE
COMMUNICATION
PREVENTION OF
INFECTION
CRISIS INTERVENTION
&
SRESS REDUCTION
EARLY DETECTION AND
PROMPT ACTION

ANTICIPATORY NURSING CARE
• The First principle in Critical care is anticipation. The
Critical care nurse has to recognize the high risk patients
and anticipate the requirements.
• Critical care nurse initiates proactive measures using the
evidence-based guidelines, critical care pathways, and
care bundles before the complications erupt.
• Nurses need to be aware of and vigilant for possible
unexpected outcomes, anticipate adverse reaction, and
monitor for side effects for best outcome.

EARLY DETECTION & PROMPT
ACTION
• The prognosis of the patient depends on the early detection of
variation , prompt and appropriate action to prevent or combat
anticipation.
• Delay in identification and initiation of appropriate intervention
may lead to catastrophic consequences.
• Critical care nurses must apply the advanced assessment skills
and carefully observe the cardiopulmonary, neurological and
renal system functions and document these parameters from
time to time.

COLLABORATIVE PRACTICE
• Critical care warrants a team approach and every member of
the team deserves recognition for his or her irreplaceable
contribution for the provision of high – quality critical care.
• Prompt diagnosis of critical illness, initiation of treatment , and
evaluation of the effectiveness of medical and nursing
intervention need perfect collaboration and team approach.
• Critical care nurses in association with other team members
take active participation in decision making and ensures
quality and compassionate patient care.

COMMUNICATION
• Skillful communication within the critical care team is the
basis of all quality care in ICU.
• It facilitates smooth functioning of ICU team and prevents
patient safety mishaps.
• Proper communication within the nursing team members
leads to quality outcomes.
• Standardized communication can provide smooth
continuous care.

PREVENTION OF INFECTION
• Critically ill patients requiring intensive care are at a risk than
other patients due to immunocompromised state with the
antibiotic usage and stress, invasive lines, mechanical
ventilators, prolonged stay and severity of the illness.
• The nurse role is to educate the patient and family to follow
correct sanitization , disinfection and sterilization procedures.
• Nurse must help the patient understand basic disease prevention
and educate about immunizations.

CRISIS INTERVENTION &
STRESS REDUCTION
• Nurses responds to a crisis situation on a daily basis
• Knowledge of crisis intervention is an important clinical
skill of all regardless of the setting or practice speciality.
• Nurses assists the patients to express fear , confusion
and identify their grieving pattern and provide avenues
for positive coping.

COMPREHENSIVE CARE
• Provide comprehensive care by applying independent and
interdependent nursing interventions including selected proven
alternative care modalities.
• Prompt pain assessment , implementation of non-
pharmacological measures to improve comfort and alleviate
anxiety, prevention of bed sore , emotional support and
reassurance to the suffering patients and family are essential
elements for quick recovery.

ETHICAL & HUMANISTIC CARE
• Provide humanistic care in the high tech environment.
• The critical care environment is frightening to almost all
critically ill patients and their relatives.
• The human dimensions of care such as love, sense of
belonging , and making sense of the intervention by
involving the patient to the extent possible to him or her
are essential elements in the ICU that cannot be
compromised for high tech care.

03
02
01 LEVELS OF
CRITICAL
CARE UNIT
(CCU)

LEVEL :
01
• High dependency units
which could be either
separate or attached to
a general ward
• Short term cardio
respiratory support
• Resuscitation , short
term mechanical
ventilation and simple
invasive cardiovascular
monitoring for <24
1
02
n.
dard
are
port.
ician
all.
will
2
be
3

LEVEL :
01
a general ward
respiratory support
term mechanical
monitoring for <24
1
LEVEL : 02
• Located in general
hospital, undertake
prolonged ventilation.
• Provides a high standard
of general intensive care
including complex
multisystem life support.
• DMO is present
throughout and physician
will be available on call.
• Nurse – patient ratio will
be 1:2
2
be
3

LEVEL :
01
a general ward
respiratory support
term mechanical
monitoring for <24
1
LEVEL : 02
• Located in general
hospital, undertake
prolonged ventilation.
• Provides a high standard
of general intensive care
including complex
multisystem life support.
• DMO is present
throughout and physician
will be available on call.
• Nurse – patient ratio will
be 1:2
2
LEVEL : 03
• Tertiary referral unit for
intensive care patients
• Provides comprehensive
critical care including
complex multisystem life
support for an indefinite
period
• Physician will be present
throughout
• Nurse – patient ratio will be
1:1
• Ex: Hemodialysis,
3

BASED ON ORGANIZATION
OPEN ICU
Allows many
different members
of the medical
staff to manage
patients in the icu
CLOSED ICU
Is limited to ICU
certified
physicians
managing the
care of all patients
HYBRID ICU
Combines aspects of
open and closed
models by staffing
the ICU with an
attending physician
and/or team to work
in association with
primary physicians

BASED ON TYPE OF PATIENTS
SINGLE
SPECIALITY ICU
MULTI
DISCIPLINARY
ICU

SINGLE SPECIALITY ICU
• A single speciality ICU is defined as a ICU that is
primarily and exclusively engaged in the care and
treatment of the patients suffering from a specific
illness.
• It involves continuous monitoring and support for
organ systems including advanced respiratory
support , cardiovascular support, and complex
pain management.

MULTIDISCIPLINARY ICU
• A multidisciplinary ICU is a care model where
a team of health professionals from different
disciplines work together to provide critical
care to the patient.
• The team may include physicians,
nurses ,respiratory therapists, clinical
pharmacists, and other staff.

