Standards for ciritical care nurses

Standards for Critical Care Nurses
MR. AMAR MULLA, M. Sc. (N),
PhD SCHOLAR, SVBCON, DNH
1
MR. AMAR MULLA, M. Sc. (N), PhD
SCHOLAR SVBCON, DNH

The following are some general requirements
for nursing care of the intensive care patients
• 1. No critical care patient will be left without a nurse
in attendance.
Rationale: Critically ill patients may have life-
threatening changes in their condition; remove an
invasive line or self-extubate quickly.
• 2. Each nurse will be responsible for the entire care of
his/her patient, and acts to coordinate care with other
health team professionals.
Rationale: The caregiver, by assuming full
responsibility for monitoring the patient's condition and
care, can detect changes promptly.
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SCHOLAR SVBCON, DNH

• 3. Breaks will be arranged according to unit need/safe
coverage by mutual agreement between each nurse and
his/her coworkers. The nurse must give a full report to
another staff nurse prior to leaving for a break. The
second nurse assumes responsibility for the patient and
interacts with family/other health team members in the
principal nurse's absence.
Rationale: When many people are involved in the care, a
principal caregiver reduces the assumption that someone
else did or did not complete a task, and helps to maximize
resources.
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SCHOLAR SVBCON, DNH

• 4. The staff nurse will report any changes in his/her
patient's condition directly to the physician. The charge
nurse may be utilized to report the information, e.g., on
nights. The nurse will ensure a physician is aware of all lab
reports. The staff nurse will keep the charge nurse informed
of changes in the patient's condition. The charge nurse will
be notified if the staff nurse needs any direction regarding
procedure, policy or physician interaction.
Rationale: The staff nurse is the one person who has
current and detailed information on the patient's condition.
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SCHOLAR SVBCON, DNH

• 5. All critical care patients will have continual ECG
monitoring.
Rationale: A critically ill patient requires intensive
monitoring
• 6. Alarms must be left on the ECG and arterial lines
at all times. Appropriate limits will be selected at the
nurse’s discretion according to institutional policy.
Rationale: To ensure rapid detection of heart rate or BP
changes. To reduce risk associated with leaving alarm
disabled.
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SCHOLAR SVBCON, DNH

• 7. An ECG strip will be obtained and analyzed
according to institutional policy. Generally, this is
every four hours and as needed for patients with a
cardiac disorder. The ECG strips are analyzed,
rhythm identified and taped to the back of the flow
sheet. Changes are reported to the consultant.
Rationale: Heart rate and rhythm are keys to
determining the hemodynamic stability of an intensive
care patient.
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SCHOLAR SVBCON, DNH

• 8. For a stable, non-acute patient without invasive monitoring
equipment, vital signs will be done at the staff nurse's discretion,
at least every hour.
Rationale: To ensure regular vital sign monitoring
• 9. Temperatures will be measured on all patients at least q4h by
other than axilla route. Patients having abnormal temperatures (<
36 or >37.5 C) will have temperature measured by a core method
(rectally, tympanic, pulmonary artery, esophageal).
Rationale: Temperature changes may indicate infection or other
disease states. Core represents a much more accurate value.
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SCHOLAR SVBCON, DNH

• 10. All patients admitted for neurological problems will
have hourly neurological assessments performed. All
patients will have a neurological assessment evaluated
and recorded on the flow sheet at least once per shift,
using the Glasgow Coma Scale.
Rationale: To quickly reference previous, function if
deterioration occurs. This will provide a clear understanding
of the patient's neurological status and avoid uncertainty
over assessments at shift change. Unconscious patients will
have neurological assessments done q.1-4h. At the nurse's
discretion.
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SCHOLAR SVBCON, DNH

• 11. The turning of all critically ill patients every
two hours around the clock is done unless
contraindicated, with skin assessment recorded as
part of the every four-hour assessment. If turning
is contraindicated, pressure points will be relieved
q2h. If pressure relieve is not possible, rationale
will be documented.
Rationale: This is to relieve pressure points and
allow for skin perfusion as well as provide reference
for comparison of skin care.
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SCHOLAR SVBCON, DNH

• 12. All intensive care patients will have chest PT q4h and PRN
unless contraindicated. The frequency will be recorded on the
flow sheet documented in progress note.
Rationale: Immobility increases the risk for the retention of
secretions and reduced ventilation.
• 13. All critical care patients will have range of motion exercises
q4h unless contraindicated (i.e. neuromuscular blockers). This
will be recorded on the flow sheet treatment section and in
clinical record.
Rationale: To reduce possible contracture formation, disuse
atrophy, "frozen joints", and to promote venous return.
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SCHOLAR SVBCON, DNH

