INTRODUCTION TO CRITICAL CARE NURSING PRACTICE

SCOPE OF
CRITICAL CARE
Development
of Critical
Practice,
Education and
Professional
Activities in the
Philippines
Critical Care Body of
Knowledge
Critical Care Competencies
Professional
Organizations
ROMMEL LUIS C. ISRAEL III
1

SCOPE OF CRITICAL CARE NURSING
A critical care nurse is a licensed professional nurse who is responsible for ensuring that
all critically ill patients and their families receive optimal care.
To be able to work in a critical care area other requirements are necessary and may vary
depending on the institution. In the nursing schools, critical care nursing is considered
an elective subject and the exposure of students to critical care practice may not be
enough to preparethem for the complexity of critical care nursing practice once these
student nurses become licensed professional nurses. Therefore, it is necessary that the
health institution as employer provide newly hired nurses with a basic critical care nurse
specialty education and orientation prior to the deployment in the critical care areas. In
the Advanced Practice Nursing level, the advanced practice nurses in the critical care,
must earn an advanced degree either at the master’s or doctorate level in nursing.
2

DEVELOPMENT OF CRITICAL CARE NURSING
PRACTICE EDUCATION AND PROFESSIONAL
ACTIVITIES IN THE PHILIPPINES
• Critical care nursing is the specialty within nursing that
deals specifically with human responses to life-
threatening problems1.These problems deal
dynamically with human responses to actual or
potential life- threatening illnesses.
• The Critical Care Nurses of the Philippines, Inc.
(CCNAPI) is responsible for the promotion of
man’s health and welfare for national
development. It desires to support the
professional and personal growth and
development of initial core nurses. CCNAPI
has organized itself into a national association
committed to the ideals of service to the
people, equality, justice and social progress.
3

Critical Care Body of Knowledge Critical Care Competencies
Professional Organizations
To promote optimal delivery of safe and quality care to the
critically ill patients and their families by providing highly
individualized care so that the physiological dysfunction as
well as the psychological stress in the ICU are under control;
To care for the critically ill patients with a holistic approach,
considering the patient’s biological, psychological, cultural and
and spiritual dimensions regardless of diagnosis or clinical
setting;
To use relevant and up-to-date knowledge, caring attitude and
and clinical skills, supported by appropriate technology for the
the prevention, early detection and treatment of complications
complications to facilitate recovery.
4

CRITICAL CARE BODY OF
KNOWLEDGE
CRITICAL CARE COMPETENCIES
PROFESSIONAL ORGANIZATIONS
4.To provide palliative care to the critically ill
patients in situations where their health status
is progressing to unavoidable death, and to
help the patients and families go through their
painful sufferings.
On the whole, critical care nursing should be
patient-centered, safe, effective, and efficient.
The nursing interventions are expected to be
delivered in a timely and equitable manner.
5

NURSING CARE OF CLIENTS WITH LIFE
THREATENING CONDITIONS , ACUTELY ILL
/ MULTI – ORGAN PROBLEMS , HIGH
ACUITY AND EMERGENCY SITUATION
6

HISTORY
 In 1955, Hall originated the term (care, cure, core) and
developed the 3 steps: note observation, ministration, validation
 In 1959, Johnson concluded “Nursing seen as fostering the
behavioural functioning of the client”.
 1961, Orlando identified 3 steps: client’s behaviour, nurse’s
reaction, nurse’s action. “Nursing process set into motion by
client’s behaviour”
7

HISTORY
• In 1963, Weidenbach were among the first to use it to refer to a
series of phases describing the process.
• In 1967, Wiche ) defined “Nursing as an interactive process
between client and nurse”. 4 steps: Perception, Communication,
Interpretation, Evaluation.
• In 1967, Yura and Walsh suggested the 4 components –APIE.
8

HISTORY
 In 1967, Knowles described nursing process as: discover, delve, decide, do,
discriminate.
 In 1973, ANA published standards of nursing practice. Diagnosis
distinguished as separate step of nursing process .
 In 1980, published Nursing – a Social Policy Statement. Diagnosis of
actual and potential health problems delineated as integral part of
nursing practice
 In 1991, published Standard of Clinical Nursing Practice. Outcome
identification differentiated as a distinct step of the nursing process.
Therefore, the six steps of the nursing process are as follows: A.D.OI.P.I.E.
9

THE PURPOSES OF THE
NURSING PROCESS
Identify the client’s
health care needs
Determine priority
of care goals and
expected outcomes
Establish nursing
care plan to meet
client-centered
needs
Provide nursing
interventions
designed to meet
these needs
Evaluate the
effectiveness of
nursing care
10

COMPONENTS OF NURSING PROCESS
Assessment
Diagnosis
Planning
Implementation
evaluation
11