• The goal is to address as many aspects of
the patient’s care as possible by
collaborating and communicating with each
other
• Multidisciplinary collaboration in ICU is vital
for ensuring appropriate care and treatment
for critically ill patients and its important part
of establishing and meeting patient care
goals.

TYPES OF
CRITICAL CARE
UNITS
• Neonatal Intensive Care Unit (NICU)
• Pediatric Intensive Care Unit (PICU)
• Psychiatric Intensive Care Unit
• Cardiac Surgery Intensive Care Unit (CSICU)
• Cardio-vascular Intensive Care Unit (CVICU)
• Medical Intensive Care Unit (MICU)
• Medical Surgical Intensive Care Unit (MSICU)

• Neurosurgery Intensive Care Unit
(NSICU)
• Burn Intensive Care Unit (BNICU)
• Surgical Intensive Care Unit (SICU)
• Trauma Intensive Care Unit / Trauma
Care And Emergency Services
(TICU/TC&EMS)
• Respiratory Intensive Care Unit (RICU)
• Geriatric Intensive Care Unit (GICU)

ORGANIZATION OF
CRITICAL CARE UNIT

DESIGN
CONSIDERATION
LOCATION
FLOOR SPACE
NURSES STATION
OTHER FACILITIES
ENVIRONMENTAL
CRITERIA
EQUIPMENT IN ICU /
CCU
BED STRENGTH

DESIGN CONSIDERATION
01.
• Critical care unit is a vital arena in the hospital
and organization of a critical care unit is a
strategically planned process
• The bed strength , the types of patients , and
services intended to decide the ICU needs in
terms of floor space , equipment , monitors ,
manpower , etc

BED STRENGTH
02.
• In order to provide effective care the ICU
should have 6 to 14 beds
• The ICU with large number of beds has to be
divided into pods containing 10 – 15 beds with
sufficient staffs , devoted medical registrar and
intensive care specialist for effective care.

LOCATION
03.
• The CCU has to be ideally located in a
separate area with easy accessibility to the
emergency department (ED) , operation
room (OR) , radiology department ,
catheterization lab and blood bank.
• The ICU should have single entry and exit
with an anteroom.

• The unit must have sufficient big lift ,
ramps and a wide corridor that can
facilitate smooth transfer in and out of
the critically ill patients .
• There should be provision for
emergency exits in case of disasters

FLOOR SPACE
04.
FLOOR SPACE :
• 125 to 150 sq ft per patient is
recommended.
• It may vary up to 250 sq ft.
• The floor space for a separate room
should be much higher at least 300 sq ft
per patient

BETWEEN - BED SPACE :
• The bed space between two beds should be
4 – 4.5 sq ft
• The beds are separated with a removable
partition
• The head end should have enough space for
easy patient access for intubation or
resuscitation.

SEPARATE ROOMS :
• Two bigger rooms or two separate rooms should be
available for patients requiring isolation precaution or for
the immune compromised patients
• The room should be big with handwashing facility and
area to accommodate the ventilators , monitors , and
other gadgets.
• 100% to 150% extra space is recommended for other
than patient care area for nurses station , storage space
and free patient movement.

NURSES STATION
05.
•There should be a central nurses
station with tele monitoring devices.
•This will enable monitoring of patients
placed ideally in a “C” or “L” fashion.

ENVIRONMENT CRITERIA
06.
• The ICUs should be fully air
conditioned with control of humidity
and moisture
• 12 to 16 air exchanges and 55% to
60% humidity are recommended.
• Laminar flow is preferrable

OTHER FACILITIES
07.
• An ICU should have storage space for ventilators , monitors ,
infusion pumps , room for doctors office , nurses office , etc.
• Facility should be provided for medical storage ( gloves ,
medicines , suction equipment's , catheters, Ryle's tube)
• Other facility to be provided are :
Medicine preparation area
Equipment storage area
Clean linen storage
Seminar room with library

• There should be a minimum of two or three oxygen
outlets , two or three vacuum outlets and one to three
compressed air outlets
• There should be sufficient natural lighting available.
Wall mounted or ceiling mounted lights are
preferrable to save space and for good illumination.
• Hand washing facility should be easily accessible .
Isolation ICU should have separate hand washing
facility.

EQUIPMENT IN ICU / CCU
08.
MONITORI
NG
SUPPORTIVE RESUSCITATIV
E

MONITORING EQUIPMENT IN ICU
• ECG monitor
• Pressure monitor
• Temperature monitor
• End – tidal Co2 monitor
• Pulse oximeter
• Non invasive arterial pressure
monitoring
• Portable transfer monitors
• Portable ventilator

RESUSCITATIVE EQUIPMENT IN ICU
• Crash trolley with emergency
drugs and equipment
• ET tubes , laryngoscopes ,
Ambu bags form a part of
crash trolley
• Syringe infusion pumps
• Defibrillators
• Hemodialysis machines
• Glucometers
• Feeding tubes
• Central venous catheters

SUPPORTIVE EQUIPMENT IN ICU
• Special ICU beds with flat
washable surfaces , detachable
head end, holes for IV drip stand
at convenient places, easy
moving siderails , adjustable
head and foot end and height.
• Alternating pressure mattresses
• Laminar airflow systems
• Drug cart
• Fluid and bed warmers

ORGANIZATION OF
HUMAN
RESOURCES

Man power requirements again
depend on the number of patients
and the type of patients nursed.
The unit has to be headed by the
intensive care – qualified consultant

