CONCEPT OF CRITICAL CARE NURSING NUR 409

By dorcas maina

Section I

CRITICAL CARE
Define critical nursing Understand the principles of critical care nursing Identify the goals of critical care nursing State the roles and functions of critical nurse

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

CRITICAL CARE NURSING

The care of seriously ill clients from point of injury or illness until discharge from intensive care

CRITICAL CARE NURSING

Deals with human responses to life threatening problems trauma /major surgery
(Mary,L.S., Deborah, G.K. & Marthe, J.M. 2005)

CRITICAL CARE NURSING

Comprehensive, specialized and individualized nursing care services which are rendered to patients, with life threatening conditions and their families.
(Shuva, D. G.2005)

CRITICAL CARE NURSE

care for clients who are very ill provide direct one to one care Responsible for making life-and death decision At high risk of injury or illness from possible exposure to infections Communication skill is of optimal importance

CRITICALLY ILL CLIENT

At high risk for actual or potential life-threatening health problems More ill Required more intensive and careful nursing care

CLASSIFICATION OF CRITICAL CARE PATIENTS

Level O : normal ward care Level 1: at risk of deteriorating , support from critical care team Level 2 : more observation or intervention, single failing organ or post operative care Level 3; advanced respiratory support or basic respiratory support ,multiorgan failure

HIGH DEPENDENCY CARE

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

CONTINUUM OF CARE
General ward High dependency areas : CCU,Renal HDU, recovery Intensive care unit

PRINCIPLES OF CRITICAL CARE

Continuous monitoring and treatment High intensity therapies and interventions Expert surveillance and efficiency Alert to early manifestation of other organ failure Recognition of parameters denoting progress or deteriorating

GOALS OF CRITICAL CARE

Towards the survival of the critical ill patients and restoring quality of life Restoring optimal physiological, psychological, social and spiritual potential Helping the families of the critically ill patients in coping with crises

ROLES OF CRITICAL NURSE

Care provider : help the client to obtain necessary care and supporting the basic needs comprehensive direct care to the patient and family Educator: based on patients needs and severity of the condition Manager: coordinates the care provided by various health care Advocate: protects the patients rights

CRITICAL CARE NURSING

Constant and rapid assessment: close monitoring and respond to treatment Providing appropriate nursing interventions Documenting and reporting Observing mental state of family state Maintaining a spiritual attitude

Section 2

Objectives
Describe the history of CC nursing Describe the general requirements of an ICU. Describe the functions of an ICU and the admission criteria.

History of ICU
In 1854, Florence Nightingale left for the Crimean War, where the necessity to separate seriously wounded soldiers from less-seriously wounded was observed. Nightingale reduced mortality from 40% to 2% on the battlefield, creating the concept of intensive care.

In 1950, anesthesiologist Peter Safar established the concept of "Advanced Support of Life," keeping patients sedated and ventilated in an intensive care environment. Safar is considered the first intensivist.

History of ICU
In response to a polio epidemic Bjorn Ibsen established the first intensive care unit in Copenhagen in 1953. The first application of this idea in the United States was pioneered by Dr. William Mosenthal, a surgeon at the Dartmouth-Hitchcock Medical Center.

In the 1960s, the importance of cardiac arrhythmias as a source of morbidity and mortality in myocardial infarctions (heart attacks) was recognized. This led to the routine use of cardiac monitoring in ICUs, especially in the post-MI setting.

Intensive care units

Definition:
The Intensive Care Unit is a nursing care unit which is specially staffed and equipped to look after a critically ill patient with possibility to survive regardless of diagnosis, sex or economic status who require continuous observation and intensive medical and nursing care with immediate availability of life saving equipment, drugs and materials.

ICU Vs Ward (Differences)

All beds to be equidistant from nursing station Nursing station centralized monitoring required Nursing requirement N/B ratio - 1 : 1 or 2 Equipment ventilators, defibrillator, ABG analyzer, etc. Support services linen, instruments, electricity,A/C, etc Support Staff trained and skilled to handle ill patients

ICU Vs Wards

Special procedures Intubation, CVP, Resuscitation, ALS Maintenance cleanliness, UPS, Ventilation, Medical gases Handling Visitors Restricted entry Highly trained junior doctors required Attendants to patients Accommodation ? Design aspect Toilet, Wash Area not close to ICU beds Nursing care more complex apart from clinical care, physical functions like dressing, feeding, mouth care, shifting position in bed, bladder function, bowel function etc. have to be taken care of. Cannot afford to under staff this unit even if under occupied.

TYPES OF ICU
Intensive Care Unit can be organized as a generalized ICU or a specialized ICU i.e. for a specialty e.g. - Post operative unit - Cardiac care unit - Burns unit - Dialysis unit
- New Born Nursery, etc.

