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Introduction to Critical Care Nursing

Oct 03, 202418 min read

This page is based on three different discussions from three professors. I tried my best to keep it cohesive while being comprehensive.

Critical Care Nursing is the delivery of specialized care for the seriously-ill clients from the point of injury or illness until discharge from intensive care. This deals with human responses to life-threatening problems (AACN) and comprehensive, specialized, and individualized nursing services. It aims for survival and restoring quality of life, and helping families of the critically-ill in coping with stress. Critical Nurses take on the roles of Caregivers, Educators (facilitator of education for patients, family, and staff), Managers, Critical Thinkers, Team-Players (collaborator) and Advocates (work on behalf of the patient). They work to:

  1. Care for clients who are very ill or at risk for potential life-threatening health problems. These include: major surgery post-operative clients, illness involving the vital organs, and even stable clients with signs of impending doom. They may be classified as the following:
    • Level 0: Patients in normal ward care
    • Level I: Patients at risk of deteriorating
    • Level II: Patients that require more observation or intervention
    • Level III: Patients with multi-system failure
  2. Provide one-to-one care
  3. Are responsible for making life-and-death decisions
  4. Are at risk for injury and illness
  5. Utilize effective communication skills

Responsibilities of a Critical Care Nurse

  1. Assessment: constant assessment of patients for subtle changes and monitoring of equipment.
  2. Planning: the patient’s psychological and physiological needs are considered and realistic (SMART) goals are set.
  3. Implementation: carrying out specific interventions to address existing and potential patient problems.
  4. Evaluation: continuing evaluation of response to interventions and revision of the plan care plan to continue working towards goals.

(According to Dr. Rotario) Nurses are responsible for efficient individualized continuous care, specifically continuous monitoring, recording, infection control, and knowledge advancement with research and EBP.

  • Keeping the emergency cart available and stocked
  • Maintaining vigilance to meet the changing needs of the client, promoting the best health outcomes in a caring, competent manner to ensure positive optimal outcomes for the clients and families.
  • Counselling
  • Observation of core competencies: patient care, medical knowledge, professionalism, ethics, interpersonal communication skills, practice-based learning and improvement, system-based practice, clinical judgment, advocacy, response to diversity, clinical inquiry.

Critical Assessment Process

Critical care requires Continuous Monitoring and Treatment, High Intensity Therapy, Export Surveillance and Efficiency, and Alertness for Early Manifestations of Progress or Deterioration. There are four stages in the assessment framework: pre-arrival assessment, admission quick check, comprehensive admission assessment, and on-going assessment.

Pre-Arrival Assessment

Pre-Arrival Assessment begins when the patient is enroute to the ICU, from the ward, operating room, or emergency room. It is an abbreviated report on the patient to determine the possible picture of the client and their needs.

  1. Assess the Patient: age, gender, chief complaint, diagnosis, pertinent history, physiologic status, invasive devices, equipment, and laboratory tests.
  2. Assess the Environment: Setup, Functional Equipments, ECG and Electrodes, Sphygmomanometer, Pulse Oximeter, Suction Machine and Catheters, Bag Valve Mask Device, Oxygenation Equipment, IV Poles and Infusion Pumps, Bedside Supply Cart, Admission Kit, and Forms and Care Documentations
    • This may also be subdivided as the mnemonic FRC: Fluids, Respiration, and Cardio.
    • Fluids: IV pole, IV fluids, infusion pumps, syringe pumps
    • Respiration: Suction machine, catheters, bag valve, oxygen, pulse oximeter, ventilator
    • Cardio: Electrocardiograph, electrodes, sphygmomanometer, defibrillator, AED

Admission Quick Check

The initial assessment conducted after the arrival of the patient. It is a quick overview of ventilation (respiratory), circulation (cardiac), and chief complaint (diagnostics) of the patient. Common diagnostic tests include (a) serum electrolytes, (b) CBG, (c) CBC with platelets, (d) coagulation studies e.g. PTT, PT, (e) ABG, (f) CXR, and (g) ECG.

  • Appearance
  • Airway: patency and positioning of artificial airways (if present)
  • Breathing: quantity and quality of respirations, breath sounds, and presence of spontaneous breathing
  • Circulation, Cerebral Perfusion, and Chief Complaint: ECG, blood pressure, peripheral pulses, capillary refill, skin color, skin temperature, skin moisture, presence of bleeding, level of consciousness, and responsiveness.
  • Drugs: drugs used prior to admission, current medications
  • Diagnostic Tests: diagnostic test results
  • Equipment: patency of vascular and drainage systems, equipment functioning, and labeling.