CRITICAL CARE MEDICAL
TEAM
• Head of the critical care medicine or
Director , who will manage the unit
• Critical care medicine consultant
• Intensive care medicine specialist
• Other specialists
• Residents or critical care fellowship trainees
• Junior medical officer

• Critical care specialized nurse manager of the unit
• Senior charges nurses with critical care training
• Full time critical care nurse educator , 1 for every 50 ICU
nurses to take care of the teaching and training needs of
registered nurses
• Nurse : patient ratio:
 RN in the ratio of 1:1 for ventilated patients
 RN in the ratio of 1:2 for nonventilated patients
 RN in the ratio of 2:1 for patients on ECMO support
CRITICAL CARE NURSING
TEAM

These include the
following:
• Respiratory therapist
• Physiotherapist
• ICU technician
• Dietician
• Clinical pharmacist
• Radiographer
OTHER PERSONNEL

• Computer operator and receptionist
• Biomedical engineer
• Hospital attendant, 2 in each shift for the first
and second shifts , and 1 in night shift for every
10 ICU beds
• Sanitary attendant , 2 in each shift for the first
and second shifts , and 1 in night shift for every
10 ICU beds
• Security guards to cover 24 hours

PROTOCOLS
AND
POLICIES
IN CRITICAL
CARE UNIT

WHAT IS A PROTOCOL ?
Protocol is a set of written rules or
precisely delineated steps usually
developed and tested by well –
controlled clinical research for desired
clinical outcome.

PROTOCOLS IN THE CCU / ICU
• Stress ulcer prevention protocol
• Deep vein thrombosis prevention protocol
• Sedation interruption protocol
• Weaning protocol
• Oral hygiene protocol
• Basic life support (BLS) protocol
• Advanced cardiac life support (ACLS)
protocol

WHAT IS A POLICY ?
A Policy is a statement , verbal ,
written ,or implied , of those
principles and rules that are set by
the Board of Directors as guidelines
on organization actions.

POLICIES OF THE CCU / ICU
• There should be written policies for the
Intensive care units (ICU) or Critical care
units (CCU) which will guide the personnel
working there.
• The policies making body , there should be
representation from administrative team ,
medical team , and the nursing team.

1.ADMISSION POLICIES:
• This should specify whether the
patients can be admitted directly top
CCU / ICU or through the casualty
department.
• There should be policies regarding
the admission of medico – legal
cases.
COMMON TYPES OF POLICIES IN ICU /
CCU

2. Discharge of patient policies
3. Transfer of patients from ICU to other units
4. Medical consultation
5. Policy for protocols for administration of drugs
equipment’s and procedures
6. Policy for managing the emergency situation
7. Infection control policies
8. Maintenance of records policies
9. Payments policies
10. Visiting policies

HOSPITAL ACQUIRED INFECITON
IN CRITICAL CARE UNITS
DEFINITION :
Nosocomial infection or HAI can be defined as
any newly acquired infection that arises 48 hours of
admission to the hospital.
HAI increases the cost of care , length of ICU stay ,
and hospital stay , and diminishes the favorable
outcome of care

SOURCES AND RISK FACTORS
SOURCES
• ICU environment , the ventilators , monitors , floors
and doorknobs.
• Organisms being harboured by patients themselves,
which may be transmitted endogenously to elsewhere
• Other patients
• Health care professionals
• Visitors

RISK FACTORS
• Acuity of illness
• Physiological stress response
• Too many invasive procedures and lines in ICU
• Malnutrition
• Comorbidities
• Antibiotic abuse
• Immobilization
• Immunocompromised state
• Other external factors such as understaffing and breach in
implementation of infection control protocols

TYPES OF HOSPITAL ACQUIRED
INFECTIONS
Six major types of HAI occurring in critical care units are
the following :
1. VAP : ( Ventilator associated pneumonia )
2. CAUTI : ( Catheter associated urinary tract infection )
3. CRBSI : (Central catheter related blood stream
infection ) or CLABSI : ( Central line associated blood
stream infection)
4. SSI : ( Surgical site infection )
5.DAI : ( Dialysis associated infections )
6.PRESSURE ULCERS

VENTILATOR ASSOCIATED
PNEUMONIA (VAP)
DEFINITION:
Ventilator – associated
Pneumonia (VAP ) is
defined as pneumonia that
occurs 48 hours or more
after ET intubation or
tracheostomy , caused by
infectious agents not
present before
mechanical ventilation was
started.

• Practice of standard precaution should be
observed, perform tracheal suction properly
with aseptic precaution and avoid routine
saline instillation during suctioning.
• Ensure appropriate disinfection , sterilization ,
and maintenance of respiratory equipment
• Place the ventilated patient in semi upright
position around 45 degrees.
PREVENTION STRATEGY OF VAP

CATHETER ASSOCIATED
URINARY TRACT INFECTION
(CAUTI)
DEFINITION:
The catheter associated urinary tract
infection occurs when the organism
enters the urinary tract through the
urinary catheter and causes infection.

CENTRAL LINE –
ASSOCIATED BLOOD
STREAM INFECTION
(CLABSI)
DEFINITION:
A CLABSI is a serious
infection that occurs
when microbes enter
the bloodstream
through the central
line.

PREVENTION OF CENTRAL LINE – ASSOCIATED
BLOOD STREAM INFECTION (CLABSI)
• Perform hand hygiene with soap and water or alcohol
based gels
• Use maximum sterile barrier precautions during CVC
insertion, which include wearing sterile PPE and draping
the whole body with a large sterile sheet.
• Apply an alcohol based or antiseptic solution for skin
preparation before puncture.
• Allow the antiseptic solution to dry before making the skin
puncture.