• 14. Perineal care will be done every shift and
as needed PRN for all patients.
Rationale: To promote hygiene and comfort.
• 15. All Critical Care patients will have mouth
care done every four hours with inspection for
oral skin sores. Teeth will be brushed every
shift and as needed.
Rationale: Intubation increases risk for
developing mouth ulcers and/or infections.
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SCHOLAR SVBCON, DNH

• 16. The Critical Care nurse may restrain
patients at his/her discretion. Provided
documentation done according to hospital
policies and procedures.
Rationale: To ensure life-supporting tubes or
lines are not disconnected.
• 17. All restraints will be secured to allow rapid
lowering of bedside.
Rationale: For rapid access in a crisis.
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SCHOLAR SVBCON, DNH

• 18. Any patient who expires, that falls into the
classification of a coroner's case, or who is going to have a
autopsy must have all lines/airways/tubes left in place
unless the coroner confirms that they may be removed.
Rationale: Correct tube placement is occasionally evaluated
at post mortem.
• 19. All routine dressing changes, I.V. tubing changes and
catheter changes will be done on night shift. The Flow
sheet will be updated with the new date change, and the
procedure documented in the clinical record.
Rationale: To maintain consistency among all nurses.
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SCHOLAR SVBCON, DNH

• 20. Routine daily baths will be done on night shift. This will include total
skin care, fingernails and hair washing q. weekly and prn dressing
changes.
Rationale: The night shift is quieter and less hectic
• 21. All dressings unless otherwise indicated will be changed daily.
Rationale: To remove bacterial contaminates and replace with an aseptic
dressing
• 22. TED hose (anti-embolism stockings) and SCD’s (sequential
compressing device) will be removed for thirty minutes once per shift.
Rationale: To promote venous return and reduce thrombus formation and to
permit circulation and inspection of the limb.
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SCHOLAR SVBCON, DNH

• 23. Nursing care will be spaced out to allow
periods of rest.
Rationale: Sensory overload predisposes the
patient to disorientation.
• 24. All patients who have not had a bowel
movement will be checked for impaction
q.3. days and the flow sheet updated.
Rationale: To monitor bowel function
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SCHOLAR SVBCON, DNH

• 25. Procedures will be explained to patients; person, place and time
being repeatedly stated to the patient. Sensory stimulation, ie., radios,
tape recorders, will be provided for patients as indicated during the
day.
Rationale: It is not known how much an unconscious patient can hear or
comprehend. Sensory deprivation leads to disorientation. Anxiety
decreases with an awareness of one's surroundings. Maintain a normal
sleep/wake pattern.
• 26. Information and emotional support needs for the family and
patient will be provided by the nurse/physician/social work/pastoral
care/palliative care, as required.
Rationale: The critical nature of the patient's illness places tremendous
strain on the patient and family unit.
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SCHOLAR SVBCON, DNH

• 27. The environment will be maintained in a mechanically safe
condition through: dry floors, good repair of furniture, proper
placement of machines and equipment, cleanliness, freedom from
clutter, and good repair of equipment.
Rationale: To reduce risks to patients, visitors, or staff.
• 28. Isolation technique will be followed as per infection control
manual.
Rationale: To minimize cross infection to patients, visitors, and staff.
• 29. Safety signs, such as, "isolation", "can hear", or
"neuromuscular blocking agent in use" will be posted when
indicated
Rationale: To communicate important information 17
SCHOLAR SVBCON, DNH

• 30. Sharps and glass will be disposed of into point of
use sharps containers.
Rationale: To protect health care workers from
injury/contamination.
• 31. Any containers of body fluids (i.e. suction
canisters or chest drainage sets) must be disposed in
the appropriate biohazard bag or box.
Rationale: To reduce risk of contamination to health
care workers during handling.
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SCHOLAR SVBCON, DNH

• 32. All electrical equipment will: be grounded,
have 3-prong plugs, be used away from water or
wet floors, be protected from spillage of liquids, be
inspected by Biomedical Department. Any
equipment that malfunctions or appears damaged
will be reported to Biomedical Dept.
Rationale: Particularly with patients having
access catheters into the heart, electrical shocks could
pose serious risk for harm.
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SCHOLAR SVBCON, DNH

• 33. Labels will be affixed to: all bedside
medications, intravenous bags and bottles,
all wound or bladder irrigations, multidose
vials, multiple drainage bags/bottles,
hemodynamic transducers and monitors
(identifying waves and pressures).
Rationale: To reduce risk for errors.
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SCHOLAR SVBCON, DNH

