This presentation includes the Medical as well as the Nursing Management of the patients in the ICU or CCU or those are critically ill.

1. Management Of Patients
With Critical Illness
Presented by : Chetna Bhatt
College of Nursing
Dr. Rml hospital
3rd year

2. Introduction
◦ The concept of critical care was introduced by Ms. Florence
Nightingale in the 1800s .
◦ Critical care nursing is a well developedspecialty of nursing
that focuses on care of the patients with life-threatening
health problems requiring continuous monitoring and
advanced treatment .
◦ Intensive care , also known as critical care , is a
multidisciplinary and interprofessional specialty dedicated to
the comprehensive management of patients having ,or at risk
of developing acute , life threatening organ dysfunction .

3. Principles Of Critical Care
Nursing
• Astute assessment and continuous monitoring
✓Smart in making quick but accurate assessment
✓Early identification and treatment
✓Must apply advanced assessment skills
✓Carefully observe the cardiopulmonary , neurological and renal system
functions
✓Documentationof these parameters
✓Proficiency in advanced assessment and complex procedure and
competencyin handling gadgets such as ventilators , hemodynamic
monitors , defibrillators , extracorporeal membrane oxygenator (ECMO)
machine

4. • Anticipation of complications
✓Anticipation and identificationof evolvingcomplications
✓Facilitates intervention to avert deterioration in the patients
condition
✓Critical Care Nurse initiatesproactivemeasures using evidenced-
Based Guidance , Critical Care Pathways and care bundles before
complications
• Collaboration
✓Critical care warrants a team approach and every memberof the
team deserves recognitionfor his or her irreplaceable contribution
for the provision of high-quality critical care.
✓Critical care nurses in association withother team members take
activeparticipationto save the patient
• Comprehensive care
✓Providecomprehensive care by applying independent and
interdependent nursing interventions including selectedproven
alternative care modalities.

5. •Communication
✓ Skillful communication within the critical care team is the basis of
all quality care in ICU. It facilitatessmooth functioning of ICU team
and prevents the patient safety mishaps.
•Ethical and humanistic care:
✓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 ICUS
that cannot be compromised for high-tech care.
✓Breaking bad news has to follow a certain so that the bereaved
family membersare protocol supported well physically,
emotionally, and spiritually.
✓Nurses help in meetingthe spiritual needs of the dying patients
according to their beliefs and cultural norms.

6. Intensive Care Unit
• An ICU or CCU is a geographical area in a hospital where the
patients with life threatening illness or injuries are cared .
• ICU is the area of the hospital where the sickest patient and
capability to manage are moreconcentrate .
• It provides vital function and uses the skills medical nursing,
and other personnel experienced in management of those
problems .

7. Classification
Level I Level II Level III
It is located in a small
hospital, providing
resuscitationand
short-term pulmonary
support for less than
24 hours.
It is an adult ICU
located in a larger
hospital with
qualifiedintensivisit
and provides
multisystem support
. It may lack in some
form of advanced
therapy
Its an adult ICU
located in a large
tertiary care
center with the
capability of
providing
comprehensive
critical care of
prolonged period
of time .

8. Open ICU
•Open ICU is one where a group of critically ill
patients may be treated and managed not by
critical care medicine qualified consultants but by
different specialist.
Closed ICU
•Closed ICU is an ICU that is managed by a qualified
critical care specialized physician round the clock
24x7. patient care management decisions are taken
primarily by the intensive care consultant.

9. Organisation of a Critical Care Unit
❖ Bed Strength :
• ICU should have 6 to 14 beds .
• In an ICU with a larger number of beds , it has to be divided into pods
containing 10 to 15 beds .
❖ Location :
• CCU has to be ideally located in a separate area with easy accessibility to the
emergency department , operation room ,radiology department
,catheraterization laboratory and blood bank .
• Should be big lift , ramps and a wide corridor that can facilitate smooth
transfer in and out .
• Single entry and exit .
❖ The Floor Space :
• 125 to 150 sqft. per patient
• For separate room , 300 ft2 per patient
• Between bed space : 4 to 4.5 ft
• Separate rooms : the room should be bed with hand washing facility and area
to accommodate the ventilators , monitors and other gadgets .

10. ❖Nurses Station :
• There shouldbe a central nursing station with telemointoring devices . This
will enable monitoring of patients placed ideally in a “C” or “L”.
❖ Other Facilities:
• Storage space for equipments .
• Separated room for doctors office , nurses office and toilet have to be
provided .
• There may be provision of RO-purified.
• There shouldbe minimum of 2 or 3 O2 outlets , 2or 3 vacuum outlets , and 1
or 3 compressedair outlets .
• 16 or 18 electricoutlets / patient .
• Natural lightning .
• Hand washing facility .
❖ Environmental criteria:
• Fully air conditioned.
• 12 or 16 exchanges and 55% to 60% humility .
• Laminar flow is preferable.