SURGICAL SITE
INFECTION (SSI)
DEFINITION:
Surgical site infections can
be defined as invasion of
organisms through tissues
following a breakdown of
local and systemic host
defenses at the surgical
wound that occurs within
30 days of surgery.

INFECTION CONTROL IN ICU
Infection control in ICU include:
General measures for infection control
 Specific preventive measures for selected
infections
The general measures aim at prevention of all
types of hospital acquired infections in the ICU

1. Early identification and isolation of patients
with signs of infection
GENERAL MEASURES FOR
INFECTION CONTROL
• Perform vigilant and continuous
monitoring of all critically ill patients for
early signs of infections
• Identify those with evidence of
infections at an early stage and
isolate.(symptomatic isolation)

2. Strict adherence of standard
precautions
• Minimize contact with blood,
body secretions, and patient
care areas.
• Wear personal protective
equipment(PPE)
• Adherence to strict hand
hygiene

4. Disinfection and cleaning of
instrument and linen
• Used contaminated instruments
should be cleaned thoroughly
and dried before immersing in
chemical disinfectants.
• Linens contaminated visibly with
blood and body fluids need to be
treated with 2% sodium
hypochlorite solution before
further cleaning and sterilization
to kill the blood borne pathogens.

5. Maintenance of ICU environment
• Floor cleaning more than once a day is needed.
• There should be provision for hand hygiene at the
entrance of the critical care unit.
• There should be provision of alcohol-based hand
rubs at each bed side.
• There should be restriction of street clothes for all
visitors and healthcare professionals.
.

6. Training and education of all
health care workers
Hand hygiene and other infection
control policies need to be oriented
to all new employees and
periodical refresher course on
infection control is essential to
implement the infection control
program effectively.

7. Antibiotic stewardship
• Antibiotic abuse will lead to
development of antibiotic-
resistant strains.
• Follow institutional policy for
effective antibiotic use.
• Nurse's role is to follow correct
schedule at appropriate time.

SPECIFIC PREVENTIVE MEASURES
• Certain airborne infectious agents spread through
droplets; nuclei measuring more than 5 micro meters
that are expelled into air during coughing and sneezing
and can spread infection to susceptible patients or
healthcare providers.
• Similarly infections spread through direct contact.
Specific measures need to be instituted to address
such infectious microbes.

1. AIRBORNE OR DROPLET PROTECTION
• Patients harbouring agents that spread through
air droplets such as Mycobacterium
tuberculosis, Haemophilus influenzae,
Neisseria meningitidis, and Mycoplasma
pneumoniae have to be isolated in a private
room.
• The room has to have glass partition and tight
doors for sealing of air. The isolation room
should have negative pressure ventilation.
• Visitors and care providers have to wear N95
respirator mask.

2. Contact precautions
Some of the organisms that spread through direct contact
with an infected patient or indirect contact, i.e. through the
personal care items such as herpes zoster, rotavirus,
hepatitis A virus can spread through direct and indirect
contact. To prevent the spread of such organisms, the
following measures need to be followed:
• Isolate the patient
• Avoid use of equipment and patient care items of other
patients
• In unavoidable circumstances, proper disinfection of the
items should be done.
• Limit the movement of patients.

ROUTINE
PROCEDURES
Endotracheal
intubation
Gastro
intestinal
intubation
Venous
catheterization
Arterial
catheterization
Epidural
catheterization
Lumbar
puncture
Thora
centesis
Intercoastal
chest drainage
Para
centesis
Urinary
catheterization

PARACENTESIS /
PERITONEOCENTESIS

NURSING
MANAGEMENT
OF
A CRITICALLY
ILL PATIENT

CRITICALLY ILL PATIENTS
According to AACN ( American
Association of Critical care Nurses ) :-
Critically ill patients are those who are at a high
risk of actual or potential life threatening health
problems.
The more critically ill the patient is, the more likely
he or she is to be highly vulnerable, unstable and
complex, thereby requiring intense and vigilant
nursing care.

CRITICAL CARE NURSE
A Critical Care Nurse is a licenced
professional nurse who is
responsible for ensuring that acutely
and critically ill patients and their
families receive optimal care.

Roles And
Responsibilities Of
Critical Care Nurse
• Assessing a patient’s condition and planning and
implementing patient care plans.
• Provides direct comprehensive bedside care to
patients .
• Treating wounds and providing advanced life
support.
• Assisting physicians in performing procedures
• Able to attach equipment on patients as ordered and
interprets the data, graphs on monitors , etc.