Classification On Type Of Patient Admitted

Intensive Care Unit Critical Care Unit NICU / PICU Neuro ICU / Respiratory ICU / Obstetric ICU Surgical ICU / Medical ICU Coronary Care Unit Acute Nursing Care Unit High Dependency Unit Step Down ICU Intensive Therapeutic Unit Burns Ward, Dialysis Does it come under ICU ?

Classification On Organizational Structure

Open unit: All attending physicians may admit
and care for patients.

Semi Closed Unit: Closed unit:

The Directors of ICU &/or associates must review and approve all admissions. The directors &/or associates are responsible for all admissions and discharges.

General requirements of an ICU

LOCATION OF ICU
Should be easily accessible to each part of the hospital. Location should be chosen so that the unit is adjacent to the Emergency department, operating room, intermediate care units, and the Radiology Department

Location of ICU
Each ICU should be a geographically distinct area within the hospital, when possible, with controlled access . No through traffic to other departments should occur. Supply and professional traffic should be separated from public/visitor traffic

SIZE OF ICU
Min 4-8 beds. U.S standards 4 beds per 100 Inpatient Beds U.K standards 1 bed per 100 acute beds and always a 4-8 bedded unit. Germany 5 % of total ICU beds Economical to have 8 beds and 500 cases per year.

Area
It is suggested that the minimum of 150 square feet per bed in open ward areas and 225 square feet for isolation unit be provided. Nursing is easy and heavy emergency equipment are manoeuvred with ease. Clear Area 15 Sq. Ft / Bed Distance between head end and wall 1.2 Feet Distance between beds 8 feet Width of Entrance 8 Feet Medication and Nourishing area 50 Sq. Ft.

Air Conditioning
Centrally air conditioning is necessary to cope up with extreme weather and to prevent dust. Temperature 22-26 degree C. and humidity 50-60 percent should be maintained.

Lights
The patient area should be uniformly lit. There should be provision for light below bed level to check the drainage bottle, water seal.etc.

Piped Supply
Piped oxygen with two outlets for each bed with suitable flow meters, capable of supplying 20 litres per minute at a pressure of 60 Lbs./Sq. ft. Piped vacuum - Central suction with two outlets with manometer for each bed is necessary and air extraction should be 40 litres/minute. The vacuum in pipeline is 500 mm. of Hg.

COMMUNICATION
There should be a call bell attached from each bed to nursing station. Nursing station should have a call bell attached to doctors room. Telephone at least two telephones one for internal and one for external lines are required. Paging system should be introduced for calling consultants and residents from the respective area of their work place.

ELECTRICAL FACILITY
4-5 power plugs arrangements for each bed and a special socket of 60 amperes. 230 volts, single phase for portable radiographic equipment should be provided. All outlets and lights should be connected to the emergency power system. There should be provision for a stand by generator for ICU.

PATIENT AREA
Arrangement: ample visibility of all the patients from the nurses' desk. Arranged in circular or semicircular or rectangular design placing each bed at equidistance from nurses desk. One or two isolation rooms should be attached to unit for isolation or reverse isolation. Each bed should be separated from the other by glazed partition to provide necessary privacy.

Patient Areas
Noise levels in hospital acute care areas not exceed 45 dB(A) in the daytime, 40 dB(A) in the evening, and 20 dB(A) at night. Floor coverings that absorb sound should be used, keeping infection control, maintenance, and equipment movement needs under consideration. Walls and ceilings should be constructed of materials with high sound absorption capabilities.

Work Areas and Storage

Work areas and storage for critical supplies should be located within or immediately adjacent to each ICU. There should be a separate medication area of at least 50 square feet containing a refrigerator for pharmaceuticals, a double locking safe for controlled substances, and a sink with hot and cold running water.

Receptionist Area.
Each ICU should have a receptionist area to control visitor access. Ideally, it should be located so that all visitors must pass by this area before entering. The receptionist should be linked with the ICU(s) by telephone and/or other intercommunication system . Visitors entrance separate from that used by healthcare professionals.

Special Procedures Room

It should be located within, or immediately adjacent to, the ICU. One special procedures room may serve several ICUs in close proximity.

Clean and Dirty Utility Rooms.

Clean and dirty utility rooms must be separate rooms that are not interconnected. They must be adequately temperature controlled, and the air supply from the dirty utility room must be exhausted. The clean utility room should be used for the storage of all clean and sterile supplies, and may also be used for the storage of clean linen. The dirty utility room must contain separate covered containers for soiled linen and waste materials.

Other Areas
Staff Lounge. A staff lounge should be available
on or near each ICU or ICU cluster to provide a private, comfortable, and relaxing environment. Conference Room. A conference room should be conveniently located for ICU physician and staff use. Visitors Lounge/Waiting Room. should be provided near each ICU or ICU cluster. Visitor access should be controlled from the receptionist area. One and one-half to two seats per critical care bed are recommended.

Patient Transportation Routes.

Patients transported to and from an ICU should be transported through corridors separate from those corridors used by the visiting public. Patient privacy should be preserved and patient transportation should be rapid and unobstructed .