11. Equipments And Supplies
◦ Ventilators ( at least one per bed)
◦ Noninvasive ventilators
◦ Multichannel monitor
◦ Defibrillators and pacemakers
◦ Infusion pump
◦ Fluid and bed warmers
◦ Specialized beds
◦ Bedside trolleys , drug cart and emergency cart
◦ Portable X- Ray machine
◦ ECG monitor
◦ Pressure monitor
◦ Temperature monitor
◦ End-tidal CO2 monitor
◦ Pulse oximeter
◦ Endotracheal tubes (ET) , tracheotomy tubes , airways , suction tips
and ICU tubes

12. Organization of Human Resource
Medical
Team
Director
Critical Care
Medicine
Consultant
Intensive Care
Medicine
Specialist
Other
Specialist
Junior Medical
Officer
Residents

13. Nursing
Team
CC
Specialized
Nurse
Manager
Senior
Charge
Nurse
CC Nurse
educator
Nurse-Patient Ratio : 1:1 ( for ventilated ) , 1:2 ( for non-ventilated) and 2:1
(on ECMO)

14. Other
Personnel
Respiratory
Therapist
Physiother
apist
ICU
technician
Dietician
Clinical
Pharmacis
t
Radiograp
h
Computer
operator
Health
attendant
Sanitary
attendant
Security
Guard

15. Protocols and Policies
Protocol is a set of written rules or precisely delineatedsteps usually
developedand tested by well controlledclinical research for desired
clinical outcome .
▪ Stress ulcer prevention protocols
▪ DVT prevention protocols
▪ BLS protocols
▪ ACLS protocols
Guidelines are written policy statements.They help in smooth functioning of
the unit and avoid confusions in delivery of care.
▪ AdmissionPolicy
▪ Discharge Policy
▪ Organ Donation Policy
▪ Treatment Policy

16. QualityIndicators
InCriticalCare

17. Hospital-Acquired Infection
Nosocomial infectionor HAI can be defined as any newly acquired
infections that arise after 48 hours of admissionto the hospital .
CCU are the seat of many HAI because of two reasons;
1) The no. of invasive procedures occurring in the CCU.
2) The critical nature of illness renders the patient susceptible to
Nosocomial infection.
4 Major Types of HAI :
1. VAP
2. CAUTI
3. Central catheter-related bloodstream infection ( CRBSI)
4. Surgical Site Infection (SSI)

18. Sources
◦ ICU environment , the ventilators monitors , floors, and door knobs , which
may harbor some notorious infectious agent
◦ Possibility of some organisms being harbored by patients themselves ,
which may be transmittedendogenously to elsewhere .
◦ Other patients
◦ Healthcare professionals
◦ Visitors
Risk factors
◦ Acuity of illness
◦ Physiological stress response
◦ Too many invasiveprocedures and lines in situ
◦ Malnutrition
◦ Comorbidities
◦ Antibiotic abuse
◦ Immobilization
◦ Immunocompromised state

19. Ventilator-associated
Pneumonia

20. ◦ Serious infection, defined as pneumoniathat occurs within 48
hours or more after ET intubation or tracheostomy caused by
infectious agents not present or incubating at the time when
mechanical ventilation was started
CLINICAL FEATURES :
❖Newly occurring infiltrationon lungs fields in the chest X-Ray
❖Fever
❖Leukocytosis/leukopenia
❖Purulent Tracheal Secretion
❖Positive culture for tracheal aspirate

21. Pathop
hysiolo
gy
Pneumonia
Colonization and infiltration of lower airway and lung field
Movement of these organism down the lower airway with
mechanical ventilation
Escape of the pathogenic biofilm into trachea through fold in
the cuff
Pooling of secretion above the cuff and rapid colonization
Aspiration from nasogastric
tube
Biofilm formation within the
ET tube
Loss of protective upper airway reflexes
ET tube insertion and mechanical ventilation
The artificial
airway
introduced
into the
respirator
tract negates
the
protective
such as a
gag reflex ,
coughing
reflex ,
humidificatio
n and filtering
of air
available to
the patient .

22. Prevention
◦ Keep the head end of the bed elevatedat the degree 30 to 45
to prevent aspiration of gastric content and gastric reflux .
◦ Provide oral care with chlorhexidinesolution (strength 0.12%)~
reduce the colonization
◦ Reduce unplanned extubation and reintubation.
◦ Institute gastric ulcer prophylaxis .
◦ Monitor ET tube cuff pressure (20-30mm Hg)
◦ Provide suctioning through the subglottic port to avoidpooling of
secretion.