• Observing and recording patient vital signs
• Ensuring that ventilators , monitors and other
type of medical equipment function properly
• Administering intravenous fluids and
medications
• Collaborating with fellow members of the
critical care team
• Responding to life saving situations , using
nursing standards and protocols for treatment

ASSESMENT OF CRITICALLY ILL PATIENTS IN THE
ICU
• Assessment of critically ill patients is a challenging task that
requires critical thinking , competence , and accuracy.
• The first step is to enquire from the patient the following :-
How are you ?
What is your name ?
What happened ?
• If the patient could answer properly , it could be inferred that his or
her airway , breathing , and cerebral perfusion are alright.
• If the patient is unresponsive , it indicates critical alignment and
needs quick assessment and intervention

INITIAL ASSESSMENT
INITIAL ASSESSMENT
AIRWAY

INITIAL ASSESSMENT
INITIAL ASSESSMENT
BREATHING

INITIAL ASSESSMENT
INITIAL ASSESSMENT
CIRCULATION

INITIAL ASSESSMENT
INITIAL ASSESSMENT
DISABILITY

INITIAL ASSESSMENT
INITIAL ASSESSMENT
EXPOSURE

• Look , listen and feel for obstruction.
• Seesaw respiration of chest and
abdominal muscles that indicates airway
obstruction.
• Noisy respiration indicates partial
obstruction.
• Stridor, rattling noise indicates secretion
clogging the airway.
• No breath sounds indicate complete
obstruction.
• Feel for air movement with your hand
closer to the mouth.
A - AIRWAY

• Look for bilateral chest movements.
• In case of pneumothorax sucking of
chest may be present.
• Check respiratory rate and rhythms,
RR <8 or >25 breaths/min indicate
ventilation problems.
• Listen for breath sounds
• Observe for cyanosis
• Check the oxygen saturation using
a pulse oximeter
B - BREATHING

• Observe the colour of the digits , oral
mucosa and lips
• Assess pulse rate and rhythm, PR <60
or >120beats/min indicates
compromised circulation
• Barely palpable carotid pulse suggest
a poor cardiac output while a
bounding pulse may indicate sepsis.
• Feel for peripheral warmth , cool and
clammy extremity indicates poor
cardiac output.
C - CIRCULATION

• Review the ABC
• Assess the level of consciousness
using GCS and pupillary reaction
• Assess AVPU
[A – Alert ]
[V – Verbal response]
[P – Painful stimuli]
[U – Unresponsive]
• Check for traumatic brain injury
• Check for blood glucose levels
• Identify and check for
D - DISABILITY

• Complete Head-to-Toe
assessment including the
back for injury after ensuring
complete privacy and dignity
• Look for signs of trauma ,
rashes , swelling ,etc
• Assess the temperature for
hypothermia
• Assess pain
E - EXPOSURE

• When primary survey is
completed with
simultaneous
resuscitation ,
secondary survey is
carried out . Its consists
of the following :-
SECONDARY SURVEY
HISTORY
MRI
BLOOD
TESTS
REASSESSMENT
OF ABC
VITALS
HEAD TO TOE
EXAMINATION
ECHO OR
ULTRASOUND
X RAYS
ECG

NURSING DIAGNOSES
Based on the patient assessment the commonly encountered
nursing diagnoses in a critically ill patient are :-
Ineffective airway clearance related to
diminished gag reflex and/or excessive
secretions as evidenced by visible or
audible secretions, increased RR,
increased airway pressure alarm in
ventilated patients and restlessness.
01

•Place an oropharyngeal airway.
•Elevate the head end of the bed 30º to 40º
.
•Perform gentle suctioning.
•Auscultate the breath sounds
•Provide chest physiotherapy to loosen the
secretion.
NURSING INTERVENTIONS

Impaired gas exchange related to
ventilation-perfusion mismatch as
evidenced by cyanosis in the oral
mucosa , lips, SpO2 <93%, hypoxemia,
hypercapnia, decreased mentation,
restlessness and abnormal RR and
rhythm.
02

•Place the patient in low fowlers position.
•Monitor the positive end-expiratory
pressure (PEEP)
•Monitor ABG, SpO2
•Change patient position every 2 hours
•Give bronchodilators at scheduled time

Decreased cardiac output related to
decreased fluid volume or poor
contractility of the heart as evidenced
by hypotension, increased or
decreased heart rate , feeble
peripheral pulse and cool extremities
and urine output <30mL/hr.
03

• Monitor the blood pressure continuously.
• Establish venous access either central or
peripheral.
• Replace electrolytes lost through infusion of
IV fluids.
• Monitor strict intake – output chart.
• Monitor CVP pressure, and check peripheral
pulse ,peripheral warmth hourly.

Impaired cerebral tissue perfusion related to
increased intracranial pressure or CNS
depression/infection as evidenced by changes
in the level of consciousness , bradycardia ,
changes in the rate and pattern of respiration ,
changes in the pupillary reflex , size and
shape of the pupils.
04

• Elevate the head end of the patient at 30º
• Maintain the head , neck , and body in normal
alignment .
• Monitor neurological status , vital signs , pupillary
signs and reflexes.
• Administer prescribed supplemental oxygen.
• Maintain normothermia.
• Administer prescribed anticonvulsants

Effective communication
is crucial in the
Intensive Care Unit
(ICU) to ensure
patient safety,
improve outcomes,
and reduce errors
COMMUNICATION IN ICU

VERBAL COMMUNICATION
1.Clear and concise language: Avoid using jargon or
technical terms that may be unfamiliar to patients or
families
2.Active listening: Pay attention to patients', families',
and colleagues' concerns and questions.
3.. Regular updates: Provide frequent updates on
patient condition, treatment plans, and progress.

NON - VERBAL COMMUNICATION
1.Body language: Maintain eye contact, use open and
approachable body language, and avoid crossing
arms or legs.
2.Facial expressions: Be mindful of facial expressions,
as they can convey empathy, concern, or
reassurance.
3.. Touch: Use therapeutic touch, such as holding a
patient's hand, to provide comfort and reassurance.

