NURSING MANAGEMENT OF PATIENT IN CRITICAL CARE

UNITS (CCU)
Critical care also known as Intensive Care is the multi professional healthcare specialty that
cares for patients with acute, life-threatening illness or injury.
Critical care nursing is the field of nursing with a focus on the care of the critically ill or
unstable patients. These units are designed to deliver the highest of medical and nursing care
to the sickest of patients.
The ICU is highly specified and sophisticated area of a hospital which is specifically designed,
staffed, located, furnished and equipped, dedicated to management of critically ill patients,
injuries or complications.
It is a department with dedicated medical, nursing and allied staff. It operates with defined
policies; protocols and procedures, having its own quality control, education, training and
research programmes.

Definition:
An intensive care unit (ICU) or Critical Care Unit (CCU) is a specialized section of a hospital
that provides comprehensive and continuous care for persons who are critically ill and who can
benefit from treatment.

Critical care nursing is a comprehensive, specialized and individualized nursing care services
which are rendered to patients, with life threatening conditions and their families.

Goals of Critical Care:

1. Towards the survival of the critical ill patients and restoring quality of life.

2. Restoring optimal physiological, psychological, social and spiritual potential.

3. Helping the families of the critically ill patients in coping with crises.

NURSING ASSESSMENT - HISTORY AND PHYSICAL EXAMINATION

NURSING ASSESSMENT

Nursing assessment is the gathering of information about a patient's physiological,

psychological, sociological, and spiritual status.

Assessment the first stage of the nursing process in which the nurse should carry out a complete
and holistic nursing assessment of v patient's needs, regardless of the reason for the encounter.

The purpose of this stage is to identify the patient's nursing problems. These problems
expressed as either actual or potential.

Components of Nursing Assessment

1. Nursing History: Taking a nursing history prior to the physical examination allows a nurse
to establish a rapport with the patient and family.
Elements of the history include:
  Health status
 Course of present illness including symptoms
 Current management of illness
 Past medical history including family's medical history
 Social history
 Perception of illness

2. Psychological and Social Examination: The psychological examination may include:

 Emotional health
 Physical health
 Spiritual health
 Intellectual health

3. Physical Examination: A nursing assessment includes a physical examination: the

observation or measurement of signs, which can be observed or measured, or symptoms
such as nausea or vertigo, which can be felt by the patient.
The techniques used may include Inspection, Palpation, Auscultation and Percussion in
addition to the "vital signs" of temperature, blood pressure, pulse and respiratory rate, and
further examination of the body systems

Documentation of the Assessment:

The assessment is documented in the patient's medical or nursing records, which may be on
paper or as part of the electronic medical record which can be accessed by all members of the
healthcare team.

Assessment Tools
A range of instruments has been developed to assist nurses in their assessment role.
These include:
 Index of independence in activities of daily living
 Barthel index
 Crichton royal behaviour rating scale
 Clifton assessment procedures for the elderly
 General health questionnaire
 Geriatric mental health state schedule

PHYSICAL EXAMINATION

Physical examination or Clinical examination is the process by which a doctor investigates the
body of a patient for signs of disease. It generally follows the taking of the medical history.
Together with the medical history, the physical examination aids in determining the correct
diagnosis and devising the treatment plan. This data then becomes part of the medical record.
A complete physical examination includes evaluation of general patient appearance and
specific organ systems. It is recorded in the medical record in a standard layout which facilitates
others later reading the notes. In practice the vital signs of temperature examination, pulse and
blood pressure are usually measured first.

CLASSIFICATION OF CRITICAL CARE UNITS

There are three different levels of ICU defined according to three main criteria: the nature of
the facility, the care process and the clinical standards and staffing requirements.

Critical care units may be classified into three levels depending on the staffing and support
facilities of the hospital. A three level classification consist of:

A. Level - I Units: These units care for the complicated, critically ill patients requiring the
continuous availability of sophisticated equipment, specialized nurses and physicians
with critical care training.

It must be capable of providing basic multisystem life support usually for less than a 24
hour period. It must be capable of providing mechanical ventilation and simple invasive
cardiovascular monitoring for a period of at least several hours.

 It is recommended for small district hospital, small private Nursing homes and rural
centres
 Ideally 6 to 8 beds
 Provides resuscitation and short-term Cardio respiratory support including
Defibrillation
 Able to ventilate a patient for at least 24 to 48 hrs, including non-invasive ventilation
 Non-invasive Monitoring - SPO2, ABG, HR & rhythm, NIBP, ECG and Temperature
 Able to have arrangements for safe transport of the patients to secondary or tertiary
centres.
 The staff should be encouraged to do short training courses like Fundamentals of
Critical Care Support (FCCS) or Basic Assessment and Support in Intensive Care
(BASIC) courses.
 In charge should be preferably a trained doctor in ICU technology and knowledge.
 Blood Bank support and should have basic clinical Lab (CBC, BS, Electrolyte, LFT
and RFT) and Imaging back up (X-ray and USG), ECG

B. Level - II Units: These units have limited resources to provide critical care. These units
may be able to deliver a high quality of care to patients.

Level II unit provides observation, monitoring & 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.

 Recommended for larger General Hospitals.

 Bed strength 6 to 12
 Director be a trained/qualified Intensivist
 Multisystem life support
 Invasive and Non-invasive Ventilation, Long term ventilation ability and Invasive
monitoring
 Access to ABG, Electrolytes and other routine diagnostic support 24 hours
 Nurses and duty doctors trained in Critical Care
 CT must & MRI is desirable
  Protocols and policies for ICUs are observed
 Research will be highly recommended
 Supported ideally by Cardiology and other super specialities of Medicine and Surgery
 Resident doctors must be exposed to FCCS course/BASIC course/Ventilation
workshops
 Blood banking either own or outsourced

C. Level - III Units: Level III units provides all aspects of intensive care including invasive
haemodynamic monitoring & dialysis. Optimum patient / Nurse ratio is maintained with 1/1
patient / Nurse ratio in ventilated patients.

All recommendations of Level II Plus -:

 Recommended for tertiary level hospitals
 Bed strength 10 to 16 with one or multiple ICUs as per requirement of the institution
 Multidisciplinary unit headed by Intensivist
 Preferably Closed ICU
 Protocols and policies are observed
 Have all recent methods of monitoring, invasive and non-invasive
 Long term acute care of highest standards
 Intra and inter-hospital transport facilities available
 Multisystem care and referral available round 24 hrs
 Bedside x-ray, USG, 2D-Echo available, CT Scan and MRI facilities should be there
 Bedside bronchoscopy, side dialysis and other forms of RRT available
 Adequately supported by Blood banks and Blood component therapy
 In addition there is optimum additional space for storage, nursing station and relatives.

TYPES OF CRITICAL CARE UNIT / ICU

Specialized types of ICUs include:
1. Neonatal Intensive Care Unit (NICU): NICU stands for neonatal intensive care unit,
sometimes called a special care nursery. These nurseries care for babies who are born early,
who have problems during delivery, or who develop problems while still in the hospital.

2. Pediatric Intensive Care Unit (PICU): The PICU is a multidisciplinary unit that provides
care for infants, children and adolescents who become critically ill or injured.

3. Psychiatric Intensive Care Unit (PICU): The Psychiatric Intensive Care Unit provides
care for adult patients with acute mental illness. Care is provided in a secure unit designed
for the safety and security of the patients and staff.

4. Coronary Care Unit (CCU): The Coronary Care Unit is a place for patients who have
heart-related illnesses. Conditions such as myocardial infarction, angina, congestive heart
failure etc.

5. Cardiac Surgery Intensive Care Unit (CSICU): The Cardiac Surgery Intensive Care
Unit is a unit that provides care to adult patients requiring pre- and post-operative care for
cardiac surgical conditions.
6. Cardiothoracic Intensive Care Unit (CICU): The Cardiothoracic ICU cares for patients
who need heart (cardiac) and chest (thoracic) surgery. Surgical procedures may include
operations on the heart, the heart's blood vessels, the chest or the lungs.

7. Medical Intensive Care Unit (MICU): The MICU is an adult critical care unit providing
comprehensive care for critically ill medical patients with a vast variety of diagnoses well-
trained team of intensivists, physicians and nurses to provide expert care to patients with
pulmonary problems.

8. Surgical Intensive Care Unit (SICU): The Surgical Intensive Care Unit (SICU) is a 10-
bed adult critical care unit designed to provide comprehensive care for critically ill surgical
and trauma patients.

9. Overnight Intensive Recovery (OIR): The Overnight Intensive Recovery is part of the
main recovery area. It is situated in a four bedded bay adjacent to Recovery.

10. Neuro Intensive Care Unit (NICU): The Neuro Intensive Care Unit cares for patients
with brain or spinal cord conditions and occasionally other medical or surgical problems.

11. Burn Wound Intensive Care Unit (BWICU): The Burn Intensive Care Unit (BICU) is a
ten-bed adult critical care unit designed to provide comprehensive care for the burn patient
who may have surgical needs or some type of trauma.

12. Geriatric Intensive Care Unit (GICU): Geriatric intensive care unit is a special type of
intensive care unit dedicated to management of critically ill elderly.

13. Mobile Intensive Care Unit (MICU): Mobile Intensive Care Units are well-equipped unit
staffed by highly trained paramedics dispatched to emergency situations where patients
require a higher level of care.

14. Post Anesthesia Care Unit (PACU): Post Anesthesia Care Unit is an area of a hospital
designated for "recovering" from the immediate effects of anesthesia whether it be general
anesthesia, regional anesthesia, or local anesthesia before either going home or on to
another in-hospital destination.

15. High Dependency Unit (HDU): Patients admitted into the hospital may require a level of
care that cannot be provided on a general ward but does not require admission into an
Intensive Care Unit.

16. Medical Surgical Intensive Care Unit (SICU)

17. Neurotrauma Intensive Care Unit (NICU)

18. Trauma Intensive Care Unit (TICU)

19. Neuroscience/ Neurotrauma Intensive Care Unit (NICU)

20. Medical Surgical Intensive Care Unit (SICU)

PRINCIPLES OF CRITICAL CARE NURSING
Continuous monitoring and treatment; high intensity therapies and interventions; expert
surveillance and efficiency; alert to early manifestation of other organ failure; and recognition
of parameters denoting progress or deteriorating are principles of critical care.

There are following principles of critical care nursing:

1. Anticipation
2. Early detection and prompt action
3. Collaborative practice
4. Communication
5. Prevention of infection
6. Crisis intervention and stress reduction

1. Anticipation: The first principle in critical care is anticipation. One has to recognize the
high risk patients and anticipate the requirements, complication and be prepared to meet
any emergency.
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, which has originated as technical subspecialized
body of knowledge, has evolved in to a comprehensive discipline requiring a very
specialized body of knowledge for the physicians and nurses working in the unit.
Collaborative practice is more and more than warranted for critical care more than in any
other field.
4. Communication: Intraprofessional, interdepartmental and interpersonal communication
has a significant importance in the smooth running of unit.
5. Prevention of Infection: Nosocomial infection cost a lot in the health care service
6. Crisis Intervention and Stress Reduction: Partnerships are formulated during crisis.
Bonds between nurses, patients and families are stronger during hospitalization. As
patient advocates, nurses assist the patient to express fear and identify their grieving
pattern and provide avenues for positive coping.

ORGANIZATION AND PHYSICAL SETUP OF CCU

Intensive care has its roots in the resuscitation of dying patients. Exemplary critical care
provides rapid therapeutic responses to failure of vital organ systems, utilizing standardized
and effective protocols such as advanced cardiac life support and advanced trauma life support.

DESIGN OF INTENSIVE CARE UNIT

Overall ICU floor plan and design should be based upon patient admission patterns staff and
visitor traffic patterns, and the need for support facilities such as nursing stations storage,
clerical space, administrative and educational requirements, and services that are unique to the
individual institution.

1. The Design Team: ICU design should be approached by a multidisciplinary team consisting
of, but not limited to, the ICU medical director, the ICU nurse manager, the chief architect,
hospital administration, and the operating engineering staff. The ability to provide specific
levels of care must be determined by analysing physician resources, staff resources (nursing,
respiratory therapy, etc.), and the availability of support services (laboratory, radiology,
pharmacy, etc.).
2. Location /Entry / Exit Points of ICU in Hospital: There should be a single entry and exit
point to ICU. However, it is required to have emergency exit points in case of emergencies and
disasters. Safe, easy, fast transport of a critically sick patient should be priority in planning its
location. Therefore, the ICU should be located in close proximity of ER, Operating rooms,
trauma ward, etc.

3. ICU Bed Designing and Space Issues: Space per bed has been recommended from 125 to
150 sq ft area per bed in the patient care area or the room of the patient. In addition there should
be 100 to 150% extra space to accommodate nursing station, storage, patient movement area,
equipment area, doctors and nurses rooms and toilet.

4. Floor and Wall Coverings: The ideal floor should be easy to clean, non-slippery, able to
withstand abuse and absorb sound while enhancing the overall look and feel of the
environment. Carts and beds equipped with large wheels should roll easily over it.

Walls should meet following criteria: Durability, ability to clean and maintain, flame
retardance, mildew resistance, sound absorption and visual appeal. Wooden panelling has also
found favour with some architects but costs may go high.