23. Catheter-related
Bloodstream Infection
or
Central Line-Associated
Bloodstream Infection
(CLABSI)

24. Definition
◦ CLABSI is a laboratory-confirmedbloodstream infection in which
central line is in place within 48hrs before the development of the
blood stream infection .
◦ CRBSI is defined as the bloodstream infection fulfilling at least one
of the three criteriastated below .
i. Same organism has grown in the quantitative blood culture
drawn through the central line and the peripheral veinwith
colony count 3 times higher in the central line .
ii. Same organism extracted from the precutaneous blood culture
and the catheter tip
iii. Shorter time to positive culture from the central line sample than
from the peripheral line sample (>2 hrs earlier )

25. ◦ Causes :
➢Coagulase-negativestaphylococci
➢Enterococci ( vancomycin-resistant enterococci)
➢MRSA-positiveStaphylococcus aurers
➢Klebisella
➢Pseudomonas
➢Aceinetobacter
➢E.Coli
◦ Risk factor present in the host :
➢Immunocompromisedstate
➢Prolonged hospital hospitalization before catheter insertion
➢TPN and dialysis
➢Chronic illness
➢Extremes of age
➢Burns and other skin pathology

26. Pathophysiology
◦ In the non-tunneledcatheter , the bacteria found on the skin
migrate along the catheter from the skin exit point and enter
point and enter the blood vessel causing colonizationand
infection
◦ Improper hub manipulation causing breech in the aseptic
precaution leads to intraluminal spread of the infection.
◦ Femoral catheter insertion, especially in obese patients , causes
extraluminal spread of fungal infectionmore easily.

27. Management
◦ After taking blood culture , empirical antibiotictherapy may be
started .
◦ On receiving culture report based on the sensitivity , systemic
antibiotictherapy shouldbe started and may be given for 2 week
◦ If CLABSI is proven , the catheter can be removedand tip sent for
culture and sensitivity
◦ In hemodialysis , topical and systemic antibiotic therapy may be
initially attempted
◦ In case of tunneled catheter getting infected, it needs to be
removed.

28. Prevention◦ At the time of central line insertion
i. Perform hand hygiene with soap and water or foam or alcohol-basedgels .
ii. Ensure adherence to infection control protocol while the insertion
iii. Use of gloves does not prevent hand hygiene.
iv. Avoidusing the femoral vein for central venous access in obese adult
patients
v. Do not use peripherally insertedCVC (PICS) as a strategy to reduce the risk
of CLABSI.
vi. Use maximum sterile barrier precautions during CVC insertion, which include
wearing sterile PPE and draping the whole body with a large sterile sheet.
vii. For smooth complication-free internal jugular catheter insertion, use
ultrasoundguidance.
viii. Apply an alcohol based or chlorhexidine antiseptic solution for skin
preparation before puncture.
ix. Allow the antiseptic solution to dry before making the skin puncture.

29. CLABSI/CRBSI prevention: Catheter
maintenance bundle
◦ Maintain appropriate nurse: patient ratio.
◦ Before touching the patient and the central venous , perform hand
hygiene.
◦ Catheter hubs , needleless connectors,and injection ports need to be
disinfectedby using sterile swab and 70% alcohol or povidone-
iodine/chlorhexidine based sol. before accessing the central line.
◦ Apply mechanical friction for no less than 5 seconds before touching any
part of tubing , hubs or connectors ports to reduce contamination.
◦ Use the central vascular access to the period most necessary.
◦ Regularly assess the need for central venous access and if not necessary,
remove it at the earliest.

30. ◦ For nontunneled catheter, change the soiled dressing at once. If
there is gauze dressing, change the dressing with all aseptic
precautions once in 2 days. In case of transparent dressing, it can
be changed once in 5 to 7 days' time.
◦ Blood sets have to be changed in 24 hours' time
◦ IV sets used for infusing lipidemulsion, propofol, need to be
changed in 12 hours' time.
◦ - IV line can be changed at least within 96 hours.
◦ - Use antimicrobial locks.

31. CATHETER-ASSOCIATED
URINARY TRACT
INFECTION

32. CAUTI Urinary Catheter
Insertion Bundle
Perform hand hygiene immediately before and after insertion or any
manipulation of the catheter device or site.
Ensure that only trained persons who know the correct technique of aseptic
catheter insertion and maintenance are given this responsibility.
Insert urinary catheters using aseptic technique and sterile equipment.
Use sterile gloves,drape, sponges, and an appropriate antisepticor sterile
solution for periurethral cleaning, and single-use packet of lubricant jelly for
insertion.
Properly secure indwelling catheter after insertionprevent movement and
urethral traction.
Consider using the smallest-bore catheter possible, consistent with good
drainage, to minimizebladder neck and urethral trauma.