Design Aspects
Supply
A perimeter corridor with easy entrance and exit should be provided for supplying and servicing each ICU. Removal of soiled items and waste should also be accomplished through this corridor. The corridor should be at least 8 feet in width. Doorways, openings, and passages into each ICU must be a minimum of 36 inches in width to allow easy and unobstructed movement of equipment and supplies. Floor coverings should be chosen to withstand heavy use and allow heavy wheeled equipment to be moved without difficulty.

and

Service

Corridors.

Design Aspects
ICU design should consider natural illumination and view. Windows are an important aspect of sensory orientation, and as many rooms as possible should have windows to reinforce day/night orientation. Drapes or shades of fireproof fabric can make attractive window coverings and serve to absorb sound . Comfort considerations should include methods for establishing privacy for the patient. Shades, blinds, curtains, and doors should control the patients contact with his/her surroundings .

Utilities
Each ICU must have electrical power, water, oxygen, compressed air, vacuum, lighting, and environmental control systems that support the needs of the patients and critical care team under normal and emergency situations.

It is preferable to place lighting controls on variable-control dimmers located just outside of the room. This approach permits changes in lighting at night from outside the room, allowing a minimum disruption of sleep during patient observation.

ICU BED
Specific requirements

A bed with adjustable position, removable bed head, tilting facility and cot sides. Patient monitoring: ECG, core and skin temp, arterial oxygen sat. Ventilator, re-breathing bag, oropharyngeal airway, intubation equipment, humidification equipment

Wall mounted sphygomanometer At least 4-5 electric sockets with emergency back up at least 90 metres from the floor. At 3 oxygen, 2 compressed air, and 3 vacuum outlets situated on either side of the bed at least 1.5 meters from the floor.

One oxygen flow meter should have an oxygen flow meter and rebreathing bag permanently attached for emergencies. one vacuum outlet should have a suction unit permanently attached and set for ETT suction.

Provision for charts, documentation, and drug preparation on appropriately situated surfaces to allow easy view of the patient. Storage space for linen and disposables e.g. syringes, needles Space for patients possessions and hygiene requirements

Functions of an ICU
Provide care for severely ill patients with potentially reversible conditions. To provide care for patients who require close observation and/or specialized treatments that cannot be provided in the general ward.

To provide care for patients with potential or established organ failure. To reduce avoidable morbidity and mortality in critically ill patients.

Which patients benefit from intensive care?

Define objective criteria should be laid

down for admission and discharge of patient based on the patient's condition: degree of illness, nursing and medical needs. As a general rule, patients in need of continuous observation and monitoring of vital signs and the total support of physiological system should be admitted to ICU.

Admission criteria
Respiratory failure Post successful CPR. Post neurosurgery (Brain surgery). Fluids and electrolytes imbalance. D.I.C. (Disseminated intravascular coagulopathy. Acute renal failure

Pneumothorax and hemothorax affecting respiration. Shock. Chest trauma (Flail chest). Poisoning Post major surgery. Coma with unknown cause.

Staff Requirements
Medical Staff 1. ICU Incharge 2. Senior Residents 3. Junior Residents

Nurses
One nursing sister in charge of the ICU is recommended.
As all the patients in an ICU are critically ill or need intensive nursing care, i.e. 10-12 hours of bed side nursing care per day, for each bed at least two nurses should be provided per day which make the nurse patient ratio as 2:1. Though in the Western countries, the norm followed is 1:1 per shift or 4:1 per day.

MANAGEMENT
ICU committee should be appointed consisting of one representative of surgery, medicine, neuro-surgery, nursing service and hospital administration and anesthetists as chairman. The medical officer incharge of the ICU for day-to-day administration should have a final authority to transfer in and out the ICU. Any controversy or problem should be referred to the ICU committee. A patient who is transferred to ICU is the responsibility of
the transferring unit for his treatment.

Policies and procedures

Bed Utilization: Ideal bed occupancy rate for ICU is 75-80 per cent

leaving 20-25 per cent of beds vacant for unforeseen emergencies. All treatment and medication should be written. Special observation chart for each patient should be maintained.

Policies and procedures

Rules for Visitors:
(a) visitors should be restricted to immediate family; (b) one person should be allowed at a time, and (c) duration of the visit should be very short.

Proper Information System for Relatives:

The doctor in charge of the patient is responsible to inform the relatives about the condition of the patient.

PROBLEMS
To determine the size of Intensive Care Unit. It is difficult to decide its location. In determining the layout of the unit in already existing hospital. It is difficult to staff the unit adequately. It becomes difficult to make the supply system function efficiently and to provide continuous supply of life saving drugs and materials. Problems regarding admission and transfer of patients to and from ICU.

PROBLEMS
It is difficult to have biomedical engineering services available for the maintenance of the equipment specially sophisticated electronic equipment. Political and outside interferences to admission and transfer of patients. Team building which is very much essential for critical care becomes difficult. It becomes problematic to have coordination among various units. It posts psychological stress on the relations and at times on patients.