5. Patient Areas: Patients must be situated so that direct or indirect (e.g. by video monitor)
visualization by healthcare providers is possible at all times. This permits the monitoring of
patient status under both routine and emergency circumstances. The preferred design is to allow
a direct line of vision between the patient and the central nursing station.
It is recommended that there should be a partition/separation between rooms when patient
privacy is desired. Standard curtains soften the look and can be placed between two patients
which is very common in most Indian ICUs.

6. Central Nursing Station: This is the nerve centre of ICU. A central nursing station should
provide a comfortable area of sufficient size to accommodate all necessary staff functions.
All/nearly-all monitors and patients must be observable from there, either directly or through
the central monitoring system.

 There must be adequate overhead and task lighting, and a wall mounted clock should
be present.
 Adequate space for computer terminals and printers is essential when automated
systems are in use.
 Patient records should be readily accessible.
 Adequate surface space and seating for medical record charting by both physicians and
nurses should be provided.
 Shelving, file cabinets and other storage for medical record forms must be located so
that they are readily accessible by all personnel requiring their use.
 It is also important that a storage space is provided for equipment, linen, instruments,
drugs, medicines, disposables, stationary and other articles to be stored at the Nursing
station must be provided.
 All these cupboards should be labelled.

7. 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.
 Countertops must be provided for medication preparation, and cabinets should be
available for the storage of medications and supplies.

8. Special Procedures Room: If a special procedures room is desired, it should be located

within or immediately adjacent to the ICU. One special procedures room may serve several
ICUs in close proximity.

9. Clean and Dirty Utility Rooms: Clean and dirty utility rooms must be separate rooms that
lack interconnection. They must be adequately temperature controlled, and the air supply from
the dirty utility room must be exhausted. Floors should be covered with materials without
seams to facilitate cleaning. 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 a clinical sink and a hopper both with hot and cold mixing
faucets. Separate covered containers must be provided for soiled linen and waste materials.

10. Equipment Storage: An area must be provided for the storage and securing of large patient
care equipment items not in active use. Space should be adequate enough to provide easy
access, easy location of desired equipment, and easy retrieval.

11. Nourishment Preparation Area: A patient nourishment preparation area should be

identified and equipped with food preparation surfaces, an ice-making machine, a sink with hot
and cold running water, a countertop stove and/or microwave oven, and a refrigerator.
A hand washing facility should be located in or near the area.

12. Staff Lounge: A staff lounge must be available on or near each ICU or ICU cluster to
provide a private, comfortable, and relaxing environment. Secured locker facilities showers
and toilets should be present.

13. Receptionist Area: Each ICU or ICU cluster 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.

14. Visitors' Lounge / Waiting Room: A visitors' lounge or waiting area should be provided
near each ICU or ICU cluster. Visitor access should be controlled from the receptionist area.
Public toilet facilities and a drinking fountain should be located within the lounge area or
immediately adjacent.

15. Isolation Rooms: 10% of beds (1 or 2) rooms may be used exclusively as isolation cases
like for burns, serious contagious infected patients or immunosuppressed patients.

16. Conference Room: A conference room should be conveniently located for ICU physician
and staff use. This room must be linked to each relevant ICU by telephone or other
intercommunication system, and emergency cardiac arrest alarms should be audible in the
room. The conference room may have multiple purposes including continuing education,
house-staff education or multidisciplinary patient care conferences.
17. Administrative Offices: It is often desirable to have office space available adjacent to the
ICU(s) for medical and nursing management and administrative personnel. These offices
should be large enough to permit meetings and consultations with ICU team members and/ or
patients' families.

STAFFING NORMS OF CRITICAL CARE UNIT

The Intensive Care team consists of many different, highly trained staff, working together,
caring for seriously ill patients to ensure the best possible outcome for the patient. ICU staffing
is one of the most important tasks and components of the whole programme. They include:

 INTENSIVE CARE DOCTORS

There are three levels of ICU depending on the size of the hospital. Each unit is staffed
according to the complexity of patients who are admitted there. All units will have a specialist
doctor in charge. The Intensive Care doctor is also referred to as the Intensivist or ICU
Consultant. They are responsible for coordination of patient care in the ICU and will consult
with other specialists. Intensivists are specialists who have completed advanced training in
intensive care medicine or a related speciality such as anaesthetics, cardiology or emergency
medicine. They are skilled in diagnosing and treating critical illnesses and injuries.

 RESIDENT DOCTORS
Post graduates from Anesthesia, Medicine or Respiratory Medicine or other allied branches
including surgical specialties. Other residents may be graduates depending upon total Bed
strength of ICU. It is understood and recommended that one doctor cannot take care of more
than five patients who are critically sick on ventilator and/or undergoing invasive monitoring
with multiorgan failure. Therefore, it is suggested that one PG resident with one graduate
resident may be good for an ICU of 10 to 14 beds with 1/3 of the patients may be falling into
above category.

 INTENSIVE CARE NURSES

Intensive Care nurses are responsible for the coordination and implementation of treatment and
care for critically ill patients. Many have special experience, education and training in caring
for critically ill and injured patients. ICU nurses' provide continuous bedside patient care and
the constant monitoring allows for early identification of changes in a patient's condition. They
are skilled in caring for and implementing treatment for critical illnesses and injuries. 1:1
nursing for Ventilated patients is desirable but in no circumstance the ratio should be < 2 nurses
for three patients. 1:2 to 1:3 nurse patient ratio is acceptable less seriously sick patients who do
not require above modalities.

ALLIED HEALTH PROFESSIONALS

The ICU team cannot care for the ICU patient without the help of other health professionals.
Within the ICU you may also meet other staff such as:
 Respiratory Therapist looks after ventilator management and respiratory physiotherapy.
This takes away lot of load off the duty doctor and the nurses.
 Physiotherapists are responsible for providing physical therapy for patients such as
mobility assistance and chest physiotherapy.
 Pharmacists attend ward rounds and assist doctors and nurses with advice regarding
medications as well as ensuring a supply of medication for patients.
 Technicians who can perform simple procedures like taking samples and sending them to
proper place in proper manner makes the task easy and less stressful.
 Occupational therapists evaluate the ability of the patient to carry out everyday activities
of daily living and develop treatment plans to improve the patient's abilities.
 Nutritionist is also a very important professional who can contribute to outcome of patient.
They have to be trained in desired practices and should be more inclined towards enteral
feeding than TPN.
 Biomedical engineer within the campus makes the job of ICU less frustrating when snags
creep in within sensitive ICU equipment. He can be correct them fast.
 Computer operators can prepare reports, enter data and bring out print outs as and when
needed. He can also maintain library, Internet and protocols practiced in ICU.
 Cleaning, class IV and Guards are also important to ICU particularly when they
understand needs of ICU and its patients. They have a huge role to play in prevention of
Nosocomial infection, keeping ICU clean and protect from overcrowding.
 In addition the ICU should be ably supported by clinical Lab staff, Microbiology and
Imaging staff who can understand the protocols of ICU and act within discipline of ICU
protocols. One person should be responsible for observing protocols of Pollution and
Infection control.

PROTOCOLS FOR CRITICAL CARE UNIT

1. Protocols for ICU Admission and Discharge: Every ICU should have and use admission
and discharge criteria. The criteria should be endorsed by the intensivist or other appropriately
qualified physician. In hospitals where there is no intensivist or appropriately qualified
physician, the Medical Executive Committee should endorse the criteria.

Admissions Policy:
 Patients are managed by the ICU staff during their stay in ICU.
 Admission is reserved for patients with actual or potential vital organ system failures,
which appear reversible with the provision of ICU support.
 All admissions, including transfers and retrievals, must be approved by the duty
Intensivist.
 Retrievals must be discussed with the Consultant when the SR is on 1st call.
 Resuscitation or admission must not be delayed in imminently life threatening cases,
unless specific advanced directives exist and are clearly documented.
 Such admissions should be discussed with the Duty Intensivist ASAP.

Discharge Policy:
1. All discharges should be:
i) Approved by the responsible ICU consultant.
ii) Discussed with the parent clinic prior to patient transfer, including any ongoing
or potential problems.
iii) Transferred "In hours" i.e. prior to 18:00 - unless specifically approved by a
consultant
2. A discharge summary must be completed and a copy filed in the case-notes.
3. All patients on insulin protocols should be referred to the Endocrine Unit prior to
discharge
4. Patients discharged on TPN must be entered in the TPN folder in Unit A.
5. Treatment limitation/non-escalation directives must be discussed with the patient or
patient's family and clearly documented prior to discharge.
6. Referral to the Palliative Care should occur pre-discharge where indicated.
2. Protocols for Patient Care: Every ICU should have protocols for patient care that have
been developed by the intensivist or other appropriately qualified physician and other
multidisciplinary team members. The protocols should establish procedure as it relates to:
 Daily rounds: Protocols should stipulate when and how multidisciplinary team rounds
should be conducted.
 Patient plans of care: Protocols should stipulate how plans of care and goals are
established and evaluated.
 Protocol compliance: Protocols should include a measure to monitor compliance with
protocols.
 Protocol topics: The following clinical care areas have well-tested protocols of care and
should be adopted by all ICUs.

INTENSIVE CARE PROTOCOL

A. Conventional
1. Oxygen administrated arbitrarily in concentrations that maintain Sao2, well above 95%.
2. Frequent airway suctioning via the tube.
3. Supplemental oxygen increased when desaturations occur.
4. Ventilator weaning attempted at the expense of hypercapnia.
5. Extubation not attempted unless the patient appears to be ventilator weaned.
6. Extubation to CPAP or low span bi-level positive airway pressure and continued
oxygen therapy.
7. Deep airway suctioning by catheterizing the upper airway along with postural drainage
and chest physical therapy.
B. Protocol
1. Oxygen administration limited only to approach 95% SaO2
2. Expiratory aids used when desaturations occur.
3. Ventilator weaning attempted without permitting hypercapnia.
4. Extubation to continuous nasal ventilation and no supplemental oxygen.
5. Oximetry feedback used to guide the use of expiratory aids, postural drainage, and chest
physical therapy to reverse any desaturations due to airway mucus accumulation.
6. Discharge home after the SaO2, remained within normal limits for 2 days and when
assisted coughing was needed less than 4 times per day.

INTENSIVE CARE UNIT SAFETY TIPS

The following lists of items are recommended strategies for improving patient safety the ICU.
 Open communication among all staff is a key element for successful teamwork.
 Ask questions and avoid making assumptions.
 Clearly label patient beds; consider having a removable sign at the foot of the bed the
patient's name and bed number.
 Verify patient identification by verbally communicating with the patient and/or check
patient's identification band.
 Institute a standard change of shift policy.
 Perform a medication audit on each patient once during each shift, which could be
performed at change of shift.
 Create a mentoring culture for medical students, residents, nurses and other ICU staff
where every question is welcomed and proper supervision is exercised.
 Check the Pyxis machines daily to ensure medications and doses are stored in
appropriate bins.
 Reconcile drugs at the time a patient is discharged.
  Use a rolling line cart to keep all sterile supplies needed for insertion and maintenance
of central line catheters.

INTENSIVE CARE UNIT EQUIPMENT AND SUPPLIES

Definition:
Intensive care unit equipment includes patient monitoring, respiratory and cardiac support, pain
management, emergency resuscitation devices, and other life support equipment designed to
care for patients who are seriously injured, have a critical or life-threatening illness, or have
undergone a major surgical procedure, thereby requiring 24-hour care and monitoring.

PURPOSE:
 A CCU may be designed and equipped to provide care to patients with a range of
conditions, or it may be designed and equipped to provide specialized care to patients with
specific conditions.
 For example, a neuromedical CCU cares for patients with acute conditions involving
the nervous system or patients who have just had neurosurgical procedures and require
equipment for monitoring and assessing the brain and spinal cord.
 A neonatal CCU is designed and equipped to care for infants who are ill, born
prematurely, or have a condition requiring constant monitoring.
 A trauma/burn ICU provides specialized injury and wound care for patients involved
in auto accidents and patients who have gunshot injuries or burns

DESCRIPTION:
Intensive care unit equipment includes patient monitoring, life support and emergency
resuscitation devices, and diagnostic devices.

Patient Monitoring Equipment: The intensity of the care provided in ICU requires many
monitoring devices. Patients in the ICU generally have many wires attached to them for various
types of monitoring.
Some of the patient monitoring equipment seen in the ICU includes the following:

1. Acute care physiologic monitoring system - These may include the monitoring of
electrical activity of the heart via an Electrocardiogram (EKG), respiration rate (breathing),
blood pressure, body temperature, cardiac output, and amount of oxygen and carbon
dioxide in the blood. All monitors are networked to a central nurses' station.
2. Pulse oximeter - Monitors the arterial haemoglobin oxygen saturation (oxygen level) of
the patient's blood with a sensor clipped over the finger or toe.
3. Intracranial pressure monitor - Measures the pressure of fluid in the brain in patients
with head trauma or other conditions affecting the brain (such as tumors, edema, or
haemorrhage).
4. Apnea monitor - Continuously monitors breathing via electrodes or sensors placed on the
patient. An apnea monitor detects cessation of breathing in infants and adults at risk of
respiratory failure, displays respiration parameters, and triggers an alarm if a certain
amount of time passes without a patient's breath being detected. Apnea monitoring may be
a capability included in a physiologic monitor.
5. Swan - Ganz catheter: A Swan-Ganz, or pulmonary artery catheter, is used to measure
the amount of fluid filling the heart as well as to determine how the heart is functioning.
6. Arterial lines (A - lines): Arterial lines are used for continuous monitoring of blood
pressure. Arterial lines can also be used for drawing blood thus eliminating the need for
repeated venipuncture.