33. CAUTI-Urinary Catheter
Maintenance
◦ Following aseptic insertion of the urinary catheter, maintain a closed
drainage system.
◦ If break in aseptic technique, disconnection, or leakage occur, replace
the catheter and collecting system using aseptic technique and sterile
equipment.
◦ Consider using urinary catheter systems with preconnected sealed
catheter-tubing junctions.
◦ Maintain unobstructed urine flow by the following:
◦ Keep the catheter and collecting tube free from kinking
◦ Keep the collecting bag below the level of the bladder at all times.
◦ Do not rest the bag on the floor.
◦ Empty the collecting bag regularly using a separate, clean collecting
container for each patient; avoidsplashing, and prevent contact of the
drainage spigot with the nonsterile collecting container.

34. •Use standard precautions, including the use of gloves and gown as
appropriate, during any manipulation of the catheter or collecting
system.
•Changing indwelling catheters or drainage bags at routine, fixed
intervals is not recommended. Rather, it is suggested to change
catheter and drainage bags based on clinical indications such as
infection, obstruction, or when the closedsystem is compromised.
•Unless clinical indications exist (e.g., in patients with bacteriuria on
catheter removal post urological surgery), do not use systemic
antimicrobials routinelyto prevent CAUTI in patients requiring either
short or long-term catheterization.
•Do not clean the periurethral area with antiseptic to prevent CAUTI
while the catheter is in place. Routine hygiene (e.g. cleansing of the
meatus during daily bathing) is appropriate.
•Unless obstruction is anticipated (e.g., as might occur with bleeding
after prostatic or bladder surgery), bladder irrigation is not
recommended.

35. Infection Control
In ICU

36. General Measure for
Infection Control
1. Early identification and isolation of patients with signs of infection:
❖ Perform vigilant and continuous monitoring of all critically ill patients for
early signs of infections such as Leukocytosis,diarrhea, skin rashes,
fever, known carrier of pathogenic bacteria, and neutropenia
❖ Identify those with evidence of infections at an early stage and isolate
(symptomatic isolation).
❖ For those with neutropenia, follow reverse isolation to protect the
patients from acquiring infectionfrom others.
2. Strict adherence of standard precautions:
❖Minimizecontact with the blood, body secretions,and patient care
areas.
❖Adhere to strict hand hygiene
❖Wear personal protective equipment
❖Perform appropriate biomedical waste management

37. ❖Prevent needlestick/sharpinjuries.
❖Perform appropriate spill management environmental cleaning and
environmental cleaning .
3. Biomedical waste disposal:
❖There shouldbe strict adherence to segregation of waste at the point
of generation and disposal of waste as per the biomedical waste
management protocol.
❖All laboratory specimens shouldbe packed in spillage free container
and transported at the earliest.
❖Specimens taken from patients known to harbor HBV, HCV, and HIV are
to be labeled with biohazard symbol and sent separately.
4. Disinfection and cleaning of instrument and linen:
❖Used contaminatedinstruments such as bronchoscopes and
endoscopes can be cleaned thoroughly and dried before immersing in
chemical disinfectants(use 2% glutaraldehyde for more than 20
minutes).
❖Linen contaminatedvisibly with blood and body fluids need to be
treated with 2% sodium hypochloritesolution before further cleaning.

38. 5. Maintenance of ICU environment:
❖Floor cleaning more than once a day is needed.
❖There shouldbe restriction of street clothes for all visitors and healthcare
professionals.
❖There shouldbe provision for hand hygiene at the entrance of the
critical care unit.
❖It is desirable to have automated doors with sensors fitted on the doors.
❖There shouldbe provision of alcohol-based hand rubs at each bed side.
6. Training and education of all healthcare workers:
Hand hygiene and other infectioncontrol policies need to be oriented to all
new employees and periodical refresher course on infectioncontrol is
essential to implement the infectioncontrol program effectively.
7. Antibioticstewardship:
Antibiotic abuse will lead to development of antibiotic-resistant strains.
8. Institute an active infection control committee and appropriate infection
control surveillance

39. Specific Preventive
Measures
Airborne / Droplet
Protection
Contact
Precautions
Patients harboring agents that spread
through air droplets such as M.tuberculosis,
H. influenza, Neisseria meningitidis , and
Mycoplasma pneumoniae have a 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 neg. pressure ventilation
Limit the movement of patients
Visitors and care providers have to wear
N95 respirator mask
Isolate the patient.
Avoid use of equipment and
patient care items of eye
patients.
Limit the movement of
patients.
In unavoidable circumstances,
proper disinfection of items
should be done.

