“ Introduction to Critical Care Nursing : Where every life counts”

Concept , Scope and Need of Critical Care Nursing

Critical care :- Medical care for people who have life-threatening injuries and illnesses. Monitoring and
treatment of critically ill or injured patients in intensive care. Care of patients who are extremely ill and
whose clinical condition is unstable or potentially unstable.
Critical care unit :- It is defined as the unit in which comprehensive care of a critically ill patient which is
deemed to recoverable stage is carried out. The Critical Care Unit is not merely a room or series of rooms
filled with patients attached to interventional technology; it is the home of an Organization.

Critical Care Nursing :- It refers to those comprehensive, specialized and individualized nursing care
services which are rendered to patients with life threatening conditions and their families.

Critical care nursing is the field of nursing with a focus on the level best care of the critically ill or unstable
patients following extensive injury, surgery or life threatening diseases.

Concept of critical care :-

1. Many disciplines, one team.

2. The concept of critical care is to ensure the survival of the patient and prevent end organ damage by
providing optimal support.

3. It involves set interventions based on evidence-based practice to improve the survival of critically ill
patients with minimal disability.

4. Care givers comprise of a team of care givers with special training.

5. Each member of the team has specific role in the care giving and includes a check list to monitor at each
level.

Focus on Critical Care Nursing

 It is an established fact that critical illness affects both patient and family from various angles
including effect on psychological, emotional and socio economical aspects.
 Hence the focus of Critical Care Nursing should be on patients and their families.

Focus on Patient

 Patient differs in biological capability in their response to injury in maintaining homeostasis.

Critically ill patients are in a physiologically highly unstable state and are at high risk. They require
special, intensive and continuous care.

Focus on Family

 Family is an important source of information about patient illness status

 Family support help patient in regaining Self-confidence, self-image which he has lost due to illness.
 Family members help the patient to communicate to express their fear, and anxiety, frustration etc.
  Family fulfils the roles of biological, psychological emotional and social functioning as they will
continue to influence the patient’s recovery process.

Goals of critical care nursing: -

 To promote optimal delivery of safe and quality care to the critically ill patients and their families by
providing highly individualized care so that the physiological d dysfunction as well as the
psychological stress in the ICU are under control.
 To care for the critically ill patients with a holistic approach considering the patient’s biological,
psychological, cultural and spiritual dimensions regardless of diagnosis or clinical setting.
 To use relevant and up-to-date knowledge, caring attitude and clinical skills, supported by appropriate
technology for the prevention, early detection and treatment of complications to facilitate recovery.
 To provide palliative care to the critically ill patients in situations where their health status is
progressing to unavoidable death, and to help the patients and families go through their painful
sufferings.

Classification of critical care units: -

Level – 1 Provides monitoring, observation, and short-term ventilation. Nurse patient ratio is 1:3 and the
medical staff are not present in the unit all the time.

Level – 2 Provides observation, monitoring and long-term ventilation with resident doctors. The nurse-
patient ratio is 1:2 and junior medical staff is available in the unit all the time and consultant medical staff is
available if needed.

Level – 3 Provides all aspects of intensive care including invasive haemodynamic monitoring and dialysis.
Nurse patient ratio is 1:1 for all patients always.

Principles of critical care nursing:-

 Anticipation
 Early detection and prompt acting
 Collaborative practice
 Prevention of infection
 Communication
 Crisis intervention and stress reduction
 Efficacy
 Appropriateness
 Availability
 Timeliness
 Effectiveness
 Continuity
 Safety
 Efficiency
 Respect and caring

Principles of critical care nursing:-

1. Anticipation - One must recognize the high-risk patients, and anticipate the requirements and
complications. Be prepared to meet any emergency. Unit is properly organized with all necessary
equipment and supplies for smooth running of the unit.
2. Early detection and prompt action - The prognosis of the patient depends on the early detection
of variation. Prompt and appropriate action to prevent or combat complication. Monitoring of
cardiac respiratory function is of prime importance in assessment.

3. Collaborative practice - Critical Care, has evolved into a comprehensive discipline requiring a
very specialized body of knowledge for the physicians and nurses working in the critical care unit.
Fosters a partnership for decision making and ensures quality and compassionate patient care.
Collaborate practice is more necessary in critical care more than in any other field.

4. Prevention of infection - Nosocomial infection cost a lot in the health care services. Critically ill
patients requiring intensive ca re are at a greater risk than other patients due to the
immunocompromised state with the antibiotic us age and stress, invasive lines, mechanical
ventilators, prolonged stay and severity of illness and environment of the critical unit itself.