NURSING PROCESS
• Assessment: data collection:-
• Subjective data … pain
• Objective data …fever
• Diagnosis: determining the problem.
• Planning: developing a plan for care.
• Implementation: applying the plan.
• Evaluation: evaluating the outcomes.
12

NURSING
ASSESSMENT
13

PURPOSES OF NURSING
ASSESSMENT
• To establish a nurse-client relationship
• To gather data about the client’s general
health status, integrating physiologic,
psychologic, cognitive, sociocultural,
developmental, and spiritual characteristics
• To identify the client strengths and coping
abilities
• To identify health problem
• To establish a database for the nursing
process
14

TYPES OF
ASSESSMENT
Comprehensive
assessment
Health history and complete
physical examination
conducted when a patient
first enters a healthcare
setting
Ongoing partial
assessment
Conducted at regular
interval during care of the
patient
Focused
assessment
Conducted to assess specific
problem
Emergency
assessment
A type of rapid focused
assessment conducted to
determine potentially fatal
situation
15

METHODS OF DATA COLLECTION
Interview Nursing health
history
Physical examination Results of laboratory
& diagnostic tests
16

COMPONENT
OF NURSING
ASSESSMENT
A health history and (carried out
first)
Nursing examination (a head-to-
toe, system-by-system physical
examination)
Review of record
17

HEALTH
HISTORY
•The health history is a collection
data that provides a detailed
profile of the client’s health
status
18

COMPONENT OF THE HEALTH
HISTORY
• Biographical data
(name, address, sex, age, marital status, occupation, ethnic origin)
• Informant
(most reliable source is client, other source information)
• Chief complaint
(reason the client requires health care)
19

HISTORY
• History of present illness
(PQRST)
• Past health history
(immunization, allergic, physical exam and diagnostic test, illness,
surgery and injury)
• Family history
(to determine risk factor for certain disease condition)
• Review of system (head to toe --- objective data given by client)
20

HISTORY
• Patient profile
• Developmental factors
• Education and occupation
• Environment
• Spiritual factors
• Interpersonal factors
• Life style (personal habits, diet, sleep/ rest pattern, ADLs, recreation/
hobbies)
• Self concept
• Sexuality
• Stress response
21

•Environment
•Equipment
•Client
PREPARATION
FOR
ASSESSMENT
22

PREPARING FOR ENVIRONMENT
• The nurse should plan time that is appropriate for both the client
and the nurse
• Have a special examination room that provides a quiet, private
space for assessment
• Warm
• Comfortable temperature
• Adequate direct lighting
• Precaution to prevent interruptions by visitor or other health care
personel
23

PREPARING
FOR CLIENT
Physiologic and psychologic
of the client must be considered
when doing nursing
The client is told that a nursing
examination will be done and
assessment are painless
The client is asked to change
the gown
24

PREPARING FOR
CLIENT
The client asked to
the bladder
The nurse should answer
any questions asked by
client directly and
25

POSITION FOR EXAMINATION
26

PREPARING FOR EQUIPMENT
Stethoscope
Sphygmoma
nometer
Thermomet
er
Digital
watch
Tape
measure
Ophthalmos
cope
Otoscope
Snellen
chart
Nasal
Speculum
Percussion
hammer
Clean non
latex gloves
27

PHYSICAL EXAMINATION
Inspection, used to
detect height, weight,
skin color, skin rash,
scars,…
Palpation, used to
detect tenderness,
temperature, texture,
pulse,…
Percussion, used to
detect the location of
organs.
Auscultation, used to
listen to sounds
produced by
cardiovascular,
respiratory,
gastrointestinal
systems.
29

INSPECTION
Inspection is the systematic and
observation of the person using the
of vision, smell, and hearing to
any normal or abnormal findings
Guidelines
• Focus on observation
• Use good lighting
• Expose body part
• Make comparison
30

PALPATION
• Palpation is the use of touch during the physical examination
• Guidelines
• Warm your hand
• Minimize discomfort
• Use the correct part of your hand
• Start light
• Light palpation
• Deep palpation
• Bimanual palpation
• Any area of tenderness is palpated last
• Nurse should be sensitive to the client’s verbal and facial expressions indicating discomfort
31

USES OF YOUR
HAND
32

LIGHT
PALPATION
33

DEEP
PALPATION
34

BIMANUAL
PALPATION
35

PALPATION IS USE TO DETERMINE:
Texture (eg, of
the hair)
Temperature
(eg, of a skin
area)
Vibration (eg,
of a joint)
Position, size,
consistency,
and mobility of
organs or
masses
Distention (eg,
of the urinary
bladder)
Presence and
rate of
peripheral
pulses
Tenderness or
pain
36