40. Assessment Of
Critical Illness In
General Medical-
surgical Wards

41. Physiological alterations that occur prior to critical illness or a
cardiopulmonary arrest are hypotension, tachycardia or bradycardia,
altered respiratory rate (RR), labored breathing reduced urine output,
and new changes in neurological status
Subbe et al. (2001) have developedand validated a system a early
warning scoring with five parameters, namely,system blood pressure,
RR, heart rate, temperature, and neuralgicstatus, using AVPU score.
In the AVPU scoring system:
• A: Alert
• V: Verbal response positive
• P: Painful stimuli positive
• U: Unresponsive for all stimuli

42. Modified Early Warning Signs
(MEWS)

43. Assessment Of Critically Ill Patients In The ICU
Initial Assessment Secondary Survey
A: Airway
B: Breathing
C: Circulation
D: Disability or neurological
E: Environmental exposure
Relevant history
Head-to-toe examination
Reassessment of ABCDE and vitals
Blood test
X-ray
ECG
Echo/ultrasound
CT/MRI

44. ManagementAssessment
Secure the cervicalspine in case of
suspected injury with a hard collar
• Open airway using head-tilt/chin-
lift maneuver thrustmaneuver in
suspected cervicalinjury
• foreign body if any using finger
sweep technique
• Apply oropharyngealsuction
• Insert oral airway or, if needed,
Endotrachealairway
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 indicate secretion
clogging the airway
• No breath sounds indicate complete
obstruction
• Feel for air movement with your hand
closer to the mouth
Airway
•Administer high-concentration
oxygen
•In case of COPD, lower
concentration of oxygen using
venturimask may be administered
(2 to 3 L/min) If all these measures
are failed, administer oxygen,
through NIV or mechanical
ventilator
•In case of suspected
pneumothorax or hemothorax
insertion of intercostal drainage
tube may be necessary
Look for bilateral chest movement
In case of pneumothorax,sucking of chest
wall may be present
Check respiratory rate and rhythm:RR 8 or
>25 breaths/min indicates ventilation
problems
Listen for the breath sounds, crackles,
wheeze, etc.
Observefor cyanosis or mottled skin
appearance;indicates poor oxygenation
Check the oxygen saturation using a pulse
oximeter
Breathing

45. ManagementAssessment
•Insert a large bore needle and
send blood for investigations
including grouping and cross-
matching
•Connect the patient to
continuousECG monitor and BP
monitor
•Replace the lost fluid volume
•If the cause of compromised
circulation is cardiac with
presence of dyspnea,crackles,
and increased JVP, do not
force fluid. Instead,start
inotropic agents
•In those patients with chest
pain, start nitroglycerine and
ACS management
•If there is internal or external
bleeding, prepare the patient
for eventualsurgical
intervention to arrest bleeding
•Observethecolor of the digits, as well as
the oral mucosa, lips for peripheral and
central cyanosis
•Assess the pulse rate, rhythm;<60 or
>120/min indicates compromised
circulation
•Barely palpable carotid pulses suggest a
poor cardiac output,while a bounding
pulse may indicate sepsis
•Feel for peripheral warmth.Cool and
clammy extremities indicates poor cardiac
output
•Assess the urine output by passing a urinary
catheter.If it is <0.5 mL/ kg/h, it indicates
poor cardiac output
•Check the blood pressure. Low BP with
collapsed central veinsindicates circulatory
compromise
•Auscultatefor the heart sound; crackles
indicate pulmonary edema
•Observefor internal or external blood loss
•Assess the ECG pattern
Circulation

46. Assessment Management
Disability or
neurological
status
•Assess the level of consciousness
using GCS and pupillary reaction
•Assess AVPU, where A, alert/eye
opening; response to verbal stimuli/
for pain only/U unresponsive
•Check blood glucose values to rule
out hypoglycemia or
hyperglycemia
•Check for sedative medications
•Identify and check for consumption
of poison/drug
•Check for traumatic brain injury
•Correct the
derangements in ABC
•Nurse the patient with
head-end elevated
position
•Correct hypoglycemia
with 10% dextrose or inj.
glucagon
Exposure
•Complete assessment including
the back for injury with total
body exposed after ensuring
complete privacy and dignity
•Assess the temperature for
hypothermia
Maintain body
temperature with
blanket or warmer

47. HEMODYNAMIC
MONITORING
Hemodynamic is a general term referring to the
movement or flow of blood. More specifically , this term
refers to the measurement of and general principles
governing the flow of blood in the human body

48. Continuous arterial pressure monitoring, central venous pressure, and
pulmonary artery pressure monitoring play a vital role in appropriate
management of patient.

49. Parts of Hemodynamic Monitoring System :
❖An invasive catheter and high-pressure tubing that the patient to the
transducer connect
❖The transducer that converts the physiological signal from the patient
into electrical signals
❖The flushing system that maintains the patency of the fluidfilled tubing
and catheter
❖ A bedside
monitor that
receives electrical
energy from the
transducer and
displays it in
waveform and in
digital scale

50. Nursing Alerts in Hemodynamic
Monitoring
◦ Calibrate the equipment periodicallyfor accurate hemodynamic
measurements at the start of everyshift.
◦ Maintain the phlebostatic axis for accurate measurement.It means
that the transducer is kept at a height that corresponds to the left
atrial level.
◦ Monitorthe hemodynamic parameters and record them. Compare
the hemodynamicwaveformsand hemodynamic parameters with
other clinical parameters.
◦ Maintain the appropriate hand hygiene whilehandling the
monitoring system and maintain the closed system all times.
◦ Maintain the flushing system and the hemodynamic monitoring
system and the intravascular catheter free of air or clot.