5. Communication - Intra professional, inter departmental and inter personal communication has a
significant importance in the smooth running of unit.

6. Crisis intervention and stress reduction - Partnerships are formulated during crisis. Bonds
between nurses, patients and families are stronger during hospitalization. Nurses assist the patient
to express fear and identify their grieving pattern and provide avenues for positive coping.

7. Efficacy - The degree to which the care and the nursing interventions have achieved the projected
or desired patient outcome.

8. Appropriateness - This indicate the degree to which the care and interventions rendered are
relevant to patient’s clinical needs.

9. Availability - It refers to degree to which appropriate care and intervention are available to meet
patients and family needs, i.e., Critical Care Unit are properly staffed and equipped.

10. Timeliness - The degree to which prompt care and intervention s are provided to patient, family.
This requires sufficient familiarity and keen observation of patient progress during different
phases of the illness and promptness in diagnosis, deviations and taking actions.

11. Effectiveness - The degree to which care and interventions are rendered in correct manner to
achieve the desired or projected patient outcome. This refers to knowledge and skills of the nurse
to make proper nursing diagnosis of patient and skilful handling of machine, gadgets,
administration of treatment therapies, carrying out Diagnostic procedure , continuous monitoring,
documenting, detecting deviations, and taking necessary action.

12. Continuity - This emphasizes the degree to which the care and intervention for the client are
coordinated among the Critical Care team and their collaborative management of the case.
continuous and keen observation of the client's condition will help us to assess his progress and
collaborate/ coordinate with team members, departments, organization involved or likely to be
 involved in patient care, good communication and IPR form the basis for effective team
functioning and continuity of care.

13. Safety - The degree to which the risk of interruption in the care-environment can be eliminated for
patient and others includes health care providers. It indicates that we should adhere to the protocol
standards of the critical care, established and modified on the basis of research conducted or
available in different aspect of safety e.g., physical 'care environment, therapies and procedure etc

14. Efficiency - Depends upon the relationship between the outcome and resources used for the care
e.g., competence levels of care providers, availability of required technology to save/treat patient,
availability of needed. Equipment’s, supplies, drugs, appropriate communication channels and
effective communication skills. In other words a well-established critical care system that provide
for collaborative, dedicated and compassionate care.

15. Respect and caring - Refers to degree to which the patient and family members are involved in
decision making of the c are and its implementation. With sensitivity we must listen attentively to
client concerns and respect individual difference in their expression. As critical care nurse your
aim is to promote the quality of life than mere survival. This you can ensure by helping patient to
gain control over his care through his or her gradual involvement in self-care decisions and care
activities.

Seven Cs of critical care :-

1. Compassion
2. Communication (with patient and family).
3. Consideration (to patients, relatives and col leagues) and avoidance of Conflict.
4. Comfort (prevention of suffering)
5. Carefulness (avoidance of injury)
6. Consistency
7. Closure (ethics and withdrawal of care).

Essential nurse competencies :-

 Clinical judgment
 Advocacy Caring practices
 Collaboration
 Critical Thinking
 Response to diversity
 Clinical inquiry
 Facilitation of learning

Standards of critical care nursing practice :-

1. The critical care nurse functions in accordance with legislation, common laws, organizational
regulation s and by-laws, which affect nursing practice.

2. The critical care nurse provides care to meet individual patient needs on a 24-hour basis.
3. The critical care nurse practices current critical care nursing competently.

4. The critical care nurse delivers nursing care in a way that can be ethically justified.

5. The critical care nurse demonstrates accountability for his/her professional judgment and actions.

6. The critical care nurse creates and maintains an environment which promotes safety and security of
patients, visitors and staff.

7. The critical care nurse masters the use of all essential equipment, available services and supplies for
immediate care of patients.

8. The critical care nurse protects the patients from developing environmental induced infection.

9. The critical care nurse utilizes the nursing process in an explicit systematic manner to achieve the
goals of care.

10. The critical care nurse carries out health education for promotion and maintenance of health.

11. The critical care nurse acts to enhance the professional development of self and others.

Role of critical care nurse :-

1. Care provider
2. Educator
3. Patient advocate
4. Leadership role
5. Role in research

1. Care provider :-

A. Direct patient care - Detects and interprets indicators that signify the varying conditions
of the critically ill with the assistance of advanced technology and knowledge.
Plans and initiates nursing process to its full capacity in a nee d driven and proactive
manner.
Acts promptly to prevent or halt deterioration of patients’ condition when conditions
necessitate.
Co-ordinates with other healthcare providers in the provision of optimal care to achieve
the best possible outcomes.