Comprehensive Admission Assessment

A physiologic and psychosocial assessment as baseline for comparing data for improvement or deterioration.

  • Past Medical History: medical conditions, laboratory procedures, hospitalisations, medications, allergies, and a review of body systems.
  • Social History: age, gender, ethnic origin, height, weight, education, occupation, marital status, religion, significant others, history of substance abuse, and history of domestic abuse.
  • Psychological Assessment: communication, coping styles, anxiety, stress, family needs
  • Spirituality: faith/preference, spiritual practices
  • Physical Assessment: nervous system, cardiovascular system, respiratory system, renal system, gastrointestinal system, endocrine system, hematologic system, immune system, and integumentary system:
    • Nervous System Assessment: GCS scoring, Pupil Assessment, LOC, Trauma
    • Cardiovascular System Assessment: Pulses, Perfusion
    • Respiratory System Assessment: Breathing Pattern (rate, rhythm, depth), Breath Sounds, ABG, Secretions
    • Urinary System Assessment: urine amount, color, odor, diagnostic tests (UA, BUN, Creatinine)
    • Gastrointestinal System Assessment: nutrition, hydration status, contour and symmetry of abdomen.
    • Integumentary System Assessment: check overall integrity and presence of ulcers.

On-going Assessment

The continuing comprehensive assessment done to determine response to therapy, progression of improvement, and outcomes. This is done for as long as the patient remains within the hospital. Frequency of assessment depends on patient stability and risk. Unstable patients are assessed q15min, but stable patients are assessed q2hr or q4hr. Stability (ability to maintain equilibrium) may be influenced by:

  • Complexity: the number of systems implicated in the illness, e.g., a multi-system failure is much more complex than the failure of a single system.
  • Predictability: expectations of a certain course of events, e.g., increased monitoring for complications after a recent blood transfusion.
  • Vulnerability: susceptibility to actual or potential stressors.
  • Resiliency: capacity to return to a restorative level of functioning, e.g., between a 34 year old and an 96 year old patient experiencing the same infectious disease, the old patient may have more frequent assessments.

Nursing Process in Critical Care

Nursing Assessment

  1. Nursing History: rapport-formation and history-taking prior to physical examination that determines patient health status, symptoms, causes of present illness, current management, past medical history, social history, and the patient’s perception of illness.
  2. Psychological and Social Examination: client’s perception of illness (again?), emotional health, physical health, spiritual health, and intellectual health.
  3. Physical Examination: the observation or measurement of signs and symptoms (if observable), and recording of symptoms that are felt by the patient, such as nausea and vertigo. This is done with inspection, palpation, auscultation, and percussion in addition to vital signs taking (temperature, pulse, respiration, blood pressure) and further examination of body systems (cardiovascular, musculoskeletal)
  4. Documentation: the use of medical or nursing records (paper or electronic) for patient data and care, to be accessed by all members of the health care team.

Principles in Critical Care Nursing

  1. Anticipation: the recognition of high-risk patients and anticipation for requirements, complications, and emergencies. The unit should be organized with all necessary equipment and supplies that are mandatory for smooth running of the unit.
  2. Early Detection and Prompt Action: the prognosis of the patient can highly depend on early detection and intervention against variations. A prime example of this principle is the monitoring of cardiac-respiratory function.
  3. Collaborative Practice: the critical care team is multidisciplinary; requires very specialized bodies of knowledge. Partnerships are created for decision-making and ensures quality and compassionate patient care. Collaboration is more warranted in critical care than in any other field.
  4. Communication: Communication in Health Care; Intra-professional, inter-departmental, and inter-personal communication has a significant importance in the smooth running of the unit.
  5. Prevention of Infection: critically ill patients are at a greater risk than other patients due to immunocompromised states with the antibiotic usage and stress, invasive lines, mechanical ventilators, prolonged stay, and severity of illness and environment of the unit itself. Healthcare-associated infections (HAI, nosocomial infections) are a major contributor to expenses in health care services.
  6. Crisis Intervention and Stress Reduction: serving as patient advocates, nurses assist the patient in expressing fear and identify their grieving pattern and provide avenues for positive coping. The bonds between nurses, patients and families are stronger during hospitalization.