51. ◦ Perform sterile dressing changes to the catheter insertion site
◦ Monitor the peripheral pulse, peripheral warmth, and capillary refill distal
to the catheter insertion site.
◦ Maintain sterility of port while handling it for flushing, taking samples for
ABG, etc., by cleaning it with alcohol swab and by taking samples
aseptically. After taking samples or handling the port, wrap it with a
sterile towel.
◦ Inspect the catheter insertion area for signs of Infection such as redness,
induration ,warmth at the site, and fever.
◦ Prevent air embolism by purging out the air bubbles, Let out the air
bubbles from the whole flush solution and system before connecting it.
◦ Maintain the transducer without getting damped to maintain accurate
recording
◦ Do not introduce dextrose-containing solutioninto the monitoring system

52. Nursing
Management

53. Nursing Diagnosis
1. Ineffective airway clearance related to diminished gag reflex and/or
excessive secretion as evidencedby visible or audible secretion,
increasedRR, increasedairway pressure alarm in ventilatedpatients, and
restlessness
2. Impairedgas exchange related to ventilation-perfusionmismatch as
evidencedby cyanosis in the oral mucosa, lips , SpO2 <93%, hypoxemia,
hypercapnia, resettlement, and abnormal RR and rhythm
3. Decreased cardiac output related decreased fluidvolume or poor
contractility of heart and/or dysrhythmiaas evidencedby hypotension,
increasedor decreased heart rate, feeble peripheral pulses and cool
extremities, and urine output 30 mL/h or <0.5 mL/kg/h
4. Impairedcerebral tissue perfusionrelated to increased Intracranial
pressure (ICP) or CNS depression/CNS infection as evidencedby changes
in the level of consciousness, bradycardia, changes in rate and pattern of
respiration, changes in the pupillary reflex and size and shape of pupils

54. 5. Self-care deficit related to critical illness and low consciousness
6. Anxiety related to threat to lifeand fear of death
7. Pain related to tissue damage
8. Impairedphysical mobility related to changes in the level of
consciousness or poor cardiac reserve or increasedwork of breathing
and fatigue or trauma
9. Impairedverbal communication related to presence of artificial airway
10. Sensory perceptual disturbances related to noisy gadgets ICU
environment, etc.
11. Risk for infection related to presence of invasive lineand physiological
stress
12. Risk for fall related to changes in the level of consciousness

55. Airway Management
To maintain patent airway, the following nursinginterventions have to be followed:
• Place oropharyngeal airway to prevent tongue falling back/to prevent biting the
ET tube.
• Elevate the head end of the bed 30 ° to 40° to prevent aspiration of gastric
content and gastric reflux.
• If Oral secretions are more, apply suctioning.
• If the patient is intubatedand on ventilator, perform gentle ET suctioning. While
introducing, do not apply suction as the suction tip is withdrawn. Apply suction
and rotate the tube 360° and complete suction. The duration of suction should be
limited to 15 seconds.
• At the end of ET suctioning, oropharyngeal suctioning can be done.
• If secretion is thick, provide nebulization therapy.
• If patient is on ET tube, mark the lip level and record it and maintain the same to
identify and prevent the descent of ET .
• Auscultate the breath sounds.
• Provide chest physiotherapy to loosen the secretion.

56. Gas Exchange and Ventilator
Management
◦ Assess the mode and ventilator parameters, the ventilator connections, and
circuits.
◦ Place the patient in low Fowler's position.
◦ Monitor that the patient is delivered set tidal volume and pressure.
◦ Monitor the positive end-expiratory pressure (PEEP).
◦ Monitor the ABG, SpO2
◦ Set the alarm at the appropriate level.
◦ Before silencing the alarm, check the reason for alarms and manage
appropriately.
◦ Ensure that the set tidal volume is delivered by inflatingthe cuff with
appropriate pressure (20 to 25 mmHg) using minimal leakor minimal occlusive
volume technique so as to prevent air leakor aspiration of pooled secretion.
◦ As and when required (high airway pressure alarm, patient fighting with
ventilator, audible or visible secretion, decrease in SpO2), perform gentle ET
suctioning to keep the airway patent.
◦ Administer nebulizer as per prescription.