B. Indirect patient care - Understands family needs and provide information to allay fears
and anxieties.
Assists family to cope with the life-threatening situation and/or patient’s impending death.

2. Educator - As an educator, the critical care nurse must be able to:

Provides health education to patient and family to promote understanding and acceptance of
the disease process thus facilitate recovery.
 Participates in the training and coaching of novice healthcare team members to achieve
cohesiveness in the delivery of patient care.

3. Patient advocate - The Critical Care Nurse may be in the best position to act as the liaison
between patient and family and other team members and departments.
Acts in the best interests of the patient.
Monitors and safeguards the quality of care which the patient receives.

4. Leadership role - Performance of management and leadership skills in providing safe and
quality care.
Accountability for safe critical care nursing practice.
Delivery of effective health programs and services to critically-ill patients in the acute setting.

5. Role in research - Engage self in nursing or other health – related research with or under the
supervision of an experienced researcher.
Utilization of guidelines in the evaluation of research study or report.
Application of the research process in improving patient care infusing concepts of quality
improvement in partnership with other team-players.

Family needs of patients :- The top nine priorities of critical care families

1. Assurance that the best car e was being given to their family member by caring Personnel
2. To feel that there is hope
3. To know the prognosis
4. To understand how the client was being treated medically
5. To be reassured that it is all right to leave for a while
6. To feel accepted by hospital staff
7. To feel someone is concerned for the family's health
8. To feel the hospital personnel care about the client
9. To have explanations given in terms that can be understood.

Scope of critical care nursing :-

 With the increasing critical care services in the country and overseas, scope for specialization and
employment in Critical Care Nursing is also widening.
 In India training for Critical Care Nursing specialization has commenced recently in 2006 and
employment opportunity for Critical Care nurses will be there in hospitals, educational institution, and
Community Health Care.
 Specialization in Critical Care Nursing
It is not mandatory for professional nurse to specialization in Critical Care Nursing to work in
Critical Care Units.
Some institutions do prefer to employ nurses who have acquired specific higher competence in
Critical Care Nursing.

Educational programmes:
 Post Basic Diploma in Critical Care Nursing
 MSc nursing with Critical Care speciality
 Nurse Practitioner In Critical Care (Post Graduate- Residency Program)
Extended role as critical care nursing :-
With proper training and in accordance with established guideline s, algorithms, and protocols,
critical care nurses also perform procedures and therapies that are otherwise done by doctors.
Such procedures are:

1. Weaning patients off ventilators.

2. Sampling and analysing arterial blood gases.
3. Adjusting intravenous analgesia / sedations.
4. Titrating intravenous and central line medicated infusion and nutrition support.
5. Initiating defibrillation to patient with ventricular fibrillation or lethal ventricular
tachycardia.
7. Removal of pacer wire, femoral sheaths and chest tubes.
8. Other procedures deemed necessary in their respective institutions under a clinical
protocol.

Challenges of critical care nursing :-

1. To develop, foster and maintain a level of know ledge about the norms, values, beliefs,
patterns of illness, health and care needs of the people.
2. To analyse and evaluate critical care nurses specialty skills and their evolving roles.
3. To review current studies and researches and to examine contextual issues that will
enable evaluation and synthesis of new knowledge, traditional techniques, religious and
cultural influences to be applied in nursing practice, particularly evidence-based nursing
practice.
4. To exercise professional judgments expected of them in the critical care clinical
setting.

Ethical issues of most concern :-

1. Protecting patients’ rights & human dignity

2. Providing care with possible risk to your health (e.g. TB, HIV, violence)
3. Respecting/not respecting informed consent to treatment
4. Staffing patterns that limit patient access to nursing care
5. Use/non use of physical/chemical restraints
6. Prolonging the dying process with inappropriate measures
7. Working with an unethical/incompetent/ impaired colleague
8. Not considering a patient’s quality of life

Critical nursing is not nursing in a specific place; rather, it is nursing with a specific
mind-set that utilizes a specialized body of knowledge and skills.

Critical thinking and clinical decision-making become more consistent, the longer the critical
care nurse practices in the critical care environment provides holistic care.
Ultimately, however, it is the bedside critical care nurse who coordinates the entire team's
efforts to implement the plan of care and modify it as needed by the client's response.