Admission Criteria Models

  1. Prioritization Model: the assignment of priority levels to patients based on their presentation:
Priority LevelDescriptionCare Required
Priority 1Critically ill, unstable patients requiring ICU treatment and monitoring.Monitoring, ventilator support, continuous vasoactive drug infusions
Priority 2Patients potentially requiring immediate intervention, requiring intensive monitoring.Intensive monitoring
Priority 3Critically ill patients with reduced likelihood of recovery because of underlying disease or nature of their acute illness.Palliative care
Priority 4Often not appropriate for ICU admission.Care required is on an individual basis, under unusual circumstances and at the discretion of the ICU director.
  1. Objective Parameter Model: a model that bases ICU admission to observed values:
ParameterThreshold Value
Pulse Rate<40 or >150 BPM
Systolic Pressure<80 mm Hg or 20 mm Hg below baseline
Mean Arterial Pressure<60 mm Hg
Diastolic Arterial Pressure>120 mm Hg
Respiratory Rate>35 breaths/min
Serum Sodium<110 mEq/L or >170 mEq/L
Serum Potassium<2.0 mEq/L or >7.0 mEq/L
PaO₂<50 mm Hg
Serum pH<7.1 or >7.7
Serum Glucose>800 mg/dL
Serum Calcium>15 mg/dL
Serum Drug LevelsAny drug level that is toxic in a hemodynamically or neurologically compromised patient
ImagingCerebral vascular hemorrhage, contusion, or subarachnoid hemorrhage with altered mental status or focal neurological signs.
Ruptured viscera, bladder, or uterus with hemodynamic instability
Dissecting aortic aneurysm
ElectrocardiogramMI with complex arrhythmias, hemodynamic instability, or congestive heart failure
Sustained VT or VF
Complete heart block with hemodynamic instability
Acute Physical FindingsUnequal pupils in an unconscious patients
Burns covering >10% BSA
Anuria
Airway obstruction
Coma
Continuous Seizures
Cyanosis
Cardiac Tamponade

Multidisciplinary Teams in Critical Care

Nurses work with critically ill patients commonly collaborate with a multidisciplinary team of health care professionals. A team approach allows for a patient’s diverse needs, and include: (a) registered nurses, (b) doctors, (c) physician assistants, (d) advanced practice nurses e.g. clinical nurse specialists and nurse practitioners, (e) patient care technicians, (f) respiratory therapists, and others. They use standardized protocols and guidelines for a consistent approach to all issues, with an emphasis on research, education, ethical issues, and patient advocacy.

  • Rapid Response Teams (RRTs) was identified as an evidence-based, lifesaving strategy that improves patient outcomes by preventing avoidable patient deaths outside the critical care areas. They mostly consist of a structured group and usually include a critical care nurse, a respiratory therapist, and possibly a doctor who collaborates with the patient’s nurse and intervenes appropriately. They may be called upon at 24/7 if concerns about the patient’s condition is raised.

Critical Care Unit & Practice Patterns

A Critical Care Unit is defined as the unit in which comprehensive care of a critically-ill patient which is deemed to be in recoverable stage is carried out.

A good ICU is well organized with coordinated care, has a full-time intensivist that performs daily rounds, has established protocols and policies, is staffed with bedside nurses (with master degrees) and no interning staff. The team is composed of doctors, nurses, respiratory therapists, and pharmacist, led by full-time intensivists. The unit is availably in a timely fashioned (24/7) with no competing clinical responsibilities. The CCU/ICU is equipped with critical care technology, including:

  • ECG monitoring, arterial lines, O2 saturation, ventilation, ICP monitoring, temperature monitoring, pulmonary artery catheters, IABP, and extensive pharmaceuticals
  • ICU bed, cardiac monitoring, IV infusion pump, injection pump, defibrillator, ventilator, crash card (emergency drugs, Ambu-Bag, intubation equipment)
  1. Open Unit: any attending physician with hospital admitting privileges can be the physician of record and direct and ICU care.
    • Disadvantages: lack of a cohesive plan, inconsistent night coverage, and duplication of services.
  2. Closed Unit: an intensivist is the physician of record for ICU patients. All orders and procedures are carried out by ICU staff. This is the preferred method for a “good” ICU if resources are available.
    • Advantages: improved efficiency and standardized protocols for care.
    • Disadvantages: potential to lock out private physicians and increases physician conflict.
  3. Transitional Unit: intensivists are locally present, and share co-managed care between ICU staff and private caregivers. They share a final common pathway for orders and procedures.
    • Advantages: reduce physician conflict, standard policies and procedures are usually present.
    • Disadvantages: confusion and conflict regarding final authority and responsibilities for patient care decision.