1.Family meetings: Hold regular family meetings to
discuss patient condition, treatment plans, and
progress.
2. Empathy and compassion: Show empathy and
compassion when communicating with families,
acknowledging their concerns and emotions.
3.Involving families in care: Encourage families to
participate in patient care, such as assisting with
daily care activities.
FAMILY-CENTERED COMMUNICATION

1.Multidisciplinary rounds: Conduct regular multidisciplinary
rounds to discuss patient care, share information, and
coordinate treatment plans
2. Clear communication channels: Establish clear
communication channels among team members, including
nurses, physicians, and other healthcare professionals.
3. Respect and open-mindedness: Foster a culture of respect
and open-mindedness, encouraging team members to
share their perspectives and ideas.
INTERDISCIPLINARY
COMMUNICATION

• Impaired cognition
• Patients in delirium
• Sedation
• Altered level of
consciousness
• Language barriers
• Educational and cultural
variations
• Presence of tracheostomy or
ET tube
• Poor skills of nurses
interpreting nonverbal
communication
• Lack of time for nurses to
understand nonverbal
communication
BARRIERS IN COMMUNICATING WITH
CRITICALLY ILL PATIENTS

STRATEGIES TO IMPROVE
COMMUNICATION IN CCU
1.Standardized Communication Protocols: Establish
standardized communication protocols for handoffs, rounds,
and family meetings to ensure consistency and clarity
2.Multidisciplinary Rounds: Conduct regular multidisciplinary
rounds to facilitate communication among healthcare
providers, patients, and families
3. Clear and Concise Language: Encourage healthcare
providers to use clear and concise language when
communicating with patients, families, and colleagues

4. Active Listening: Foster a culture of active listening by
encouraging healthcare providers to pay attention to patients',
families', and colleagues' concerns and questions
5. Family-Centered Communication: Prioritize family-centered
communication by involving families in care decisions,
providing regular updates, and addressing their concerns
and questions.
6. Communication Boards: Use communication boards or
whiteboards to display patient information, treatment plans, and
goals to facilitate communication among healthcare providers

.7. Handoff Communication Tools: Implement handoff communication
tools, such as the Situation, Background, Assessment, and
Recommendation (SBAR) framework, to ensure accurate and concise
communication during handoffs.
8. Debriefing Sessions: Conduct regular debriefing sessions after critical
events or challenging situations to discuss communication strategies
and identify areas for improvement
.9. Communication Training: Provide regular communication training for
healthcare providers to enhance their communication skills, address
communication barriers, and promote a culture of effective
communication
.10. Feedback Mechanisms: Establish feedback mechanisms to
encourage healthcare providers to reflect on their communication
practices and identify areas for improvement.

ETHICAL AND
LEGAL ISSUES
IN CRITICAL CARE
NURSING

01
• BENEFICENCE
02
• NON - MALEFICENCE
03
• AUTONOMY
04
• JUSTICE
FUNDAMENTAL
ETHICAL PRINCIPLES

05
• VERACITY
06
• FIDELITY
07
• ACCOUNTABILITY
08
• CONFIDENTIAILITY

Nurses have an
obligation to
render the most
appropriate
interventions that
will facilitate
recovery for the
patient
BENEFICENCE

Refers to the avoidance
of causing any harm to
the patients
( intentional or
unintentional ).
NON
MALEFICENCE

• Refers to a persons
independence, self-
reliance , self
determination.
• Respecting the patients
right to determine the
course of treatment and
care at the ICU without
judgment or coercion.
AUTONOMY

Fairness , to
provide care
that is equitable
and evenly
distributed
JUSTICE

VERACITY
Telling the complete
truth, not
withholding any
part of the truth,
even if it is
upsetting .

FIDELITY
Nurses should
be faithful and
true to their
professional
promises

ACCOUNTABILITY
Accepting
responsibility for
the actions ,
nursing care and
the consequences
of actions.

CONFIDENTIALITY
Confidentiality means
protecting personal
information.
It means that patients
personal and clinical
information must not be
disclosed to others
without their consent.

ETHICAL DILEMMAS
EXPERIENCED BY NURSE
WORKING IN CRITICAL CARE
UNTS
END-OF-LIFE ISSUES :-
• Palliative care
• DNR Order
• Euthanasia
• Withholding and withdrawal
of life support

PALLIATIVE
CARE
• Caring for a patient to
relieve pain and make
the dying process as
peaceful as it can be.
• Depending on patients
wishes they are given
food and hydration

DNR Order
• Allowing the person to die without
initiating active resuscitation
process presents a lot of stress and
dilemma to critical care team
members.
• Orders are commonly
implemented in the critical care
setting as a prelude to end-of-life
care.

EUTHANASIA
Euthanasia a Greek word meaning “good
death” is popularly known as “mercy
killing”
• It is an intentional killing of a patient by
the direct intervention of the doctor for
the good of the patient of others.
• Active euthanasia is an act of
commission when termination of life is
done at patients request , it is otherwise
known as physician-assisted suicide.

WITH HOLDING OR
WITHDRAWAL OF LIFE
SUPPORT
It is the cessation and removal of an
ongoing medical therapy such as :
• Withdrawal of dialysis for a patient
with renal failure.
• Withdrawal of ventilator support to a
patient with acute respiratory failure.
It is performed with an intent of
allowing patient to embrace natural
death due to underlying illness.