Life Support and Emergency Resuscitative Equipment

Intensive care equipment for life support and emergency resuscitation includes the following:
1. Ventilator - Assists with or controls pulmonary ventilation in patients who cannot breathe
on their own. Ventilator monitors and alarms may interface with a central monitoring
system or information system.
2. Infusion pump – Device that delivers fluids intravenously or epidural through catheter.
The pump hung on an intravenous pole placed next to the patient's bed.
3. Crash cart - Crash carts, also called resuscitation carts or code carts, are strategically
located in the ICU for immediate availability when a patient experiences cardiorespiratory
failure.
4. Intra-Aortic balloon pump - A device that helps reduce the heart's workload and helps
blood flow to the coronary arteries for patients with unstable angina, myocardial infarction
(heart attack), or patients awaiting organ transplants.

Tubes and Catheters in the ICU

1. Central venous catheter (CVC): This type of catheter is a soft, pliable tube that is inserted
into a large vessel (vein) in the neck (internal jugular vein), in the upper chest (subclavian
vein), or in the groin area (femoral vein).
CVCs are used: to administer frequent or continuous medication; to administer large
multiple IV products that do not fit in one line; and to measure central venous pressure.
2. Intravenous (IV): An IV is a plastic catheter (tube) that is inserted into the veins or a larger
size catheter inserted into the larger veins of the neck. Fluids, medications, nutrition
preparations, and blood products are administered through IV catheters.
3. Chest tubes: Chest tubes are inserted through the chest wall into the space around the lung
to drain fluid or air that has accumulated and prevent the lung from being able to expand.
4. Urinary catheter: Urinary catheters, often referred to as Foley catheters, are inserted
through the urethra into the bladder. Urinary catheters continuously drain the bladder and allow
for accurate measurement of urinary output, which is extremely important in fluid management
and in assessing kidney function.
5. Endotracheal tubes: Endotracheal tubes are used when mechanical ventilation is necessary.

Diagnostic Equipments
The use of diagnostic equipment is also required in the CCU. Diagnostic device commonly
used in the ICU are mobile x-ray units are used for bedside radiography particularly of the
chest. Handheld, portable clinical laboratory devices, used for blood analysis at the bedside.

Other CCU Equipment for Monitoring

Disposable CCU equipment includes urinary (Foley) catheters, catheters used for arterial and
central venous lines, Swan-Ganz catheters, chest and endotracheal tubes, gastrointestinal and
nasogastric feeding tubes, and monitoring electrodes.

Operation
The CCU is a demanding environment due to the critical condition of patients and the variety
of equipment necessary to support and monitor patients. Therefore, when operating CCU
equipment, staff should pay attention to the types of devices and the variations between
different models of the same type of device so they do not make an error in operation or
adjustment.

Maintenance
Since CCU equipment is used continuously on critically ill patients, it is essential that
equipment be properly maintained, particularly devices that are used for life support and
resuscitation.

Training
Manufacturers of more sophisticated ICU equipment, such as ventilators and patient
monitoring devices, provide clinical training for all staff involved in ICU treatment when the
device is purchased.

SPECIAL EQUIPMENTS IN CRITICAL CARE UNIT

Common equipment in a critical care unit includes following:
1. Continuous Positive Air Pressure Machine: CPAP is a type of breathing machine that is
designed to help oxygen enter the lungs. CPAP does not breathe for the patient.
CPAP does help hold the lungs open to allow more oxygen to enter the lungs. The CPAP
machine is connected to tubing and a face mask worn by the patient.
Complications associated with CPAP include mask discomfort, skin sores around the mask,
and bloating swallowing air.

2. Breathing Bag (Manual Resuscitator): A breathing bag is a device used to tem help a
patient breathe. When a patient needs help breathing, a respiratory therapist, doctor or nurse
places the breathing bag face mask over the patient's mouth and nose. A breathing bag is used
for a short period of time. If the patient requires help breathing for more than a short period of
time, a breathing machine may be used.

3. Bedside Monitor: A bedside monitor is a display of major body functions on a device that
looks like a television screen or computer monitor. The monitor is attached to wires, called
leads. At the other end, the leads are attached to sensing devices attached to the patient's body.
The sensing device sends electronic signals to the monitor, which displays the readings for the
specific body function being monitored.
The monitor is typically used when the doctor wants to measure functions like the heart rate,
respiratory rate, blood pressure and temperature
All patients admitted to the ICU have a bedside monitor attached to them. The bedside monitor
is normally used the entire time a patient is in the ICU.

4. Brain Tissue Oxygen Monitor: This is one way to measure how the brain is working after
a brain injury. A Brain Tissue Oxygen probe is placed into the brain tissue of the unconscious
patient. This measures the amount of oxygen that is reaching the brain.

5. Capnography Monitor: A capnography monitor is a device that measures carbon dioxide.

A capnography monitor is used when the patient's condition may affect the carbon dioxide
levels in the blood. The capnography monitor is attached to tubing near the end of the breathing
or tracheostomy tube. The carbon dioxide values from the capnography monitor are often
displayed on the bedside monitor.

6. Biospectral Index Monitor (BIS): Biospectral Index or BIS monitoring is a new way of
measuring how 'asleep' or sedated a patient is in the Operating room or in the ICU. This
machine picks up the electrical patterns of the brain from a band that goes across the patient's
head. This information is translated to a number that indicates the patient's level of awareness.

7. Resuscitation (Crash) Cart: The resuscitation cart contains all of the equipment and
medications needed for advanced life support and CPR (cardiopulmonary resuscitation). This
emergency equipment is used only if the patient's heart or lungs stop working.

8. Intravenous (IV) Infusion Pump: An intravenous (IV) infusion pump is a machine that
carefully controls the rate at which IV fluids and/or IV medications are given. Intravenous (IV)
infusion pumps are used as long as precise control of the intravenous infusion rate is needed.
These pumps are very reliable.

9. Dialysis Machine: A dialysis machine is a machine that cleans the blood of toxins when the
kidneys are not working. A dialysis machine is used when a patient's kidneys cannot effectively
clean the blood. The patient's blood enters the dialysis machine and goes through a special filter
that works like the kidney to remove fluid and toxins from the blood. The use of the dialysis
machine is termed hemodialysis. The dialysis machine can be used for a short period of time
or for a long period of time, depending on what is wrong with the kidneys.

10. Defibrillator: A defibrillator is a device that is designed to pass electrical current through
a patient's heart. The passing of electrical current through the heart is called defibrillation.
A defibrillation is done through pads placed on the patient's chest. A defibrillation is used to
restore a patient's heart rhythm to normal. Defibrillation may be done using the manual
defibrillator or the automatic external defibrillator (AED).

11. Electroencephalograph (EEG) Machine: An EEG machine is a device that measures the
electrical activity in the brain. The electrical signals that come from the brain can help the
doctor identify what is wrong with the brain. An EEG machine is used when the doctor wants
to monitor the electrical activity in the brain. This machine is used when the doctor wants to
see if the brain is functioning normally and to monitor therapies that affect the brain.

12. Ventricular Assist Devices: A Ventricular Assist Device (VAD) is a device that takes over
some of the function of the heart when it is critically weak. It is most commonly used while
waiting for a suitable donor heart to be available for transplant.

13. Intra - Aortic Balloon Pumping: Intra-aortic balloon pumping is a temporary emergency
measure to help the heart pump more blood and improve blood flow to the heart. An intra-
aortic balloon pump (IABP) is a device that provides the assistance to the heart.

14. Arterial Line: An arterial line or arterial catheter is a small thin plastic tube, similar to an
IV catheter that is inserted into a patient's artery. An arterial catheter allows the intensive care
staff to constantly monitor a patient's blood pressure, which may be essential for the
stabilization of the patient's condition. An arterial catheter also provides access for the frequent
blood sampling a critically ill patient needs.

15. Brain Stem Evoked Response Equipment: Auditory brain stem responses evoked by
stimulating the brain stem with painless sound waves using headphones. These sound waves
are received by the brain, and a machine is used to test whether the brain stem has received the
signals.
16. Pulse Oximetry: Pulse oximetry is the study of arterial oxygen saturation, the amount of
oxygen dissolved in the blood. A pulse oximeter is the device that measures and displays the
oxygen arterial saturation. The device is usually place on the patient's finger, earlobe, toe or
nose. The pulse oximeter gives off light that determines the oxygen saturation of the blood.

17. Central Venous (CVP) Line: A Central Venous Catheter (CVC) or Central Line is an
intravenous line that is used for giving the patient fluids and / or medications. It may be used
when the patient's veins in the arms are difficult to access or when certain medications or
nutrients need to be given that cannot be administered into the smaller veins found in the arm.

18. Intracranial Pressure Monitoring (ICP): ICU patients who have sustained head trauma,
brain hemorrhage, brain surgery, or conditions in which the brain may swell might require
intracranial pressure monitoring. The purpose of ICP monitoring is to continuously measure
the pressure surrounding the brain.
The ICP monitor consists of a small plastic tube connected to a bedside monitor, which
continuously displays the pressure surrounding the brain. The ICP monitor is usually inserted
in the left or right top-front part of the brain.

19. Pulmonary Artery Catheterization: Pulmonary artery catheterization is a procedure

performed to provide information regarding the patient's blood circulation, specifically the
pressure and amount of fluid or blood in the circulation and an assessment of the pumping
action of the heart.

20. Chest Drainage Device: The chest drainage device includes a chest tube and a chest
drainage unit. A chest tube is placed to remove air or fluid from around a patient's lung.
The chest drainage unit is attached to the chest tube by elastic tubing that allows the air or fluid
to drain. The chest drainage unit may be seen attached to the patient's bed or resting on the
floor next to the patient's bed.

21. Colonoscope: A colonoscope is an instrument used for performing colonoscopy. It is a

flexible tube with an eye piece or video screen. The instrument allows the doctor to see the
inside of the large intestine (colon). This procedure may be done at the patient's bedside, in the
gastrointestinal (GI) laboratory, or in the operating room. With use of the colonoscope, the
doctor can assess a colon blockage, infection or injury, including injury to the colon from a
lack of blood flow (ischemia) or other diseases.

22. Gastrostomy Tube: A gastrostomy tube is a flexible plastic hollow tube placed into the
stomach through the skin overlying the stomach. The purpose of gastrostomy is to provide a
way to give patients food and medications.

23. Tracheostomy Tube: A tube inserted into a temporary surgical opening at the front of the
throat providing access to the trachea and windpipe to assist in breathing tracheostomy tube is
a small tube placed in a patient's trachea (windpipe) through the neck. The tracheostomy tube
is an artificial airway.

24. Nasogastric (NG) Tube: A nasogastric (NG) tube is a flexible plastic tube that goes
through the patient's mouth or nose into the stomach. It is designed to remove stomach contents
or provide a route to give medication or food to a patient who cannot swallow. The portion of
the NG tube outside of the patient may be plugged closed, connected to a delivery device or
connected to a suction device.
25. Breathing (Endotracheal) Tube: A breathing tube is a plastic tube used during artificial
respiration, a procedure to assist a patient in breathing. One end of the breathing (endotracheal)
tube is placed into the windpipe (trachea) through the mouth or nose. The other end of the tube
is connected to a breathing machine (mechanical ventilator) or breathing bag (manual
resuscitator). The breathing tube provides an airway so that air and oxygen from the breathing
machine or breathing bag can be provided to the lungs.

26. Balloon Tamponade Tubes: A balloon tamponade tube is used when the bleeding from
esophageal varices is dangerous, and the tube is usually inserted during an endoscopy by
medical staff. Once in position usually only the gastric balloon is inflated to control esophagus
and stomach.

27. Suction Catheters: Suction catheters are long flexible tubes that are used in intensive care
to remove fluids from the mouth and airways of critically ill patients. Critically a patients often
have difficulty with swallowing or coughing. Removal of these fluids is important to ensure
the lungs remain clear and the patient is able to breathe properly.

28. Liquid Tube Feeding Pump: A liquid tube feeding pump is a specialized pump designed
to accurately deliver liquid tube feeding to a patient. The dietician and doctor determine the
amount of liquid tube feeding that a patient needs for each day. This amount is entered into the
liquid tube feeding pump by the nurse.

29. Gastroscope: A gastroscope is a special kind of endoscope. The gastroscope is a flexible

plastic tube approximately four feet long and one half inch wide. The gastroscope contains
optic fibers with a light source that allow the gastroscope to function like a video camera.
The doctor uses the gastroscope to see the swallowing tube (esophagus), stomach, and part of
the small intestines (duodenum). The gastroscope also has a hollow channel or tunnel
throughout its entire length. The medical term for the use of the gastroscope is
esophagogastroduodenoscopy or EGD.