PERCUSSION
• Percussion is the act of striking
one object against another for the
purpose of producing sound
• Uses to assess the location, shape,
size, and density of tissue
• Two percussion method
• Direct
• Indirect/ Mediate
37

MEDIATE PERCUSSION
38

SOUND PRODUCED BY PERCUSSION
39

AUSCULTATION
Auscultation is the act of
sound produced within the body
Two methods of auscultation:
Direct (eg, respiration wheeze,
grating of the moving joint)
Indirect (using stethoscope)
40

Order --- IPPA,
except abdomen use
IAPP
41

VITAL SIGNS
Measures :
Body
temperature
Pulse
Respirations
Blood
pressure
42

BODY
TEMPERATURE
The balance
between the
heat produced
by the body
and the heat
lost from the
body
Two kinds of
body
temperature:
Core
temperature
(deep tissues,
eg. Cranium,
thorax,
abdominal +
pelvic cavity)
Surface
temperature
(skin,
subcutaneous
tissues, fat)
43

WHAT PARTS OF THE
BODY ARE USED IN
DETERMINING
TEMPERATURE?
44

FACTORS AFFECTING
BODY TEMPERATURE
• Age
• Diurnal variation
(highest temp 8pm-
midnight, lowest temp
4-6am)
• Exercise
• Hormones
• Stress
• Environment
46

VARIATION IN
BODY
TEMPERATURES
BY AGE
Age Average temperature
Newborn Axillary 36.1-37.7 C 97.0-100F
1 year Oral 37.7C 99.7F
3 years Oral 37.2C 99.0F
5 years Oral 37.0C 98.6F
Adult Oral 37.0C 98.6F
Axillary 36.4C 97.6F
Rectal 37.6C 99.6F
Forehead 34.4C 94.0F
Tympanic 37.7C 99.9F
Elderly (over
70yr)
Oral 36.0C 96.8F
47

PULSE
A WAVE OF BLOOD
CREATED BY
CONTRACTION OF
THE LEFT VENTRICLE
OF THE HEART.
THE PULSE WAVE
REPRESENTS THE
STROKE VOLUME
OUTPUT AND THE
COMPLIANCE OF THE
ARTERIES
48

FACTORS AFFECTING
PULSE RATE
• Age
• Sex
• Exercise
• Fever
• Medications
• Hemorrhage
• Stress
• Position changes
49

PULSE SITES
50

RESPIRATIONS
• The act of breathing; it
includes the intake of
oxygen and the output of
carbon dioxide
51

BLOOD PRESSURE
• Arterial blood pressure is a
measure of the pressure
exerted by the blood as it flows
through the arteries
• Systolic pressure (peak level
when ventricle giving
contraction)
• Diastolic pressure (lowest level
when ventricle rest)
• Normal range (adult) 100/60
sampai 140/90.
52

FACTORS AFFECTING BLOOD PRESSURE
Age Exercise Stress
Race Obesity Sex
Medication
s
Diurnal
variations
Disease
process
53

1. ASSESSMENT
Steps:- Health history
Physical
examination
Laboratory data &
diagnostic
procedures
Validating data Documenting data
54

SOURCES OF
DATA
Client
Family
Health care team
Medical records
Military records
55

TYPES OF DATA
1- SUBJECTIVE DATA
Clients perception about his health problems usually includes
A - Presence of pain
B- Feeling of anxiety
C- Physical discomfort
D. Mental stress
56

TYPES OF DATA
2- OBJECTIVE DATA
Observation or measurement made by the data
collector includes
A – observation (body rash )
B- measured (BP , T , R , head circumference )
57

DIAGNOSIS
58

2. DIAGNOSIS
Steps:-
• Interpreting data
• Identify problems
• Formulating nursing diagnosis
• Documenting nursing diagnosis
Two types:-
- Actual
- Potential
59

3. PLANNING
Steps:-
• Identify client’s goals
• Establish expected outcomes
• Selecting nursing actions
• Delegating action
• Writing nursing care plan
• Consulting
60

Types of goals:-
• short term goals
• Achieved in a short period,
usually less than one week.
• Long term goals
• Achieved over a long period,
usually over weeks or months.
61

4. IMPLEMENTATION
Steps:-
Reassessing client
Reviewing and modifying existing care plan
Performing nursing action
62

5. EVALUATION
Steps:-
• Comparing client response to
criteria
• Analyzing reasons for results
• Modifying care plan
63

NURSING DIAGNOSIS
COMPONENTS
67

PLANNI
NG
1. Planning for Health Promotion
2. Planning for Health Restoration and Maintenance
The planning stage is where goals and outcomes are
formulated that directly impact patient care based on EDP
guidelines. These patient-specific goals and the attainment of
such assist in ensuring a positive outcome. Nursing care plans
are essential in this phase of goal setting
Nurses are the catalysts for healthier
lifestyles through encouragement and teaching,
helping patients to potentially receive
preventative services such as counseling,
screenings, and precautionary procedures or
medications.
Alternative Hybrid Education and Asynchronous Distance Learning
69