57. Maintaining Adequate Cardiac
Output/ Fluid Management
• Monitor the blood pressure continuously using invasiveor noninvasive
technique
• Establish venous access either central or peripheral, and administer normal
saline at the prescribed rate.
• Replace electrolytes lost through infusionof IV fluids.
• If there is a blood loss, arrange and transfuse compatible blood.
• In case hypovolemiais not the cause for the decreased cardiac output,
do not rush the IV fluids; it may be counterproductive.In such a case,
inotropic agent and correction of dysrhythmiaare useful.
• Administer inotropic agents such as inj. dopamine, dobutamine, or
adrenaline or noradrenaline as per the prescribed dose.
• Monitor the CVP pressure, and check peripheral pulse, peripheral warmth,
and urine output hourly.
• Maintain optimum fluidvolume.
• Monitor strict intake-output chart. The urine output of 1 mL/kg/h is
considerednormal. Urine output <0.5 mL/kg/h is critical low.

58. Maintenance of Cerebral Tissue
Perfusion
◦ Elevate the head end of the patient at 30° to improve venous return from the
head.
◦ Maintain the head, neck, and body in normal alignment to facilitate venous
return.
◦ Monitor neurological status, vital signs, SpO2 , pupillary signs, and reflexes.
◦ Maintain patent airway by oropharyngeal or ET suctioning (as indicated).
◦ Administer the prescribed supplemental oxygen so as to have SpO2 >95% and
avoid hypercapnia that will dilate the cerebral blood vessels and increase ICP.
◦ Reduce the high-volume alarm sounds so that excessive stimulation is avoided.
◦ Maintain the blood pressure within normal limits so that appropriate cerebral
perfusion pressure is maintained.
◦ Maintain normothermia. If the patient has hyperthermia, initiate aggressive
hypothermia measures to bringback the temperature to normal level as
hyperthermia will further aggravate the ICP.
◦ Administer prescribed anticonvulsants and anti- inflammatory or diuretic agents
in case increased intracranial signs and symptoms are present.

59. Maintenance of Physical Mobility
and Prevention of Deep Vein
Thrombosis/Pressure Sore
◦ The patient may be kept on absolute bed rest if the conditionwarrants
such as ACS.
◦ Encourage bed mobility as much as possible.In unconscious patients,
provide passiveexerciseand every second hourly, change the position.
◦ Apply thromboembolicstockings.
◦ Observe the skin color over all the bony prominences every second hour at
the time of positionchange. Be alert to identify stage 1 pressure ulcer
through purple discoloration.
◦ Improve comfort in bed.

60. Pain Management
◦ Effective pain management in the critically ill not only reduces the length
of ICU stay but also improves the quality of care and patient satisfaction.
◦ Critically ill patients experiencepain during rest, routine ICU procedures,
and special Procedures
◦ Verbal self-report of pain is a reliable and easy way of assessing pain.
◦ Critical Care Pain Observation Tool and Behavioral Pain Rating Scale were
found to be validtools for pain assessment in patients who cannot
verbally report their pain
◦ In the Behavioral Pain Scale, facial expression,upper limbmovement, a
compliance with ventilator are the three areas assessed.
◦ The least score is 1 in each area, maximum is 4, and the total score is 3 to
12. Minimum score is 3, which indicates no pain, and maximum score is 12.
Scores of 6 and above need an analgesic

61. ◦ The choice of analgesics varies according to the pain intensity and the
intended procedure.
◦ The opioid analgesics,namely, fentanyl, morphine,hydromorphone,
methadone, and remifentanil, may be used alone or in conjunction with
nonopioid analgesics.
◦ In patients on mechanical ventilator, benzodiazepine sedatives such as
propofol or dexmedetomidine are preferred over benzodiazepine
sedatives, namely, midazolam and lorazepam
◦ Nonopioid analgesics such as ketamine (IV), acetaminophen/
paracetamol (IV/per oral), ketorolac (IV/IM), and ibuprofen (IV/per oral)
may be given to reduce the dose of opioid analgesics.
◦ To manage pain arising from neurological ailments, opioids along with
gabapentin or carbamazepine may be prescribed.

62. Nutritional Management
◦ Nutritional assessment shouldbe carried out based on the disease severity,
previous nutritional intake, comorbidity, and functional status of GI tract.
◦ Enteral nutrition is preferred over parenteral nutritionand should be initiated
as early as 24 to 72 hours following admissionor onset of a major critical
illness. (regardless of the presence of bowel sounds or passage of flatus or
stool)
◦ In patients with a high risk of aspiration, small bowel feeding is preferred
over gastric feeding.
◦ The calorie requirement is 25 to 30 kcal/kg/day.
◦ The protein requirement is 1.2 to 2.0 g/kg/day.
◦ Micronutrients and antioxidants are essential to combat infectionand to
facilitate recovery
◦ In obese patients, enternal formulas with less calories and more protein are
recommended.