30. Endoscope: Critically ill or critically injured patients may have or develop problems with
their swallowing tube (esophagus), stomach, small intestine, large intestine (colon) or lungs.
Doctors use slender flexible tubes with a lighted end to look at these structures. The instruments
are called endoscopes.
- The endoscope used to look at the stomach is called a gastroscope and the endoscope used to
look at the colon is called a colonoscope.
- A bronchoscope, used to view the lungs, is another type of endoscope.

31. Wound Drain: A wound drain is typically a plastic tube that provides a way for
unnecessary body fluids or air to flow out of the body from a wound. After surgery, some
patients require wound drains. The purpose of the drain is to remove fluid and/or blood from
the area of surgery. This helps the healing process.
INFECTION CONTROL PROTOCOLS

Infection control is the discipline concerned with preventing nosocomial or healthcare

associated infection. Critical care areas are Intensive Care Unit, Critical Care Unit, Neonatal
Intensive Care Unit, Surgical Intensive Care Unit and Operation Theaters. Possible
Nosocomial pathogens are MRSA, Klebsiella species, E.coli, Enterococci, Pseudomonas
species and Candida species. Sources of Infection can be IV lines, Catheters, ventilators, Air
conditioning ducts, Health care personnel, Visitors and Staff.

Strict infection control is vital and cannot be stressed too much. Inadequate training and
inadequate understanding of infection control measures are associated with increased risk of
infection.

Nosocomial infections are one of the most common complications that occur in ICU patients.
Prevention and containment of nosocomial infection is a fundamental principle of effective
medical practice. The critically ill patient is highly vulnerable to nosocomial infection, which
results in significant morbidity, prolonged length of hospital stay, increased cost and
attributable mortality.

 Hand Washing: Frequent hand washing (before and after attending to a patient) is the most
important factor in preventing infections. Hand-hygiene remains the only established
method of effective infection control and must be strictly performed by all members of the
health care team.
 Protective Barriers: There is little evidence that wearing gloves is more important than
hand washing in the ICU. Disposable gloves must be worn for all contact with patient's
bodily fluids, dressings and wounds.
 Invasive Devices: Critically ill patients frequently require multiple catheters, which alter
normal defence mechanisms by creating new portals for microbes to enter. Total parenteral
nutrition and lipid emulsions are frequently administered and are excellent media for the
growth pathogenic microbes.
 Emergence of Microorganisms Resistant to Antibiotic Agents: Patients in the ICU are
often receiving high doses of various antibiotics, are close to each other, and are being
cared for by busy physicians and nurses. All these factors create an ideal environment for
developing resistant organisms.
 Mechanical Measures: There should be enough space between beds for staff to reach
patients and equipment easily. Separate patient rooms should be provided in order to
prevent contamination. In order to facilitate hand washing by the staff, sinks should be
installed in convenient places. Sinks for disinfection should be in separate places. Where
ICU design precludes ideal sink placement, consideration should be given to providing
alcohol-based hand rubs at each patient location. Every ICU should have one or more
isolation room with a separate hall for hand washing, especially if the ICU is in a large,
open space. The ICU should have separate spaces for storage, waste products, and
disinfection. All bodily fluids should be considered contaminated, tests and measurements
involving them should be performed only in specified areas.
 Medical Devices: Medical technology seems to make constant progress, and new
diagnostic and therapeutic devices are often used in the ICU. Mechanical ventilation is the
most common cause of admission to the ICU. Mechanical ventilation bypasses the
respiratory tract's host defences. Interventions to decrease the risk of infection include
preventing aspiration; preserving gastric acidity; adhering strictly to the proper cleaning,
reprocessing, and protecting staff and patients by using appropriate isolation precautions
 and personal protective equipment, and monitoring respiratory tract infections due to
ventilator usage.
Protocols for disinfection should be given by manufacturers, and inspections should be
made by the nosocomial infection committee.
 Selective Digestive Decontamination: The purpose of selective digestive decontamination
is the prevention of growth of gram-negative aerobic bacilli and fungi through the use of
non-absorbed antibiotics that protect the internal anaerobic flora.
 Visitors: Reduce number of visitors coming to healthcare settings. Visiting hours of
hospital or healthcare setting should be less and specified. Mask for visitors is also needed.
Hand shaking, kissing and hugging should be prohibited, flowers & other items for patients
Prohibited. Healthcare staff from different departments visiting friends should be restricted.
 Care of Environment: Regular scrubbing and cleaning of surfaces is essential and
appropriate use of disinfectants is must. Surfaces should be cleaned with proper chemical.
Instruments should be cleaned properly before sterilization. Proper care of AC ducts are
also to be kept in mind. Proper cleaning of linen is necessary.

Infection Control Policies and Procedures

Given the complexity of delivering care to critically ill patients, policies and procedure are a
necessary part of the organization of any ICU. These policies ensure that personnel perform
certain procedures, such as central venous catheter insertion and care, in a consistent manner.
Written ICU policies should incorporate evidence-based infection control practices. For
policies to be effective, they should be clear, concise, and shared with the staff. Policies that
are complex or unrealistic either will be ignored. Therefore, it is important that ICU physician
and nursing staff review these policies on a routine basis in consultation with infection control
practitioners or the hospital infection control committee and revise the policies when needed.

NURSING MANAGEMENT OF CRITICALLY ILL PATIENT

Nursing care for the critically ill patient can be a challenging endeavour. To provide high
quality care, the nurse is challenged to draw from their knowledge and experiences, remain
flexible and be creative. The nurse must have a sufficient knowledge and skill base and the
ability to think critically. The knowledge base must encompass basic concepts of anatomy and
physiology as well as a basic understanding of common disease processes, diagnostic and
therapeutic procedures. The nurse should also be familiar with potential complications or risk
factors associated with these diseases, and procedures.

The nurse should be prepared to take action to minimize these risks, recognize them they occur
and take appropriate action to correct the problem.

 Patient assessment:
Upon receiving responsibility for the care of a patient the nurse should assess the patient. The
assessment includes becoming familiar with the patient's history, and performing physical
examination

The history may be obtained from the client or may be passed on between the nurses during
rounds. Rounds are an excellent forum for communication Information should provided as to
the significant changes in the patient's status. The physical exam helps establish a baseline for
comparison in evaluating ongoing or medical interventions. At minimum, a temperature, pulse,
and respiration should be checked; respiration should be checked, chest auscultated and the
bladder palpated.
 Planning patient care:
Planning patient care involves developing plans to meet the needs identified in the assessment
phase. Planning helps the nurse become organized, set priorities, and contemplate actual and
potential problems or risk factors. The nurse should be capable of recognizing and have plan
for dealing with them. A part of the planning process includes development of nursing care
plans. Nursing care plans should include monitoring ins and outs, nutritional support, meeting
comfort needs including assessing for pain. Measures should be taken to minimize the risk of
nosocomial infections. Bandage and wound care should be performed.

IMPLEMENTATION OF THE NURSING CARE PLANS

1. Monitoring Intake and Output: The nursing goal of monitoring "intake and output"
is to ensure maintenance of fluid balance and nutritional intake. "Intake and output” provide
valuable information about fluid balance and nutritional intake. The patient's entire intake
and output is monitored and documented. "Intake and output" are monitored at regular
intervals throughout the day. Intake includes all fluids (water, IV fluids including blood
products, and liquid diets). Output includes, urine feces, vomiting and third space losses
(fluid loss into body cavities). The total volume of fluids "intake" should be compared to
"output", the two volumes should be about equal. If "ins" exceeds outs the patient is at risk
for fluid overload. If "output" exceed "input" then the patient is at risk for dehydration.

2. Nutritional Support: The nursing goal is to ensure that the patient is meeting its energy
requirements. There are serious negative consequences of acute malnutrition including
decreased immune response, loss of function of tissues and organs and delayed wound
healing. The physical exam might reveal acute loss of lean body mass, fat, muscle wasting
or edema. Hypoalbuminemia and lymphopenia may indicate poor nutritional status. Once
t is decided to initiate nutritional support the nurse will need to calculate the patient's energy
requirements.

3. Patient Comfort Needs: The nursing goal for meeting the patient's comfort needs depends
on what comfort need the nurse is addressing. Comfort needs includes keeping the patient
clean and dry, seeing to the patient’s mental well-being, assessing the patient for pain. It is
important to consider the patient's mental well-being. Prior to treating a patient take the
time to make friends with the patient. It is important for a patient to have time to rest; try
and group treatments together so that the patient has some time to rest.

4. Nosocomial Infections: Nosocomial infections are hospital-acquired infections: the patient

did not enter the hospital with the infection. Factors that predispose a patient hospital-
acquired infection include age (geriatric or neonate), immunosuppressed patients,
diagnostic and therapeutic invasive procedures, antimicrobial therapy and long-term
hospitalization. Nosocomial infections are perhaps more common in large hospitals and
referral centers. The nursing goal is to minimize the risk of nosocomial infections.

5. Recumbent Patient Care: Patients suffering neurological, orthopedic, or traumatic

problems can be recumbent for prolonged periods of time. Care of the recumbent patient
can be very challenging. Primary nursing goals are to minimize or prevent decubitus ulcers
and lung atelectasis. Decubitus ulcers develop over bony prominences as a result of
continuous pressure and damage to the skin. Bedding is an important factor in the
prevention of decubitus ulcers. Air and water mattress have also been advocated for use in
the prevention of decubitus ulcers.
Atelectasis is the collapse and consolidation of regional small airways. This is a result of
one lung being on the down side to long without adequate expansion.
6. Catheters: The nurse is charged with the care of a variety of types of catheters. In general,
the nursing goals for catheters include: minimizing the risk of infection, insuring
functionality, and prevention of complications, which are specific to the type of catheter
use. It is important to be familiar with the mechanism of catheter related infections.

7. Intravenous Catheters: IV catheter care should be performed every 48 hours of an as

needed basis. The catheter dressing should be removed and the site inspected. Look for
signs of phlebitis, infection, and or thrombosis.

8. Urinary Catheter Care: Urinary catheter care is performed every 8 hours. It entails
cleaning the prepuce or vulva and its surrounding area with Betadine scrub and water rinse.
The urinary catheter itself should be kept clean especially in the female patient where the
vulva is in close proximity to the rectum.

9. Chest Drain / Gastrostomy Tube Care: The procedure for chest drain and gastrostomy
tube care is much like IV catheter care. The bandage is removed and the insertion site is
inspected every 24 hours. The site is cleaned and re-bandaged.

10. Bandage / Incision or Wound Care: Bandages are placed to protect lacerations and
surgical incisions and provide minimal support. They should remain dry and clean. The
bandage should be free of abnormal odours. The skin above the bandage should be checked
for local irritation. The bandage should be evaluated if the patient is licking or chewing the
bandage.

RESUSCITATION EQUIPMENT
1. Ambu Bag- Introduction/Definition, Functions, Features, Procedure, Indications,
Risks
2. Laryngoscope - Introduction/Definition, Features, Procedure (briefly), Functions
3. Tracheostomy- Introduction/Definition, Indications, Procedure
4. Endotracheal Intubation- Introduction/Definition, Types of endotracheal tubes,
Procedure
5. Respirator/ Ventilator- Introduction/Definition, Indications
6. Cardiac Defibrillator- Introduction/Definition, Oxygen delivery devices (brief
explanation) ,Types, Procedure, Nursing consideration, Post defibrillation care
7. Stimulant Drugs
STIMULANT DRUGS
Stimulant is a class of drugs that enhance brain activity and /or cardiovascular system.
Stimulants generally increase alertness, heart rate, breathing rate, blood pressure and energy
level.
Some common types of stimulant drug and brand names:
 Amphetamines
 Atomoxetine (Strattera)
 Benzphetamine (Didrex)
 Caffeine (NoDoz, Vivarin)
 Cocaine
 Dexmethylphenidate (Focalin)
 Dextroamphetamine (Dexedrine)
 Diethylpropion (Tenuate)
 Methamphetamines
 Methylphenidate
 Modafinil (Provigil)
 Nicotine
 Pemoline (Cylert)
 Phendimetrazine (Bontril SR, Prelu-2)
 Phentermine (Fastin, Ionamin)
 Sibutramine (Meridia)
 Xanthine.
Stimulant drugs are generally highly addictive, can be dangerous, are often illegal, without
prescription information, and most types should be used only in controlled circumstances.

Effects of Stimulants Drugs

1. Short-term Effects: Stimulants increase the amount of norepinephrine and dopamine in the
brain, which increases blood pressure and heart rate, constricts blood vessels, increases blood
glucose, and increased breathing. Effects can feel like an increase alertness, attention, and
energy along with a sense of euphoria. There is also the potential for cardiovascular failure
heart attack) or lethal seizures

2. Long-term Effects: Stimulants can be addictive in that individuals begin to use them
compulsively. Taking high doses of some stimulants repeatedly over a short time can lead to
feelings of hostility or paranoia. Additionally, taking high doses of a stimulant may result in
dangerously high body temperatures and an irregular heartbeat. There is also the potential for
cardiovascular failure (heart attack) or lethal seizures.

MANAGEMENT OF MAJOR ORGAN FAILURE

Assessing critically ill patients requires a systematic approach. An integrated management plan
should be made, specifying goals for each organ system.

Circulatory Support:
The primary goals are to: restore global oxygen delivery by ensuring an adequate cardiac
output. Maintain a BP that ensures adequate perfusion of vital organs.
The therapeutic options are to provide inotropic support or reduce the afterload with vasoactive
drugs, or to control the heart rate and rhythm if this is abnormal.
Respiratory Support:
Respiratory support is indicated to maintain the patency of the airway, correct hypoxemia and
hypercapnia, and reduce the work of breathing.