These are further classified into levels:

  1. Level I CCU: provision of monitoring, observation, and short-term ventilation. The nurse-patient ratio is 1:3. The staff are not always present in this level.
  2. Level II CCU: provision of monitoring, observation, and long-term ventilation with resident doctors. The nurse-patient ratio is 1:2. Junior medical staff are always present, and consultant medical staff are available if needed.
  3. Level III CCU: provides all aspects of intensive care including invasive hemodynamic monitoring and dialysis. The nurse-patient ratio is 1:1.

ICU Care Models

  1. Full-Time Intensivist Model: patient care is provided by an intensivist (physician specialized for critically ill patients)
  2. Consultant Intensivist Model: an intensivist consults for another physician to coordinate or assist in critical care, but does not have primary responsibility for care.
  3. Multiple Consultant Model: multiple specialists are involved in the patient care (especially respiratory therapist doctors for ventilators), but none is designated especially as the consultant intensivist.
  4. Single Physician Model: a primary physician provides all ICU care.

Communication in Health Care

Communication failures can result in serious adverse effects. Health care professionals must pay close attention to communicating effectively. A structured communication tool, such as SBAR, improves the effectiveness of communications, provides a safer environment for patients, and promotes collegial relationships among health care team members. SBAR provides a clear, concise, and effective way to transmit information.

SBARContent
SituationWhat is going on at the present time?
BackgroundWhat relevant events have happened in the past?
AssessmentWhat do you think is happening?
RecommendationWhat do you think needs to be done?

A Nurse Calls a Physician and uses the SBAR communication tool

Dr. Garci, this is Nurse Gloria. I am calling from Fatima University Medical Center about your patient Renato. (S) Renato is having increasing dyspnea and is complaining of chest pain. (B) He had a total knee replacement two days ago. About two hours ago, he began complaining of chest pain. His pulse is 120 and his blood pressure is 128 over 54. He is restless and short of breath. (A) He may be having a cardiac event or a pulmonary embolism. (R) I recommend that you see him immediately and that we start him on oxygen stat. Do you agree?

Closed-Loop Communication is another applied form of communication where all details are confirmed by both parties by having the receiver repeat information back to confirm understanding. This type of communication is used in healthcare to avoid errors:

Example of Closed-Loop Communication

Physician: “Could you give methergine, 0.2 mg IM, now, please?”

Nurse: “I’ll get methergine, 0.2 mg IM, to give immediately.”

Certification Programs

A validation of meeting predetermined standards for care. This covers nurse knowledge and qualifications for practice in a defined functional or clinical area of nursing. The AACN Certification Corporation supports critical care nurses by administering specialty certification programs. It measures what is pertinent to the care of critically ill clients today.

National certification provides the most up-to-date knowledge, promoting continuing excellence in the nursing profession, and standardizing care through the use of practice guidelines, practice alerts and protocols. It utilizes consistent evidence-based practice guidelines to help reduce errors and improve quality of care delivered.

American Heart Association Standards

The Basic Life Support (BLS) Survey

The BLS Survey is a systematic approach to basic life support that any trained healthcare provider can perform. This approach stresses early CPR and early defibrillation. It does not include advanced interventions such as advanced airway techniques or drug administration. It helps achieve goals of supporting or restoring effective oxygenation, ventilation, and circulation until the Return of Spontaneous Circulation (ROSC) or initiation of ACLS Interventions.

Scene Safety

If in non-healthcare settings, the initial action should be to ensure scene safety. Intervention is ineffective if the intervener is at risk of becoming a victim.

ActionMethod
Check for ResponsivenessVerbalization: tap and shout “Are you alright?”
Check for absent or abnormal breathing, or gasping, by looking or scanning chest movement for 5 to 10 seconds.
Active Emergency ResponseActivate the emergency response system and get an AED or send someone to get it.
CirculationCheck the carotid pulse (adult, child) or brachial pulse (baby; <1 year old) for 5 to 10 seconds.
  • If absent, start HQCPR (30:2 for adults; if two rescuers are present, 15:2 for infants and children) starting with chest compressions (@ 100-120 compressions per minute).
  • If a pulse is present, start rescue breathing q5s/q6s (10-12/min) and check pulse q2min
DefibrillationIf pulse is absent, check for shock-able rhythm with an AED as soon as it arrives; follow each shock with CPR, bginning with compressions.