COMMONLY ENCOUNTERED LEGAL
ISSUES
NEGLIGENCE
MALPRACTICE
DEFORMATION

• It is an unintentional act of
commission or omission of a nurse
that is falling short of the expected
standard that has resulted in injury
or fatal outcome in the patient.
• It can be a medication error, failure
to recognize a serious complication ,
failure to initiate fall prevention
measure that has resulted in patient
falling or loss of vision due to lack of
eye care in unconscious patients.
NEGLIGENCE

A serious
intentional act of
crime is considered
as malpractice
such as knowingly
administering a
harmful drug.
MALPRACTICE OR FELONY

Failing to
diagnose or
misdiagnosing a
MISDIAGNOSIS IMPROPER TREATMENT
Providing
improper
medical care or
SURGICAL ERRORS
Performing the wrong
operation, operating
on the wrong part of
the body, or leaving
foreign objects in the
TYPES OF MALPRACTICE

MEDICATION ERRORS DEFECTIVE
MEDICAL DEVICES
BIRTH INJURIES
Prescribing the
wrong medication
or dosage, or giving
unnecessary
Using
defective
medical
equipment
Failing to diagnose a
medical condition or
birth defect, or
failing to handle
complications

• Revealing highly sensitive
personal information such as
details of diagnosis and clinical
condition without the consent
of the patient to others that
may be claimed to damage the
public image or reputation of
the individual.
• Discussing in public or with
people other than the patient
or his or her health surrogate is
ethically an unacceptable act.
DEFORMATION

NURSES
ROLE
IN
IDENTIFICATION
AND
MANAGEMENT
OF
INPATIENT
ARREST

•Taking cardiac arrest event through prompt
identification and effective resuscitation is part
of day-to-day affair in the critical care units as
well as ER.
•The code blue teams are organized with
competent trained health manpower for
successful resuscitation.
•Once the cardiac arrest is identified , code blue
team is called for to salvage the patient through
public call system

CPR is a basic emergency
procedure for life
support which consists
of artificial respiration
and manual external
cardiac massage.
EMERGENCY ASSESSMENT AND
MANAGEMENT - CPR

•CPR provides blood flow to vital organs
until effective circulation can be re-
established.
•The resuscitation process begins with the
immediate assessment of the patient and
action to call for assistance, as CPR can be
performed most effectively with the
addition of more healthcare providers and
equipment .

1. Respiratory arrest
• Drowning
• Stroke
• Foreign body in throat
• Smoke inhalation
• Drug overdose
• Suffocation
• Accidents
• Epiglottis paralysis
2. Cardiac arrest
• Ventricular fibrillation
{VF}
• Ventricular
tachycardia {VT}
• Asystole
• Pulse less electrical
activity
INDICATIONS FOR CPR

NAME OF
THE DRUG
MECHANISM
OF
ACTION
INDICATIONS SIDE
EFFECTS
NURSES
RESPONSIBILITY
ADENOSINE SLOWS DOWN THE
CARDIAC IMPULSE
CONDUCTION IN AV
NODE , INTERRUPTS
REENTRY PATHWAY
SUPRAVENTRICULAR
TACHYCARDIA
LIGHT
HEADEDNESS ,
NUMBNESS, CHEST
PAIN ,
SWEATING ,PALPIT
AIONS ,
HYPOTENSION ,
NAUSEA ,VOMITING
, INCREASED
RESPIRATORY
RATE
MONITOR VITALS AND ECG.
DISCONTINUE THE DRUG IF
THERE IS INCREASE IN
PULSE , RESPIRATION
ATROPINE ANTICHOLINERGIC ,
PARASYMPATHOLYTIC ,
ANTIARRHYTHMIC
IN BRADYARRHYTHMIA
ORGANOPHOSPHORUS
POISONING ,
PREMEDICATION IN
SURGICAL PATIENTS
HEADACHE ,
DIZZINESS ,
CONFUSION ,
TACHYCARDIA ,
INSOMNIA ,
DRYNESS OF
MOUTH , GI
SPASM , BLURRED
VISION, URINARY
RETENTION , PVC
I/O CHART , ECG
MONITORING FOR PVCs ,
WATCHING FOR
CONSTIPATION , URINARY
RETENTION

NAME OF
THE DRUG
MECHANISM
OF
ACTION
INDICATIONS SIDE EFFECTS NURSES
RESPONSIBILITY
AMINOPHYLLINE RELAXES BRONCHIAL
SMOOTH MUSCLE ,
BRONCHODILATION
BRONCHIAL ASTHMA
CHRONIC
BRONCHITIS
EMPHYSEMA
SEIZURES,
TACHYARRHYTHMIA,
NAUSEA , VOMITING
NO IM ONLY SLOW IV
INFUSION.
MONITOR I/O CHART.
IF URTICARIA DEVELOPS ,
DISCONTINUE THE DRUG
AMIODARONE ANTIARRHYTHMIC
AGENT PROLONGS
PR AND QT INTERVAL ,
DECREASES SINUS
RATE AND
PERIPHERAL
VASCULAR
RESISTANCE
VENTRICULAR
TACHYCARDIA ,
AF , SVT
HEADACHE ,
DIZZINESS ,
CONFUSION ,
NUMBNESS ,
BLURRED VISION ,
PHOTOPHOBIA
MONITOR ECG AND
ELECTROLYTES LEVELS .
IF CONFUSION ,
PSYCHOSIS, AND
NUMBNESS DEVELOP ,
STOP THE DRUG