Rehabilitation and Health Restoration
Rehabilitation is a process of restoring ill or injured people to
maximum and functional levels of wellness.
Essential points for Maintenance of Health
So just what are the most important factors for
establishing optimum health. Studies indicate that the
following five factors make the biggest difference in
overall health and wellness: 1) diet; 2) rest; 3) exercise;
4) posture; and 5) avoiding the use of alcohol, drugs
and tobacco.
PLANNI
NG
1. Planning for Health Promotion
2. Planning for Health Restoration and Maintenance
70

PLANNI
NG
71

Implementation is when you put the
treatment plan into effect. This typically begins
with the medical staff performing any needed
medical interventions. Then, the patient follows
the plan for optimum recovery. As a nurse, you
will be expected to monitor the implementation
to ensure the patient is following through.
IMPLEMEN
TATION
Implementation is the step that involves action or
doing and the actual carrying out of nursing
interventions outlined in the plan of care.
74

NURSING
IMPLEMENTATION
Providing physical
treatments, emotional
support, and patient
education are all examples
nursing interventions.
Nurses typically perform
these actions as part of a
nursing care plan to monitor
and improve their patient's
comfort and health.
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75

A. INDEPENDENT
NURSING CARE
1. Physiologic Care
2. Psychosocial Care
3. Spiritual Care
Independent nursing Care are the tasks that a
nurse can perform without input from another
discipline, particularly without a physician's order.
These interventions include many basic comfort care
actions such as providing water, repositioning a
patient, providing toileting assistance, and bathing.
Independent nursing Care are activities that
nurses are licensed to initiate based on their
sound judgement and skills. Includes: ongoing
assessment, emotional support, providing comfort,
teaching, physical care, and making referrals to other
health care professionals.
76

B. INTERDEPENDENT
CARE
1. Pharmacological Therapeutic
2. Complementary and Alternative Therapies
3. Nutritional and Diet Therapy
4. Surgical intervention
5. Immunologic Therapy
Pertaining to actions or activities
that require one individual to work with
another. Interdependent nursing actions
are those that are performed by the
nurse after mutual determination by the
nurse and the physician.
77

INTERDEPENDENT
NURSING CARE
Are those that nurses perform as part of
a collaborative team of medical professionals
working together to care for a patient.
An example of an interdependent
intervention could include a patient
recovering from knee surgery who is
prescribed pain medication by a physician,
administered medication by a nurse and
given physical therapy exercises by a
specialist.
78

PATIENT EDUCATION CAN
BE DEFINED AS THE PROCESS OF
INFLUENCING PATIENT BEHAVIOR AND
PRODUCING THE CHANGES IN KNOWLEDGE,
ATTITUDES AND SKILLS NECESSARY TO
MAINTAIN OR IMPROVE HEALTH.
Patient Education include:
•Delegate more responsibilities to support
staff and be more focused on patient
education.
•Begin educating patients with every
encounter from admission.
•Find out what the patient already knows.
...
•Feed patients information in layman's
terms.
79

Evaluation: Monitoring (and documenting) the
patient's status and progress towards goals, and
modifying the care plan as needed.
Outcome Evaluation The fifth step of the
process, outcome evaluation, attempts to interpret
the results and evaluate the outcomes of the
applied evidence (intervention).
Expected outcomes are statements of measurable
action for the patient within a specific time frame
that are responsive to nursing interventions. Nurses
may create expected outcomes independently or refer
to classification systems for assistance.
EVALUATION OF THE OUTCOME
OF CARE
80

REPORTING AND
DOCUMENTATION OF CARE
Documentation is anything written or printed that is
relied on as a record of proof for authorized persons.
Documentation and reporting in nursing are needed for
continuity of care it is also a legal requirement showing the
nursing care performed or not performed by a nurse.
Nursing documentation is essential for good
clinical communication. Appropriate documentation
provides an accurate reflection of nursing
assessments, changes in clinical state, care provided
and pertinent patient information to support the
multidisciplinary team to deliver great care.
81

1. Admission nursing assessment
2. Nursing Care plan
3. Kardexes
4. Pertinent
5.Medication with date of order & time of
administration
6. Daily treatment & procedures
7. Flow chart
8. Graphic record(TPRBP)
9. Fluid balance record
10. Medication
11. Skin assessment record
12. Progress notes
82

INTRODUCTION TO CRITICAL CARE NURSING PRACTICE

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