 Oxygen therapy: Ensure adequate arterial oxygenation (Sp02 >90%). If a patient remains
hypoxemic on high-flow oxygen, other measures are required.

 Non-invasive respiratory support: If the patient has respiratory failure associated with
decreased lung volume, application of CPAP will improve oxygenation.

 Endotracheal intubation and mechanical ventilation: Over 60% of patients admitted to

ICU require intubation and mechanical ventilation.

 Weaning from respiratory support: The majority of patients require mechanical

ventilation support for only a few days and do not need a process of weaning.
 Tracheostomy: Usually performed electively when endotracheal intubation is likely to be
prolonged (>14 days).

Renal Support:
Oliguria requires explanation and early intervention to correct renal hypo perfusion. Renal tract
obstruction should be excluded by USS, and underlying sepsis diagnosed and treated. If renal
function cannot be restored following resuscitation, renal replacement therapy is indicated.

Gastrointestinal and Hepatic Support:

The GI tract and liver play an important role in the evolution of multiple organ failure, even
when the primary diagnosis is unrelated. Early institution of enteral nutrition is the most
effective strategy for protecting the gut mucosa and providing nutrition. Total parenteral
nutrition (TPN) should be started if attempts at enteral feeding have failed.

Neurological Support:
The aim of management in acute brain injury is to optimize cerebral oxygen delivery by
maintaining a normal arterial oxygen content and a cerebral perfusion pressure >70 mmHg.

General Nursing Requirements of the Intensive Care Patient

The following are some general requirements for nursing care of the intensive care patients.

 No critical care patient will be left without a nurse in attendance. Critically ill patients may
have life-threatening changes in their condition; remove an invasive line or self extubate
quickly.

 Each nurse will be responsible for the entire care of his/her patient, and acts to coordinate
care with other health team professionals.

 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, eg, on nights.
 All critical care patients will have continual ECG monitoring. A critically ill patient
requires intensive monitoring.
 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.

 An ECG strip will be obtained and analysed according to institutional policy. The ECG
strips are analysed, rhythm identified and taped to the back of the flow sheet. Changes are
reported to the physician.

 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.

 Temperatures will be measured on all patients at least q4h by other than axilla rout.
Temperature changes may indicate infection or other disease states.

 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.

 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.

 All critical care patients will have range of motion exercises q4h unless contraindicated.
This will be recorded on the flow sheet treatment section and in clinical record.

 Perineal care will be done every shift and as needed PRN for all patients. To promote
hygiene and comfort.

 All Critical Care patients will have mouth care done every four hours with inspection for
oral skin sores.

 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.

 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.

 The environment will be maintained in a mechanically safe condition through: dry floors,
good repair of furniture, proper placement of machines and equipment, cleanliness etc.

 Isolation technique will be followed as per infection control manual to minimize cross
infection to patients, visitors and staff.

 Sharps and glass will be disposed of into point of use sharps containers to protect health
care workers from injury/contamination.
 Any containers of body fluids must be disposed appropriate biohazard bag or box to reduce
risk of contamination to health care workers during handling.

 All electrical equipment will: be grounded, have 3-prong plugs, be used away from or wet
floors, be protected from spillage of liquids, be inspected Department.

 Labels will be affixed to all bedside medications, intravenous bags and bottles, at wound
or bladder irrigations, multidose vials, multiple drainage bags/bottles hemodynamic
transducers and monitors.

 All medications will be reviewed by the Critical Care physicians and either reordered or
stopped. Each treatment/medication must be listed when reordered.

 All orders written other than by the Critical Care physicians will be brought to the attention
of the Critical Care physician by the nurse prior to being carried out.

 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 to maintain
narcotic control.

 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.

 The nurse/physician will notify families of significant deterioration in the patient's

condition.

 Support will be given to families that would like children to visit. Special preparation of
the children must be done

 All change of shift reports will include a review of all physician orders, lab results
medication administration record, and joint review of neuron status to ensure
communication between shifts and reduce potential for medication or treatment errors.

 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.

PATIENT EVALUATION

As a part of nursing care, technicians should constantly evaluate the patient's condition. The
technician should be looking to see if the therapy is improving the patient's condition. In
addition, evaluation of the nursing care plans should be considered.
MONITORING OF CRITICALLY ILL PATIENT
The aim of monitoring patients is to detect organ dysfunction and guide the restoration and
maintenance of tissue oxygen delivery. Monitoring is a crucial part of the care of the critically
ill patient in the emergency department.
Critical Care Unit (CCU) equipment includes patient monitoring, respiratory and cardiac
support, pain management, emergency resuscitation devices, and other life support equipment
designed to care for patients who are seriously injured, have a critical or life threatening illness
or have undergone a major surgical procedure, thereby requiring 24 hour care and monitoring.

Temperature monitoring
Peripheral temperature reflects tissue perfusion and is affected by vasoconstriction and low
cardiac output. Core temperature may be monitored by placing a deep rectal or esophageal
thermometer. When monitoring the temperature early recognition of hypo or hyperthermia will
result as trends in the patient's status.

The causes for hypothermia include prolonged exposure to a cold environment and peripheral
vasoconstriction, causing shunting of blood from the peripheral tissues and GI tract in response
to decreased perfusion. The causes for hyperthermia include a hot environment with poor
ventilation, a response to infection or inflammation, and thermoregulatory dysfunction.

Cardiovascular system monitoring

1. Cardiac Monitoring: Most critical care patients have cardiac activity monitored by a 3-
lead system; signals are usually sent to a central monitoring station by a small radio transmitter
worn by the patient. Some specialized cardiac monitors track advanced parameters associated
with coronary ischemia, although their clinical benefit is unclear.
2. Heart Rate Monitoring: Heart rate is a nonspecific parameter. It is usually measured by
auscultation of the heart and palpation of an artery, automatically taken from an ECG or arterial
pulse pressure wave. Increase in heart rate (tachycardia) may be caused by hypovolemia, fever,
excitement, exercise and pain. Decrease in heart rate (bradycardia) may be caused by high
vagal tone, severe electrolyte disturbances and atrioventricular conduction blocks.
3. Heart Rhythm: When irregularities in heart sounds are heard, the heart rate should be
compared to pulse rate and the difference in rates are called pulse deficits. Pulse deficits are
indicative of arrhythmias. Some examples of cardiac arrhythmias include:
Premature atrial contraction (PAC), atrial fibrillation, premature ventricular contraction (PVC)
and ventricular tachycardia
4. Electrocardiographic Monitoring: The ECG reflects the electrical activity of the heart.
The ECG detects the voltage difference at the body surface and amplifies and displays the
signal. The ECG provides useful information about ischemia, arrhythmias, and electrolyte
imbalance and drug toxicity.
5. Mucous Membrane Colour and Capillary Refill Time: The normal mucous membrane
colour is pink. In diseased states the mm colour may be yellow, pale, white, brick red or blue.
Capillary refill time (CRT) is an indication of peripheral perfusion and should not be thought
of as an indicator of blood pressure.
6. Pulse Oximetry: Pulse Oximeter monitors the arterial hemoglobin oxygen saturation of the
patient's blood with a sensor clipped over the finger or toe. Pulse oximetry is the study of
arterial oxygen saturation, the amount of oxygen dissolved in the blood.
7. Central Venous Pressure Monitoring: Central venous pressure (CVP) is a measurement
right atrial pressure. It evaluates three things: 1) The heart's ability to function as a pump;
2) Blood volume in relation to volume capacity; and 3) vasomotor tone (indirectly).
The normal CVP range is 0-10 Cm H2O.
8. Arterial Blood Pressure Monitoring: Blood pressure measurement is a valuable
monitoring tool when evaluated with other cardiovascular parameters. Blood pressure is a
product of cardiac output, vascular capacity and blood volume. There are two methods of blood
pressure measurement, direct and indirect. Indirect methods of measuring blood pressure
include palpation, auscultation and oscillotonometry. Direct arterial pressures can be recorded
by inserting a cannula in the radial, femoral or dorsalis pedis artery and connecting it to a zeroed
and calibrated transducer which converts pressure energy into electrical signals.
9. Pulmonary Artery Catheter Monitoring: Use of a pulmonary artery catheter (PAC)
becoming less common in ICU patients. This balloon-tipped, flow-directed catheter is inserted
via central veins through the right side of the heart into the pulmonary artery.
10. Pulmonary Artery Occlusion Pressure (PAOP): Pulmonary artery occlusion pressure is
used to monitor the left ventricular end diastolic pressures provided the mitral valve is normal.
11. Thoracic Bioimpedance: These systems use topical electrodes on the anterior chest and
neck to measure electrical impedance of the thorax. This value varies with beat-to-beat changes
in thoracic blood volume and hence can estimate CO.
12. Esophageal Doppler Monitor (EDM): This device is a soft 6-mm catheter that is passed
nasopharyngeal into the esophagus and positioned behind the heart. A Doppler flow probe at
its tip allows continuous monitoring of CO and stroke volume.
13. Toe Web-Rectal Temperature: It has been shown that skin temperature correlates well
with peripheral perfusion and cardiac output. An excellent and non-invasive technique for
monitoring peripheral perfusion is the toe web rectal temperature. Measurements are made with
an electronic thermometer, thermistor probe or a mercury thermometer from 70 - 110°F. A
thermometer is placed between the toes of the rear paw; the temperature is compared to the
rectal temperature. The toe web temperature is usually 2.9°F less than that of the rectum.
14. Sublingual Capnometry: Sublingual capnometry uses a similar correlation between
elevated sublingual Pco2, and systemic hypoperfusion to monitor shock states using a non-
invasive sensor placed under the tongue.
15. Tissue Spectroscopy: Tissue spectroscopy uses a noninvasive near infrared (NIR) sensor
usually placed on the skin above the target tissue to monitor mitochondrial cytochrome, a redox
states, which reflect tissue perfusion. NIR may help diagnose acute compartment syndromes
(e.g., in trauma) or ischemia after free tissue transfer and may be helpful in postoperative
monitoring of lower-extremity vascular bypass grafts.

Respiratory system monitoring

1. Breathing Rate: The normal breathing range is 16 - 20 breaths per minute (BPM). The
breathing rate alone does not provide much information regarding the pulmonary system,
therefore, the quality of breathing should be considered as well. Eupnea is a normal ventilatory
nature and rate. Bradypnea is a slow rate without regard to tidal volume. Tachypnea is a fast
rate without regard to volume. Apnea is the absence of any ventilatory effort.
2. Auscultation: Auscultation should be performed in a quiet room. The entire lung field
should be ausculted and all abnormal lung sounds should be localized and characterized.
Crackles during late expiratory or the early inspiratory phase are indicative of
bronchopulmonary disease (pulmonary edema). Expiratory wheezes are due to asthma.
Pleural effusion can be characterized by muffled lung sounds. Localized areas of dullness may
be caused by atelectasis or lobar consolidation while generalized dullness may be caused by
pneumothorax.
3. Mucous Membrane Colour: Cyanosis may be indicative of severe hypoxia, when it occurs
t is usually later in the disease process. For cyanosis to occur, 5 g/dl of un-oxygenated
hemoglobin must be present. If anemia is present cyanosis may not be seen.
5. Blood Gas Analysis: One of the best ways to assess pulmonary function is through arterial
blood gases. Blood gases tell us about the patient's ability to ventilate and oxygenate. Blood
gases measure the partial pressure of carbon dioxide in the blood. Arterial blood gases and
pH are useful screening test of pulmonary function and often the first laboratory signs of
impending lung problems seen as changes in Pao2, PaCO2, and pH.

Central nervous system monitoring

1. Consciousness Level: Consciousness may be categorized into four levels. Normal obtunded,
stuporous and coma.
 An obtunded patient is one who has mild to moderate reduction in alertness and often
appears drowsy, but is easily aroused.
 Stupor is a condition characterized by a deep sleep that is only responsive to vigorous
or painful stimuli, once the stimulus is removed the patient returns to its sleep-like state.
 The comatose patent totally unresponsive even to painful stimuli. It is a poor sign when
a patient moves from a higher level of consciousness to a lower level.
2. Posture: When evaluating posture the concern is for the presence or absence of abnormal
posture associated with opisthotonos. Opisthotonos is a form of spasm in which the head is
bent backwards and the body bowed forward. The three types of abnormal posture include
Schiff-Sherrington, decerebellate rigidity and decerebrate rigidity.
 Schiff-Sherrington is due to a severe spinal cord injury.
 Decerebellate posture occurs with severe cerebellar injury.
 Decerebrate posture is due to a severe brain stem injury.
3. Pupil Size: Normally pupils should be equal in size and have a direct and consensual
response to light. 11 the pupils are fixed in a midpoint position and unresponsive to light a
severe midbrain lesion is suspected and the prognosis should be considered guarded.
4. Breathing Patterns: There are several breathing patterns that are a result of CNS lesions.
They are as follows:
 Apnea shows medullary dysfunction
 Cheyne-Stokes breathing
 Biot's breathing
 Apneustic breathing may be associated with brainstem disease.
5. Intracranial Pressure Monitoring: Intracranial pressure (ICP) monitoring is standard for
patients with severe closed head injury. These devices are used to optimize cerebral perfusion
pressure. ICP is assessed by measuring the ventricular pressure directly or indirectly with the
patient in the supine position. Several types of ICP monitors are available. The most useful
method places a catheter through the skull into a cerebral ventricle (ventriculostomy catheter).
This device is preferred because the catheter can also drain CSF and hence decrease ICP.
6. Electroencephalogram (EEG): An electroencephalogram (EEG) is a test that measures and
records the electrical activity of your brain. Special sensors (electrodes) are attached to your
head and hooked by wires to a computer. The computer records your brain electrical activity
on the screen or on paper as wavy lines.