NAME OF
THE DRUG
MECHANISM
OF
ACTION
RESPONSIBILITY
DOPAMINE INOTROPIC AGENT,
INCREASES
MYOCARDIAL
CONTRACTILITY AND
THEREBY INCREASES
CARDIAC OUTPUT.
SHOCK
HYPOTENSION
OPEN HEART
SURGERY
PALPITATION,
TACHYCARDIA,
ECTOPIC BEATS ,
WIDE QRS COMPLEX
MONITOR VITALS ,
CONTINUOUS BP
MONITORING , AND ECG
MONITORING .
IF BP INCREASES START
TAPERING THE DOSE
DOBUTAMINE INCREASES
MYOCARDIAL
CONTRACTILITY AND
CARDIAC OUTPUT ,
ß AGONIST
HEART FAILURE
CARDIAC SURGERY
PALPITATION ,
HEARTBURN ,
NAUSEA ,
TACHYCARDIA ,
HYPERTENSION
ENSURE FLUID VOLUME
ADEQUACY WITH CVP
VALUES AND CARDIAC
GLYCOSIDE BEFORE
DOBUTAMINE INFUSION.
MONITOR BP , PULSE ,
ECG, SERUM
ELECTROLYTES
CONTINUOUSLY.

NAME OF
THE DRUG
MECHANISM
OF
ACTION
RESPONSIBILITY
FUROSEMIDE POTENT LOOP
DIURETIC, ENHANCES
EXCRETION OF
SODIUM AND WATER
HEART FAILURE ,
TO DECREASE ICP,
TO REDUCE FLUID
OVERLOAD IN RENAL
FAILURE ,
HEPATIC FAILURE
HYPOKALEMIA BE ALERT FOR SIGNS OF
HYPOKALEMIA
MONITOR URINE OUTPUT
LEVETIRACETAM IT BINDS TO THE
SYNAPTIC VESICLE
PROTEIN AND
THEREBY DELAYS THE
NEURAL CONDUCTION
ACROSS THE
SYNAPSES
SEIZURE DISRODER SOMNOLENCE ,
DIZZINESS , FATIGUE
MONITOR FOR ALLERGIC
REACTIONS
THE MEDICINE SHOULD BE
DISCONTINUED IN CASE OF
ALLERGIC RECTION

NAME OF
THE DRUG
MECHANISM
OF
ACTION
RESPONSIBILITY
POTASSIUM
CHLORIDE
REPLENISHES
POTASSIUM ION IN
CASE OF
HYPOKALEMIA
TO CORRECT
HYPOKALEMIA
SHOULD BE INFUSED
SLOWLY. CAN CAUSE
HYPERKALEMIA IF
EXCEEDS NORMAL
LIMIT.
NEVER GIVE AS IV BOLUS,
SHOULD BE GIVEN ONLY
AS INFUSION SLOWLY.
NEEDS CONTINUOUS
MONITORING AND SERUM
K+ MONITORING
NITROGLYCERIN SELECTIVE
CORONARY
VASODILATOR
ACUTE MYOCARDIAL
INFARCTION TO
IMPROVE THE
MYOCARDIAL
PERFUSION AND
REDUCE THE CHEST
PAIN AND REDUCE
BLOOD PRESSURE
PRODUCES VENOUS
DILATATION AND MAY
CAUSE HYPOTENSION
, HEADACHE ,
DIZZINESS
MONITOR BP AND IF
SYSTOLIC BP FALLS
BELOW 90 mmHg, IT
SHOULD NOT BE GIVEN.
IT SHOULD NOT BE TAKEN
WITH SILDENAFIL

NAME OF
THE DRUG
MECHANISM
OF
ACTION
RESPONSIBILITY
NORADRENALINE αADRENERGIC
AGONIST, INCREASES
VASOCONSTRICTION,
AND THEREBY
INCREASES BP
HYPOTENSION ,
SEPTIC SHOCK ,
NEUROGENIC SHOCK
SUPERIOR TO
DOPAMINE
DIZZINESS ,
WEAKNESS , FEELING
COLD , AND
NUMBNESS
MONITOR THE BLOOD
PRESSURE
VASOPRESSIN SYNTHETIC
ANTIDIURETIC
HORMONE THAT
INCREASES SODIUM
AND WATER
REABSORPTION IN
KIDNEY
HYPOTENSION ,
ACUTE CIRCULATORY
FAILURE , BLEEDING
ESOPHAGEAL
VARICES ,
DIABETES INSIPIDUS
SLOW OR UNEVEN
HEART RATE
GASPING
SWELLING
RAPID WEIGHT GAIN
MONITOR BP AND WEIGHT
MONITOR URINE OUTPUT,
SPECIFIC GRAVITY AND
SERUM OSMOLALITY

1. NAME OF THE BOOK :- TEXTBOOK OF MEDICAL SURGICAL NURSING
• NAME OF THE AUTHOR :- BRUNNER AND SUDDARTH’S
• EDITION :- SOUTH ASIAN
• PAGE NO :- 2143 - 2165
2. NAME OF THE BOOK :- MEDICAL SURGICAL NURSING
• NAME OF THE AUTHOR :- BT BASAVANTHAPPA
• EDITION:- 4TH
EDITION
• PAGE NO:- 781 - 797
BIBLIOGRAPHY

CONTI..
3. NAME OF THE BOOK :- TEXTBOOK OF MEDICAL SURGICAL NURSING
• NAME OF THE AUTHOR :- JAVED ANSARI
• EDITION :- 3RD
EDITION
• PAGE NO :- 1169 - 2130
4. NAME OF THE BOOK :- MEDICAL SURGICAL NURSING
• NAME OF THE AUTHOR :- LEWIS
• EDITION:- 2ND
EDITION
• PAGE NO:- 1078 - 1298

END OF PRESENTATION
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