63. Monitoring Tolerance and
Adequacy of Fluid Intake
◦ Monitor the blood glucoselevels and maintain between 140 and 180
mg/dL
◦ When patients are on parenteral feeds, maintain the flow rate optimally.
Too fast administration may lead to hypertensionand fluidoverload.
Similarly, slow administration may lead to hypoglycemic spells
◦ Avoid injecting drugs in the venous access through the parenteral fluids
are administered
◦ Ensure that the patients do not aspirate.

64. COMMUNICATION
IN ICU

65. Barriers in Communicating With
Critically ILL Patients
◦ Impairedcognition
◦ Patients in delirium
◦ Sedation
◦ Altered level of consciousness
◦ Language barriers
◦ Educational and cultural variation
◦ Presence of tracheostomy, or ET tube following head and neck
cancer surgery or a stroke or to facilitate mechanical ventilation
◦ Poor skills of nurses in interpreting nonverbal communication
◦ Lack of time for nurses to understand nonverbal communication

66. Methods Of Communication By
Patient With Problem In
Verbal Communication
◦ Head nods , gestures and mouthing words
◦ Paper and pencil writing
◦ Pictorial communicating boards
◦ Electronic voiceoutput communication aids or a prerecorded human
voice aid
◦ Digitalizedcomputer-generatedvoice message
◦ Cuffless fenestrated tracheostomy tube and Speak-EZ tracheal and
talking tracheostomy tube

67. Communicating With Other
Healthcare Team Members
◦ Collaboration: Collaborate with other team members and
participate in patient care decisions.
◦ Coordination:Coordinate with other team members,assign
responsibilities,mentor junior nurses and interns, and encourage
their inputs.
◦ Compassion: Demonstrate considerationand compassionfor
other team members.
◦ Credibility: Communicate assertively and clearly.

68. Family Needs
❑Communicationthat maintains hope
❑Questions to be answered honestly
❑Accurate and consistent informationabout the patient's
condition, possible treatment alternatives and prognosis
❑Timely notifications regarding the changes in the patient's
condition
❑Visits and time to spend with their lovedones
❑Empathetic comfort care
❑ICU family meetings are associated with beneficial outcomes for
patients, patients' families, and healthcare system.

69. ◦ For effective familycommunication,the following are necessary:

70. Nurses Role In
Identification And
Management Of
Inpatient Arrest

71. Tackling cardiac arrest event through prompt identification and
effective resuscitation is part of day-to-day affair in the critical care
units as well as in 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 calledfor to salvage the patient through
public call system.
❖Cardiac Arrest
In cardiac arrest, the heart is unable to pump and circulate blood to
the body's organs and tissues.It is often caused by a dysrhythmia such
as ventricular fibrillation, progressivebradycardia, or asystole (i.e.
absence of cardiac electrical activity and heart muscle contraction).
Cardiac arrest can also occur when electrical activity is present on
the ECG but cardiac contractions are ineffective, a condition called
pulse less electrical activity (PEA).

72. Clinical Manifestations
◦ In cardiac arrest, consciousness, pulse, and blood pressure are
lost immediately.
◦ Breathing usually ceases, but ineffective respiratory gasping may
occur.
◦ The pupils of the eyes begin dilating in less than a minute,and
seizures may occur.
◦ Pallor and cyanosis are seen in the skin and mucous membranes.
◦ The risk of organ damage, including irreversible brain damage,
and of death increases with every minute that passes.

73. Cardiopulmonary Resuscitation

75. Follow-up Monitoring And
Care
◦ Continuous ECG monitoring
◦ frequent blood pressure assessments
◦ Factors that precipitated the arrest such as dysrhythmiaor
electrolyte or metabolicimbalances are identifiedand treated.
◦ Following resuscitationand return of spontaneous circulation,
patients who are comatose may benefit from therapeutic
hypothermiaprotocol. These induce a drop in core body
temperature to 32°C to 34°C (89.6°F to 93.2°F) for 12 to 24 hours
post resuscitationin order to decrease the cerebral metabolic
rate and need for oxygen.
◦ Urine output shouldbe >30mL/hr

76. Drugs Used
In
Critical Care

81. Evaluation
1. Which of the following ICU is an adult ICU locatedin a large tertiary care
center with the capability of providing comprehensive critical care of
prolonged period of time ?
a) Level 1
b) Level II
c) Level III
d) Level IV
2. What is the Nurse-Patient Ratio ( for ventilated and for non-ventilated)
patients?
A. 1:2 , 1:3
B. 1:1 , 1:2
C. 1:3 , 1:2
D. 2:1 , 1:1
3. Definition of HAI and major 4 types .
4. What is the calorie requirement for the critically ill patients ?
5. What is the protein requirement for the critically ill patient ?

82. 6. What are the parts of hemodynamic monitoring system ?
7.What are the general measures of infection control ?
8. What are the methods Of Communication By Patient With
Problem In Verbal Communication ?