Renal system monitoring

1. Urine Output: Urinary output is an excellent reflection of tissue perfusion. If the kidneys
are producing urine then the other organs are probably being perfused. The normal urinary
output is 1.2 ml/kg/hr. Ideally, it's important to quantitate the urine output.

2. Plasma and Urine Electrolytes, Urea and Creatinine: Trends of blood urea, creatinine
and serum electrolytes are useful for evaluating the progress of renal function. Urea rise in the
absence of renal dysfunction in conditions such as gastrointestinal bleeding, high protein intake
and increased catabolism. Acute and chronic renal failure results rising urea and creatinine.
The concentrating ability of the kidney can be estimated by comparing the blood and urine
sodium, potassium and urea.

Hepatic system monitoring

The liver performs the important functions of synthesis, storage, metabolism and excretion of
toxic products. Damage to the liver may not obviously affect its activity because of a
considerable functional reserve. The liver synthesize albumin, clotting factors, anti-thrombin
III and protein C all of which can be used to assess liver function.

Haematological monitoring
1. Blood Tests: Although frequent blood draws can destroy veins, cause pain, and lead to
anemia, ICU patients typically have routine daily blood tests to help detect problems early.
Generally, patients need a daily set of electrolytes and a CBC. Patients with arrhythmias should
also have Mg, phosphate, and Ca levels measured. Commonly available tests include blood
chemistries, glucose. ABG CBC, cardiac markers, and coagulation tests.
2. Haematocrit and Haemoglobin Concentration Monitoring: Low haematocrit tends to be
associated with improved peripheral perfusion because of decreased viscosity-although the
exact contribution of this fact to the perfusion in the patient is largely unknown.
Serial decline in haematocrit indicates continued bleeding, but haemodilution with crystalloids
can also result in a fall in the haematocrit.

{CARDIOPULMONARY RESUSCITATION}-BLS & ACLS

TREATMENTS AND PROCEDURES APPLIED IN CRITICAL CARE UNIT

Routine ICU Procedures:

1. Endotracheal Intubation
2. Gastrointestinal Intubation
3. Peripheral Venous Catheterization
4. Central Venous Catheterization / PICC Line Insertion
5. Arterial Catheterization
6. Pulmonary Artery Catheterization
7. Urinary Catheterization
8. Lumbar Puncture
9. Epidural Catheterization
10. Thoracentesis / Pleurocentesis
11. Paracentesis / Peritoneocentesis
12. Underwater Seal Drain Insertion
Specialized ICU Procedures:
1. Positive Pressure Machines or Mechanical Ventilator
2. Defibrillator
3. Electrocardiography
4. Percutaneous Tracheostomy
5. Fiberoptic Bronchoscopy
6. Transvenous Pacing
7. Pericardiocentesis
8. Oesophageal Tamponade Tube Insertion
9. Intra-Aortic Balloon Counterpulsation
10. Extracorporeal Membrane Oxygenation (ECMO)

TRANSITIONAL CARE

Transitional care is a broad term that encompasses a variety of intermediate care services,
including sub-acute, skilled, and rehabilitative care services. The value of transitional care for
frail, elderly patients has long been recognized. Transitional care bridges the gap between
hospital and home for patients with complex or multiple problems.

Transitional care or care transition refers to the actions of healthcare providers designed to
ensure the coordination and continuity of health care during the movement between health
practitioners and settings as their condition and care needs change during the course of chronic
or acute illness,

What Can I Do to Ensure that Transitions Go Smoothly?

The following are steps that you and your caregiver can take:

1. Keep your own personal file of important health information and show this to each new
health care professional. You should keep a list of your health conditions, the names
and phone numbers of your health care professionals, medications you are taking, and
any allergies that you may have.
2. Take charge of your medications (both prescribed and over-the-counter) and know why
you take each one, how to take each one, and any possible side effects to watch for.
3. Make sure that you understand what services you will get at each new setting and how
these will benefit you.
4. Before leaving each setting, write down the name and telephone number of the health
professional you can contact if you have any questions or should your condition get
worse.
5. Before leaving each setting, ask what type of follow-up care you will need and how this
will be scheduled.
6. Schedule an appointment with your primary care physician or case manager to discuss
how your needs would be met if you could not care for yourself for a few days or long-
term.
Elements of Transitional Care Model

TCM targets older adults with two or more risk factors, including a history of recent
hospitalizations, multiple chronic conditions and poor self-health ratings.

1. The transitional care nurse (TCN), a master's prepared nurse with advanced knowledge
and skills in the care of this population, as the primary coordinator of care to assure
continuity throughout acute episodes of care.
2. In-hospital assessment, collaboration with team members to reduce adverse events and
prevent functional decline, and preparation and development of a streamlined,
evidenced based plan of care.
3. Regular home visits by the TCN with available, ongoing telephone support (seven days
per week) through an average of two months post-discharge.
4. Continuity of medical care between hospital and primary care providers facilitated by
the TCN accompanying patients to first follow-up visit(s).
5. Comprehensive, holistic focus on each patient's goals and needs including the reason
for the primary hospitalization as well as other complicating or coexisting health
problem and risks.
6. Active engagement of patients and family caregivers with focus on meeting their goals.
7. Emphasis on patients' early identification and response to health care risks and
symptoms to achieve longer term positive outcomes and avoid adverse and untoward
events that lead to readmissions.
8. Multidisciplinary approach that includes the patient, family caregivers and health a
providers as members of a team.
9. Physician-nurse collaboration across episodes of acute care.
10. Communication to, between, and among the patient, family caregivers, and health care
providers.

ETHICAL AND LEGAL ASPECTS IN INTENSIVE CARE

Ethics is the branch of philosophy that examines the differences between right and wrong.
Ethics is the study of good character, conduct and motives. It deals with what is good and
valuable to all. Generally, ethics is the study of the rightness of conduct. Ethics deals with one's
responsibilities (duties and obligations) as defined by logical argument.

The application of general ethical principles to health care is referred to as bioethics. Ethics
affects every area of health care, including direct care of clients, allocation of finances, and
utilization of staff. Ethics does not provide easy answers, but it can help provide structure by
raising questions that ultimately lead to answers.

Ethics in critical care is based on four fundamental principles –

1. The physician's obligation to provide treatment for the patients
2. The duty to avoid harm
3. Respect for patient's right to self determination
4. Justifiable allocation of health care resources

Ethical Principle:
1. Autonomy : Respect for an individual's right to self-determination; respect for
individual liberty
2. Nonmaleficence : Obligation to do or cause no harm to another
 3. Beneficence : Duty to do good to others and to maintain a balance between benefits and
harms
4. Justice : Equitable distribution of potential benefits and risks
5. Veracity : Means truthfulness; Obligation to tell the truth
6. Fidelity : Means faithfulness; Duty to do what one has promised

Ethical and Legal Issues in Intensive Care

1. Informed Consent: Informed consent is a process consisting of information and consent,
not merely the signing of a form. Obtaining the informed consent requires client teaching by
the health care provider health provider. Consent is a voluntary act by which a person agrees
to allow someone else to do something. Informed consent means that the client understands the
reason for the proposed intervention, and its benefits and risks, and agrees to the treatment by
signing a consent form. Laws regarding informed consent protect the client's to self-
determination.
Informed consent is legal doctrines stating that patient have the power to choose among
medically reasonable plans for care.

2. Decision-Making Capability:
Decision-making capacity is often referred to by the legal term competency. It is one of the
most important components of informed consent. Decision making capacity, or competency,
simply means that you can understand and explain the options, their implications, and give a
rational reason why you would decide on a particular option instead of the others. In practical
terms, physicians are sometimes asked to evaluate a person's capacity to make decisions. If a
physician believes that a person lacks the ability to make informed decisions about medical
care, that person is deemed "incapable."

3. Advance Directives: Advance directive as a written instruction that is recognized under

state law and is related to the provision of such care when the individual is incapacitated.
Advance directives are usually written documents designed to allow competent patients the
opportunity to guide future health care decisions in the event that they are unable to participate
directly in medical decision making.
Advance directives demonstrate respect for individuality and self-determination, and are legal
and ethical obligation. An advance directive allows the patient to communicate his or her
wishes in the event of terminal illness or a permanently comatose state. There are several types
of Advance Directives, each suited to a specific type of medical and legal situation.
A. Living Will: The living will covers health care decisions when you are terminally ill and
unable to make decisions, permanently unconscious. The living will is a formal legal
document that must be written and signed by the patient. This written statement tells
health care providers what type of life-prolonging treatments or procedures to perform if
you have a terminal condition or are in a persistent vegetative state.
B. Durable Power of Attorney: To provide broader coverage, many patients opt for a
durable power of attorney for health care. The durable power of attorney for health care
allows the patient to appoint a surrogate decision maker, known as a health care agent or
proxy, who has authority to make treatment and health care decisions in the event that the
patient is not able to do so.

4. Good Samaritan Acts: Good Samaritan acts are laws that provide protection to health care
providers by ensuring immunity from civil liability when assistance provided at the scene of
an emergency when the caregiver does not intentionally or recklessly cause client injury.
5. Do - Not - Resuscitate Orders: A do not resuscitate (DNR) order is another kind of advance
directive. Do Not Resuscitate or DNRs order on a patient's file means that a doctor is not
required to resuscitate a patient if their heart stops and is designed to prevent unnecessary
suffering. DNR is a legal order written either in the hospital or on a legal form to respect the
wishes of a patient to not undergo CPR or advanced cardiac life support (ACLS) if their heart
was to stop or they were to stop breathing.

6. Withholding or Withdrawing Life - Sustaining Medical Treatment: The withholding

and withdrawing of life-sustaining therapies is ethical and medically appropriate in some
circumstances. Withdrawal of treatment is an issue in intensive care medicine because it is now
possible to maintain life for long periods without any hope of recovery. Life sustaining
treatment is any treatment that serves to prolong life without reversing the underlying medical
condition. Life-sustaining treatment may include, but is not limited to, mechanical ventilation,
renal dialysis, chemotherapy, antibiotics, and artificial nutrition and hydration. There is no
ethical distinction between withdrawing and withholding life-sustaining treatment.

7. Active Euthanasia: Euthanasia is Greek for good death which translates into English as
easy death or mercy killing. Euthanasia refers to an intentional action or lack of action causing
the merciful death of someone suffering from a terminal illness or incurable condition. Active
euthanasia, an act of commission, is taking some action that leads to death like a fatal injection.
Active euthanasia occurs when the medical professionals, or another person, deliberately do
something that causes the patient to die. Requests for it generally arise because individuals
suffer uncontrolled pain, demand more control over their care, or fear abandonment. However,
many terminally ill people who have requested euthanasia change their minds after pain has
been relieved.

8. Restraints or Seclusion: Restraints are legal only if they are necessary to protect the client
others from harm. If a competent client refuses to follow orders and the nurse uses restraints,
the nurse can be charged with false imprisonment and/or assault and battery. In an emergency
situation when a client becomes violent and is in imminent danger of harming self or others,
the nurse may apply restraints and then immediately obtain an order from the physician. The
nurse is legally accountable for the client in restraints or seclusion.

9. Abuse of Older Adults: Family members or other caregivers can sometimes become
abusive for a variety of reasons. These may include feeling overwhelmed and burnt out by
caregiving responsibilities, lacking appropriate caregiving skills, or having no break from care-
giving. Older adults may not be able to protect themselves or know how to get help.
If the older person cannot function without extensive care and must remain at risk, support
services may be appropriate. These may include obtaining home care services, counselling the
abusive caregiver, or moving the older person to another residence. Supporting services should
be offered, although capable individuals may refuse the assistance. If a person is not capable
and the abuse seems clear, the physician or caregiver must consider a report to adult protective
service agencies or a petition to the court for a new guardian.

10. Preventing Harm: Health care providers have a duty to use their expertise for the benefit
of the people in their care. However, you retain the right to refuse treatments that your health
care provider considers to be in your best interest. Again, good communication with your health
care providers can improve your mutual understanding of risks, benefits, and underlying
beliefs.
 COMMUNICATION WITH PATIENT AND FAMILY

The Intensive Care Unit (ICU) is a very "intense" area and can create a great deal of tension
and stress for patients and families. Effective and appropriate communication is an important
part of the healing process, not only for the patient, but also for the family.