• 34. All medications will be reviewed by the Critical
Care physicians (upon admission to Unit) and either
reordered or stopped. Nursing staff will ensure this
has been done prior to carrying out any medication,
treatment or investigative orders. Each
treatment/medication must be listed when reordered
(e.g., "Renew all preoperative meds" is NOT
acceptable.)
Rationale: To ensure optimal management.
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SCHOLAR SVBCON, DNH

• 35. Respiratory orders may only be carried out when
written by the patients physician. Ventilatory changes
will only be done upon receipt of written order.
Rationale: To maintain optimal and consistent respiratory
management
• 36. All orders written other than by the consultant/
treating doctor will be brought to the attention of the
Critical Care physician by the nurse prior to being
carried out. Rationale: To ensure all therapy is consistent
with goals for the patient's management
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SCHOLAR SVBCON, DNH

• 37. Narcotics MAY NOT be kept at the bedside. If use is
not immediate after withdrawal from the narcotic
cabinet, wastage as per narcotic protocol will be carried
out.
Rationale: To maintain narcotic control.
• 38. Visiting is negotiated between the nurse and family,
with consideration given to unit activity and institutional
policy. All exceptions should be reported nurse to nurse.
Rationale: It is important to communicate information to
oncoming nurse to avoid discrepancies. 23
SCHOLAR SVBCON, DNH

• 39. The number of visitors will be limited to 2 at a
time; however, the nurse may use discretion based
on patient condition and room activity
Rationale: To promote privacy for other patients in the
bay and to accommodate space limitations.
• 40. The nurse/physician will notify families of
significant deteriorations in the patient's condition.
Rationale: The family has the right to determine when
they wish to attend their family member.
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SCHOLAR SVBCON, DNH

• 41. Support will be given to family’s that would
like children to visit. Special preparation of
the children MUST BE done.
Rationale: Research has shown that allowing
children to participate in the grieving process can
have a positive impact on subsequent adjustment
to family tragedy. Improper preparation can have
a negative and lasting impact.
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SCHOLAR SVBCON, DNH

• 42. A visitors handout will be given to one member of each patient's
family. Indicate on Nursing Note the date and family member who
received the booklet.
Rationale: To reduce the anxiety associated with visiting in the critical
care unit. To provide information regarding resources available to families.
• 43. All patients in Critical Care Unit, will be weighed daily and on
admission and recorded on the flow sheet. per week. For new hospital
admission, record weight on nursing admission database also.
• Rationale: To accurately measure Body Surface Area, for calculating
hemodynamic indexed values, to identify drug dosages, to assess
nutritional requirements, to assess adequacy of nutritional status, and to
evaluate fluid balance.
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SCHOLAR SVBCON, DNH

• 44. All patients in the critical care unit will have a minimum
IV access of two Heparin Locks.
Rationale: To ensure rapid resuscitation with IV drugs or fluid if
needed. Critical care patients are at sufficient risk to warrant
access. When a patient's illness has become chronic but stable,
they may not have an immediate need for an IV, and staff may be
unable to secure a peripheral site. If despite reasonable attempts by
a skilled individual a peripheral IV cannot be secured, the risk
associated with a central line insertion may be deemed greater than
the benefit of having an IV access. Appropriate documentation
must be included in the clinical record to justify this decision.
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SCHOLAR SVBCON, DNH

• 45. All change of shift reports will include a review of
all physician orders, lab results, medication
administration record, and joint review of neuron
status.
Rationale: To ensure communication between shifts and
reduce potential for medication or treatment
errors. Neuro status is jointly reviewed to ensure that
both incoming and out going shifts are clear on
interpretation of findings to be able to promptly detect a
change in patient condition.
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SCHOLAR SVBCON, DNH

• 46. All staff working at a bedside where an acute trauma or
actively bleeding patient is being managed will wear
protective goggles, masks and gloves. Protective gear is also
required anytime risk of splash from body fluids exists e.g.
suctioning.
Rationale: Current literature shows that it is during periods of
acute crisis when health care workers are at the highest risk for
disease transmission. This has also been shown to be the time
when health care workers are least compliant with universal
precautions. Masks, goggles and gloves in high risk situations are
a requirement as per Hospital Universal Precautions Policies.
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SCHOLAR SVBCON, DNH

• Reference: AACN Standards for Critical
Care Nurses.
30
SCHOLAR SVBCON, DNH

THANK YOU
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SCHOLAR SVBCON, DNH

Standards for ciritical care nurses

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