The Advanced Cardiac Life Support Survey (Pre-Arrest)

The ACLS survey allows for healthcare providers to continue to assess and perform appropriate actions until transfer to the next level of care. Assessment and intervention often becomes simultaneous in ACLS scenarios. An important component of this survey is the differential diagnosis, where identification and treatment of underlying causes may be critical to patient outcome.

Use the BLS Survey first, then ACLS Survey for unconscious patients. In conscious patients, use the ACLS Survey first.

SurveyCodeAction
VVisualize and Verbalize
Vital Signs (HR, BP, RR, O2, Temp.)
Airway and BreathingOOxygen if SpO2 is <94%.
  • Nasal Cannula allows for 2-4 L/min
  • Face Mask allows for 2-10 L/min
CirculationM
I		Monitor via pads on the chest, provide HRQCPR as needed, and rhythm intervention.
Establish Input and IV
Differential DiagnosisTTreat reversible causes (5 Hs and 5 Ts)
  • 5 Hs: Hypovolemia, Hypoxia, Hydrogen Ion, Hyper/Hypokalemia, Hypothermia
  • 5 Ts: Tension Pneumothorax, Tamponade (Cardiac), Toxins, Thrombosis (Pulmonary/Coronary)

Return of Spontaneous Circulation (Post-Arrest)

The resumption of sustained, perfusing cardiac activity associated with significant respiratory effort after cardiac arrest. Signs of ROSC include breathing, coughing, or movement and a palpable pulse or a measurable blood pressure. Attachments on a patient post-arrest include:

  1. Nasogastric Tube (NGT)
  2. X-Ray
  3. Cardiovascular Pressure (CVP)
  4. 12-Lead Electrocardiogram (ECG)
  5. Foley Catheter
ROSC AssessmentInterventions
C: CirculationFluids (PNSS/PLRS) 1-2 L
Perform 4-point Auscultation
A: Airway
B: Breathing		Advanced Airway Techniques
Perform 5-point Auscultation
D: DisabilityTherapeutic Hypothermia: PNSS/PLRS 30 cc/kg @ 4°C over 12 - 24 hours. Core body temperature should remain from 32°C to 34°C.

Cardiac Monitoring

Cardiac Monitoring provides continuous observation of the patient’s heart rate and rhythm and is a routine nursing procedure in critical care patients. It is common in emergency units, post-anesthesia recovery units, and operating rooms. It often involves an Electrocardiograph (ECG), a graphic representation and record of the electrical activity of the heart muscles. The record is a waveform across a grid whose X-axis is time, and Y-axis being the voltage recorded.

  • The grid consists of large squares equivalent to 200 milliseconds and 0.5 mV, subdivided further into a 5 by 5 grid whose cells are equivalent to 40 milliseconds and 0.1 mV.

Normal ECG

ComponentDescriptionTypes
WavePositive and negative deflections of the wave from the baseline.P, Q, R, S, T-waves
IntervalDurations between two specific ECG events.PR, QRS, QT, ST intervals
SegmentThe length between two specific points on the ECG which are supposed to be at the baseline amplitude.PR, ST, TP-segment
ComplexThe combination of multiple waves group together.QRS complex

Defibrillation

  1. Shockable: ventricular tachycardia without pulse and ventricular fibrillation. Immediately after shocking, CPR is instituted.
  2. Non-shockable: provision of CPR and epinephrine. This is used for asystole and pulseless electrical activity (PEA).

Arrhythmias

Arrythmias are abnormal rhythms of the heart. This may be classified as bradycardia or tachycardia.

  1. Bradycardia: treated with Atropine, given 1 mg every 3 to 5 minutes for a maximum of three doses.
    1. Sinus Bradycardia
    2. Heart Block
  2. Tachycardia:
    1. Narrow QRS: supraventricular tachycardia (SVT); this may be further classified as unstable (<90 mm Hg) or stable (>90 mm Hg), based on blood pressure.
      • Unstable SVT requires sedation with Diazepam (5 mg IV) and a 50J shock.
      • Stable SVT requires a vagal maneuver then Adenosine if ineffective (6 mg, then 12 mg IV).
    2. Wide QRS: if peaks remain, ventricular tachycardia (VT) or unstable/flattened, ventricular fibrillation (VF).

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