The following are suggestions for family members on how to communicate with a loved one
in the ICU:

 Speak in a calm, clear manner. Make short positive statements. Many family members
assume because their loved one is on a ventilator they cannot hear and so they speak
loudly, don't worry they can hear you.
 Acknowledge and recognize any discomfort your loved one may be experiencing.
 Do not ask the patient questions that cannot be answered. Use a board so the patient can
point to a word such as "pain," this allows your loved one to make his need known.
 Provide a small board for the patient to write on. Many patients can write just enough so
you know what they want. The hospital should provide this, however, these boards can
also be purchased at a drug store or art supply store.
 Offer short phrases that offer support and reassurance. For example, "Mom, its Maureen,
I'm here with you and you are doing much better. Everyone is taking good care of you."
 Simple hand gestures may work as well, such as thumbs up = "good"; and thumbs down
= "pain" or "I need something."
 Remind your loved one that "this is just temporary and they are making good progress."
Flood them with faith and hope.
 Hold your loved one's hand or touch them gently (be sure to check with the ICU staff
first). For example, rubbing lotion on their hands or feet may not be allowed.
 Orient your loved one to the surroundings, for example, the date and time of day.
 Read your loved one's favourite prayers, poems, books, stories, or bible verses.
 Music may be allowed in the ICU when appropriate. Again be sure to check with the ICU
staff for guidance.
 Finally, just ask the ICU staff may have the perfect suggestion for you to assist you in
communicating with your loved one.

General suggestions that may be helpful to family members:

 Always check with the critical care staff before touching anything or saying anything to
the patient. Stimulation can cause harm during critical periods of the recovery process.
 Ask the critical care staff to explain to you what the current status of your loved one is,
so you understand what is going on and why.
 Ask for suggestions on what would be helpful at this time for your loved one.
 Do not discuss any unpleasant matters in your love one's room. If your love one's
condition is critical, discuss this or other problems outside the room. For example, do
not discuss financial matters, or family disagreements, etc.
 If you are emotional and or upset either leave the room. It may be helpful to request a
Chaplin or social worker to help you to calm down and help you feel reassured, or sit
quietly at the bedside. It may only be harmful to your loved one to speak when you are
angry or upset.
 Request your church, the hospital, or a social worker if you feel you need further support
for yourself or for your loved one during the hospitalization.
INTENSIVE CARE RECORDS

A careful documentation of a given patient illness, the diagnostic and therapeutic approaches
of the physician to that illness, and the day-by-day progress made in dealing with each aspect
of the illness. The record should reflect the physician's thinking, and one should be able to
glean from it the exact reasons for this particular test, for that particular drug and the
justification for any diagnosis made during the course of the patient's illness. In addition, the
medical record should serve as an ideal tool, and should meet the criteria’s.

Intensive Care Records

Records: A record is a permanent written communication that documents information relevant
to individual students in an institution. It is a legal document.
In critical area such as ICU following records are used:
 Electronic Medical Record: An electronic medical record is usually a computerized
legal medical record created in an organization that delivers care, such as a hospital and
doctor's surgery. Electronic medical records tend to be a part of a local stand-alone health
information system that allows storage, retrieval and manipulation of records.
 Paper-Based Record: Paper-based records require a significant amount of storage space
compared to digital records. The costs of storage media, such as paper and film, per unit
of information differ dramatically from that of electronic storage media. When paper
records are stored in different locations, collating them to a single location for review by
a healthcare provider is time consuming and complicated, whereas the process can be
simplified with electronic records.

The following guidelines are designed to facilitate the recording of clear, relevant information
that is essential for continuity of care, audit and medico-legal review. Entries should establish
a balance, being concise but still accurately recording all relevant information and events.
1. Admission Records
2. Discharge Records
3. Patient's Records
4. Daily Case Note Register
5. Emergency Drug Records
6. Inventory Records
7. Stock Register
8. Staff Duty Register
9. Record of Duty Roster
10. Record of Emergency Equipments
1. Admission Record: All patients admitted to Unit must have a detailed admission summary.
The admitting clinic must be notified, by the admitting registrar, and invited to record an
admission summary for patients admitted directly to ICU. The admission note should
incorporate all relevant aspects of the patient's medical history, clinical examination and results
of appropriate investigations.
2. Daily Case-Note Entries: A daily entry must be made in the case notes. Notes are most
efficiently recorded after the 11:00 ward round so that current results and management plans
are recorded. Additional notes must be made for the following: significant changes in physical
condition necessitating changes in management, e.g. renal failure requiring dialysis, invasive
procedures, e.g. Laparotomy, tracheostomy, PAC/CVC insertion, results of specific
investigations or tests, e.g. CT scans, endocrine tests and changes in policy.
3. Handover Summary: Due to the large number of complex patients, an ongoing handover
summary should be established for each patient. This facilitates ease of handover between day
and night resident staff and for the duty consultant staff.
4. Discharge Summary: All patients transferred from ICU require a Medical Transfer
Summary form completed. This is a single page document outlining all relevant transfer
information. The original should be filed in the case notes and a photocopy placed in the
marked box .The duty registrar on the day of transfer is responsible for completing the form.
Incomplete or missing summary will be forwarded to the responsible registrar for completion.
Short term Unit patients do not require detailed discharge summaries, only pertinent
information relating to their stay.

How to Maintain Records

1. Record must be kept carefully and in clean conditions, safe from rats and insects.
2. It is important that records are not lost or mislaid. They are confidential and should be
shown only to authorize persons.
3. Have a good system of filing. It is useful and also to have a register or index cards filed
in alphabetical order.
4. Records must be readily available and keep up to date.

How to Write Records and Reports

The delivery of health services is not complete until details are written up in the correct register
or record. The last half an hour of each day's work should be reserved for completing the
records.
In Writing records and Reports:
1. Write them promptly, and keep them up to date.
2. Write legibly, to be understood by others.
3. Keep sentences short and clear.
4. Be accurate and complete in important details.
5. Replace records in their proper place.
6. Consult your supervisor in ease of difficulty in completing records and writing reports.

CRISIS INTERVENTIONS

Stressful situations are a part of everyday life. Any stressful situation can precipitated crisis.
When stressors exceed the person's ability to cope, a crisis develops. Crises result in
disequilibrium from which many individuals require assistance to recover. Crisis intervention
requires problem-solving skills that are often diminished by the level of anxiety accompanying
disequilibrium. Assistance with problem solving during the crisis period preserves self-esteem
and promotes growth with resolution.

Crisis intervention deals with wide range of human problem. It is not self-limiting future. Crisis
intervention should focus upon present problem giving wide range of solution. Teach more
adaptive/coping mechanism to cope future problems and crisis. Crisis intervention should be
reality oriented. Crisis intervention should serve as a stepping stone to a long process.
CRISIS
A crisis is any event that is, or expected to lead to, an unstable and dangerous situation affecting
an individual, group, community or whole society. Crisis is a sudden event in one's life that
disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem. A
crisis occurs when the individual's usual coping mechanisms are no longer effective. Crisis is
characterized by extreme anxiety, inability to function and disorganized behaviour.
A number of characteristics have been identified that can be viewed as assumptions on which
the concept of crisis is based. They include the following:
1. A crisis is experienced as a sudden event.
2. Crisis are precipitated by specific identifiable events.
3. The situation is perceived as overwhelming or life threatening.
4. The situation cannot be resolved with usual coping skills.
5. Intervention is required for equilibrium to be achieved.
6. Crisis are personal by nature.
7. Crisis are acute not chronic & will be resolved in one way or another within a brief
period.

Types of crisis:
1. Maturational Crisis: There are eight stage in the development of a person from infancy
to old age. As a person passes from one stage to another he experiences transitional
periods during which he undergoes psychological disequilibrium, emotional imbalance
and upset. These periods are termed as transitional or maturational crisis. The
transitional crisis is more during adolescence, since parent's resistance in this period
increases and results in more crisis.
2. Situational Crisis: It is based on the life events which can be both positive and negative.
This occurs when an external event upsets an individual's or a group's psychological
equilibrium.
3. Adventitious Crisis: It is sudden, unexpected and uncommon such as accident, disaster,
etc. It leads to multiple losses with gross environmental changes.

Phases in the Development of Crisis:

Gerald Caplan (1964) has outlined 4 phase of crisis development that traces the transformation
of anxieties or distress into an acute state. They are:
Phase-1: The individual is exposed unfamiliar and unanticipated stress caused by a
precipitating stressor. Anxiety increases; previous problem-solving techniques are employed.
The person attempts to use the coping skills to deal with the stress. If the coping mechanisms
work, there is no crisis and if coping mechanisms do not work a crisis occurs.
Phase-2: Event is perceived as threat and that produces anxiety. The individual begins to feel
a great deal of discomfort at this point. Attempts are made to cope with and to resolve the crisis
through usual problem solving methods. Feelings of confusion and disorganization prevail.
Phase 3: All possible resources, both internal and external, are called on to resolve the problem
and relieve the discomfort. Increases anxiety and disorganization occurs as a result of the
failure of coping mechanism. The individual may try to view the problem from a different
perspective, or even to overlook certain aspects of it.
Phase 4: Person is now in a stage of extreme distress. Inspite of mobilizing all the resources
and problem solving methods the stress remains unaltered and feel no longer to cope. Major
disorganization of the individual with drastic results often occurs. “Anxiety may reach panic
levels. Cognitive functions are disordered, emotions are labile, and behaviour may reflect the
presence of psychotic thinking.
Balancing Factors:
Three factors influence a person's resolution of a crisis. These factors affect the way in which
an individual perceives and responds to a precipitating stressor. During a crisis, one of these
factors is out of balance. When the factors return to a balanced state, the individual is able to
resolve the crisis effectively. Nursing interventions focus on re-establishing equilibrium among
these factors. These factors include:
1. Perception of the event: If the event is perceived realistically, the individual is more likely
to draw on adequate resources to restore equilibrium. If the perception of the event is
distorted, attempts at problem-solving are likely to be ineffective and restoration of
equilibrium goes unresolved.
2. Situational Supports: Aguilera states, "Situational supports are those persons who are
available in the environment and who can be depended on to help solve the problem.
“Without adequate situational supports during a stressful situation, individual is most likely
to feel overwhelmed and alone.
3. Coping Mechanisms: When a stressful situation occurs, individuals draw on behavioural
strategies that have been successful for them in the past. If these coping strategies work, a
crisis may be diverted. If not, disequilibrium may continue and tension and anxiety may
increase.

CRISIS INTERVENTIONS
Individuals experiencing crisis have an urgent need for assistance. In crisis intervention, the
therapist, or other intervener, becomes a part of the individual's life situation.
Crisis intervention can be defined as a counselling or psychotherapy for patients in a life crisis
that is directed at supporting the patient through the crisis and helping the patient cape with the
stressful event that precipitated it.
Crisis intervention aimed at helping the person resolve the situation quickly through supportive
techniques, suggestion, reassurance, environmental modifications, and hospitalization, if
necessary.

Stages in Crisis Intervention:

1. Delineating the problem focus
2. Evaluation of client and problem focus
3. Contracting
4. Intervention
 Listening
 Utilizing interpersonal resources
 Advocacy
 Confrontation
 Giving information
 Exploring alternatives
 Advice and suggestions
 Behaviour assignment
5. Termination
6. Follow-up

Gold Fried states seven steps in crisis intervention:

1. Identify the problem
2 Propose alternative solutions
3. Rehearse each alternative
4. Choose one solution
5. Define the needed steps
6. Take up the steps
7. Check the result

Roberts and Ottens (2005) provide a seven-stage model of crisis intervention:

Stage 1: Psychosocial and Lethality Assessment
The crisis worker must conduct a swift but thorough psychological assessments minimum, this
assessment should cover the client's environment supports and stressors, medical needs and
medications, current use of drugs and alcohol and internal and external coping methods and
resources.
Assessing lethality, first and foremost, involves ascertaining whether the client has actually
initiated a suicide attempt, such as ingesting a poison or overdose of medication. If no suicide
attempt is in progress, the crisis worker should inquire about the client's potential for self-harm.
Stage II: Rapidly Establish Rapport
Rapport is facilitated by the presence of counsellor - offered conditions such as genuineness,
respect, and acceptance of the client. This is also the stage in which the traits, behaviours or
fundamental character strengths of the crisis worker come to force in order to instil trust and
confidence in the client.
Stage III: Identify the Major Problems or Crisis Precipitants
Crisis intervention focuses on the client's current problems, which are often the ones that
precipitated the crisis. As Ewing pointed out, the crisis worker is interested in elucidating just
what the client's life has led her of him to require help at the present time. Roberts suggested
not only inquiring about the precipitating event but also prioritizing problems in terms of which
to work on first, a concept referred to as looking for leverage.
Stage IV: Deal with Feelings and Emotions
There are two aspects to stage IV. The crisis worker strives to allow the client to express
feelings, to vent and heal, and to explain her or his story about the current crisis situation. To
do this, the crisis worker relies on the familiar active listening skills like paraphrasing,
reflecting feelings and probing.
Stage V: Generate and Explore Alternatives
This stage can often be the most difficult to accomplish in crisis intervention. Clients in crisis,
by definition, lack the equanimity to study the big picture and tend to doggedly cling familiar
ways of coping even when they are backfiring. However, if stage IV has been achieved, the
client in crisis has probably worked enough feelings to re-establish some emotional balance.
Stage VI: Implement an Action Plan
Here is where strategies become integrated into an empowering treatment plan or heated
intervention. An action plan can involve several elements: removing the means, negotiating
safety, future linkage, decreasing anxiety and sleep loss, decreasing isolation and
hospitalization. Obviously, the concrete action plans taken at this stage are critical for restoring
the client's equilibrium and psychological balance.
Stage VII: Follow-Up
Crisis workers should plan for a follow-up contact with the client after the initial intervention
to ensure that the crisis is on its way to being resolved and crisis status of the client. This post
crisis evaluation of the client can include-physical condition of the client, cognitive mastery of
the precipitating event, an assessment of the overall functioning include social, spiritual,
employment and academic, satisfaction and progress with ongoing treatment, any current
stressors and how being are those handled and need for possible referrals.
Nurse's role in crisis interventions:
Assessment:
1. Identifying the precipitating events
2. Client's perception of the event
3. Client's strength and available support system
4. Previous coping style and strength
Plan:
To develop strength of his own, to face the crisis Interventions
1. Environmental Manipulation: To change client's physical or interpersonal situations to
remove stress.
2. General Support: Making the client feel warm, acceptance, empathy, caring by providing
reassurance.
3. Generic Approach: Reaching high risk individual and large groups as quickly as possible.
4. Individual Approach: By understanding individual psychodynamic, many techniques and
used.
 Abreaction - Release the feelings for tension reduction.
 Clarification - Identify the relationship between the event and client.
 Suggestion - To feel confident, calm and hopeful to face the crisis
 Manipulation - Manipulate clients emotional aspect.
 Reinforce - Reinforce for healthy behaviour changes.
 Support defence - Support for healthy defence mechanism than unhealthy one.
 Raise the self-esteem - Help to regain his self-worth.
 Explore solution - Help to form many alternative ways of solving the problem.

Evaluation:
1. Assess the client, whether he has returned to his pre-crisis level.
2. Whether patient experiences pre-crisis level after the interventions.

COPING WITH DEATH AND DYING

Mostly persons believe that they will live forever. But death will enter our lives. Persons
therefore need to learn how to live with death, dying and grief. Some of the discomfort with
death and dying process has come about because death has been removed from common
experience. The dying process usually begins well before death actually occurs. Death is a
personal journey that each individual approaches in their own unique way. Nothing is concrete,
nothing is set in stone. There are many paths one can take on this journey but all lead to the
destination.
Death is the cessation of the connection between our mind and our body. Most people believe
that death takes place when the heart stops beating: but this does not mean that the person has
died, because his subtle mind may still remain in his body. Death occurs when the subtle
consciousness finally leaves the body to go to the next life.

DEATH AND DYING

Dying is the active process of or associated with the process of ceasing to be or passing from
life. Dying may occur suddenly as a result of an accident, injury or pathogenic crisis such as
heart attack, it may occur after a prolonged experience of debilitating disease, such as cancer,
AIDS, etc. Some welcome death choosing the time and manner of dying, others fears death
and will try to do anything to delay it.
Death is the permanent termination of the biological functions that sustain a living organism.
Death is present when an individual has sustained either irreversible cessation of circulatory
and respiratory functions or irreversible cessation of all functions of entire brain, including
brain stem.

Dying Process
The dying process is a period of time when the body begins to shut down and prepare for death.
It's an important period of time for the dying person and their loved ones during which they
can express their feelings and show their love. It's a time of preparation for the dying person
and their loved ones-preparing for inevitable loss.

One to three months prior to death:

 Withdrawal from world and people
 Decreased food intake
 Increased sleep
 Going inside self
 Less Communication

One to Two Weeks Prior to death:

A. Mental Changes :
 Disorientation
 Altered sense of perception
 Delusions
 Hallucination; Talking with Unseen
 Agitation
 Confusion
 Picking at Clothes
B. Physical Changes :
 Decreased blood pressure
 Pulse increase or decrease
 Colour changes; pale, bluish
 Increased perspiration
 Respiration irregularities
 Congestion
 Sleeping but responding
 Complaints of body tired and heavy
 Not eating, taking little fluids
 Body temperature hot/cold

Days or Hours:
 Intensification of 1-2 week signs
 Surge of energy
 Decrease in blood pressure
 Eyes glassy, tearing, half open
 Irregular breathing, stop/start
 Restlessness or no activity
 Purplish knees, feet, hands, blotchy
 Pulse weak and hard to find
 Decreased urine output
 May wet or stool the bed
Minutes:
 Fish out of water breathing
 Cannot be awakened

Signs of Impending Death

The clinical signs of approaching death are:
 Inability to swallow
 No breathing (chest does not move)
 No heart beat (no pulse)
 Pupils large, do not change
 Pitting edema
 Bowel and Bladder incontinence
 Decreased Gastrointestinal and Urinary tract activity
 Loss of motion, sensation and reflexes
 Elevated temperature, but cold or clammy skin, cyanosis
 Lowered blood pressure
 Noisy or irregular respiration
 Cheyne -Stoke respiration
 Patient may or may not lose consciousness

Stages of Death and Dying

Each person reacts to the knowledge of impending death or to loss in his or her own way, there
are similarities in psychological response to the situation. Stages of dying, much like stages of
grief may overlap and duration of any stage may range from as little as a few to as long as
months. This process varies from person to person.

Dying is a process, the end point of which is death. In this sense dying is a terminal of living.
The coping responses during this particular segment of life are shaped by previous experiences
with death, as well as by cultural attitudes and beliefs.

Kubler-Ross (1969) postulates five stages that many dying patients pass through from the time
they first be aware of their fatal prognosis to their actual death:

1. Denial: "I feel fine."; "This can't be happening, not to me." Denial is usually only temporary
defense for the individual. This feeling is generally replaced with heightened awareness of
possessions and individuals that will be left behind after death. The patient denies that he or
she will die, may repress what is discussed and may isolate himself from reality. Patient may
think, they made a mistake in diagnosis.
2. Anger: "Why me? It's not fair!"; "How can this happen to me?"; "Who is to blame?”. Once
in the second stage, the individual recognizes that denial cannot continue. Because of anger,
the person is very difficult to care for due to misplaced feelings of rage, hostility and envy.
3. Bargaining: "I will do anything for a few more years."; "I will give my life savings if…”.
The third stage involves the hope that the individual can somehow postpone or delay death.
Usually, the negotiation for an extended life is made with a higher power in exchange for a
reformed lifestyle. Psychologically, the individual is saying, "I understand I will die but if I
could just do something to buy more time."

4. Depression: "I'm so sad, why bother with anything?", "I'm going to die soon so what's the
point… What's the point?"; "I miss my loved one, why go on?" During the fourth stage, the
dying person begins to understand the certainty of death. Because of this, the individual may
become silent, refuse visitors and spend much of the time crying and grieving. This process
allows the dying person to disconnect from things of love and affection. It is not recommended
to attempt to cheer up an individual who is in this stage. It is an important time for grieving
that must be processed.
5. Acceptance: "It's going to be okay." "I can't fight it, I may as well prepare for it." The patient
realizes that death is inevitable and accepts the universality of the experience. The patient has
now accepted deaths and is prepared to die. In this last stage, individuals begin to come to terms
with their mortality, or that of a loved one, or other tragic event.

Signs of Dying with Suggested Cares

Appreciating the preciousness of human life, based on the understanding of one's body
constantly changing, ageing, moving toward death since birth and the uncertainty of life helps
us appreciate life and prepare for death. Each person's experience is unique, but there are some
general similarities.

The following is a very simple account of the normal changes that may occur in stage of living,
commonly called "dying", with some suggested ways of caring. It is intended
to help the dying and their loved ones to understand and be prepared for these changes, in order
to provide appropriate safe support and comfort holistically.

1. Physical Weakness / Lack of Energy / Loss of Interest in Everyday Things: As the body's
systems weaken less oxygen is available to the muscles, the life force weakens, and more effort
is needed to complete everyday tasks and one may become embarrassed, discouraged,
ambivalent, depressed, irritable and/or just naturally become more interested in matters that
seem more important: matters of the mind, heart and spirit. This is often a time self-
examination, of questioning, of looking for the meaning of life.
Caregivers can best help by assisting the person with physical tasks, while being sensitive to
their feelings, maintaining their dignity and attending to their comfort as much as possible,
especially with regard to symptom control and protection from injury.

2. Withdrawal from Family and Friends / Increased Sleepiness / Coma: Neither family,
friends nor wealth can be taken with us when we leave this world.
The caregiver should try to respect the person's wishes and be aware of what personal desires
come up in their own mind and how these can be addressed without disturbing the mind of the
dying. Be careful of what you say over their body while the person is asleep or unconscious,
they may hear you and it could upset them.

3. Loss of Appetite: Food is a fuel that helps sustain life. As the digestive system gets weaker,
food may become more of a discomfort than an enjoyment, some medications may change the
tastes of food, and finally the energy required to process the food becomes greater the energy
derived it. Any of these may produce a loss of appetite. Eating habits change.
The person approaching death needs to know that it is OK not to eat. Respect acceptance brings
people closer together which comforts the dying person and the caregiver too.

4. Difficulty Swallowing: As the swallowing reflex weakens, swallowing becomes difficult.

It may become frightening for the person to attempt to eat or drink or the person may be slipping
into unconsciousness. It is best to offer very small amounts (half a teaspoon) and observe the
throat to see if swallowing has taken place.
Medications can be crushed and capsules opened and mixed with jam, jelly, yoghurt or like
foods. Do not crush time-release or long acting medications. Do not give food or liquids to a
person who is unconscious. It may cause the person to choke or to inhale the foreign matter.

5. Confusion: The level of awareness and cognition can change frequently and unexpectedly,
due to many causes (i.e. disease processes, tiredness, medication). When a person becomes
confused, there can be a decrease of oxygen to the brain and they may not recognize familiar
people, places, the time of day or year etc., or they may hear voices or see visions. Do not
negate what they say or argue with them.
Aromatherapy and their favourite music or chanting of their faith, is also helpful.

6. Restlessness: A person may become restlessness and make repetitive motions like picking
at the bed linen, their clothing or the air. This can be a sign of less oxygen available in the brain
or of being distressed due to having pain, nausea, constipation or a full bladder or could be due
to being confused or anxious about something. After the physical problems are controlled, by
using a soothing voice, remind them of their goodness and virtues, along with music,
aromatherapy or reciting the person's favourite spiritual practice may help calm and reassure
them.

7. Elimination: As the person gets weaker and is no longer able to get out of bed, the muscles
that control the bowel and bladder may relax and "incontinence" or involuntary loss of urine
or faeces may occur, often the person will feel embarrassed and/or may awaken if asleep.
Attend to them with dignity and respect and avoid exposing their private parts to others. It’s
important to keep the skin clean and dry or the skin could develop a rash or open sores and
cause more discomfort.
As the kidneys shut down and the skin takes on more elimination work; the person may
experience itching over different parts of their body and also combined with increased sweating
from failing thermal regulators it is difficult to provide comfort.
Different things work for different people: some like warm bed baths, others cool tepid
sponging, or even a cool compress to the forehead and pulse areas can cool down and soothe.
Tea tree oil, calendula or lavender oils or other commercial products can give relief, but usually
strong perfumes are not tolerated. Change the bed linen if soiled with sweat.

8. Body Temperature and Colour: Mechanisms that control the body's ability to control its
temperature will start failing. The skin may sweat and still be very cool or may be hot. The
person may kick off the bed linen but be cold to touch. As the heart becomes weaker, circulation
fails to adequately reach the hands and feet and they will become cool to touch and the nails
maybe bluish, while the arms and legs maybe pale, grey, mottled or purplish. If close to death
it is not necessary to turn for circulation. It is only necessary to turn the patient if it helps
breathing or provides more comfort. This is a difficult judgement that can be a great challenge
for the caregiver because things are always changing. One position favoured one day will not
necessarily be tolerated the next day.

9. Breathing: If breathing is difficult with or without oxygen being given, sometimes a fan
blown over the body to give the sensation of being in fresh air, combined with the mental
suggestion of visualizing sitting on a beach in the wind or the top of a high hill can give relief.
Keeping the head elevated will help breathing, be careful to maintain support of the lower back.
A lubricant on the lips will help prevent cracking. And mouth care with mouth swabs can help
keep the tongue and mouth moist and less dirty. Although this will not be necessary may not
be tolerated by someone close to death. A change in breathing pattern is significant during the
dying process.
There may be a rattling noise (often called the “death rattle”) at the back of the throat, caused
by the accumulation of saliva because the person can no longer swallow. This is of distressing
for the helpers but it doesn't seem to bother the dying person.

10. Unexpected Alertness and increased Energy: Often a day or two or even a few hours
before death, the person has a surge of energy, wakes up, becomes alert, can sometimes eat or
talk and can spend some quality time with loved ones. This is a very precious time because it
normally doesn't last long, as most people become unconscious (unresponsive) hours or days
before they stop breathing.

TYPES OF CARE AVAILABLE TO THOSE WHO ARE DYING

There are two types of care available to those that are dying - palliative and hospice.

 Palliative care is a form of medical treatment focused on reducing the severity of

disease symptoms (such as pain) or slowing the disease's progress, rather than providing
a cure. This type of care is typically provided by a team of medical professionals at a
medical facility, such as a hospital or nursing home. The goals include making the
person as comfortable as possible and addressing quality of life needs (in physical,
psychological, and spiritual realms) in the time remaining. Palliative care can be
delivered at any point during an illness and for an extended period of time as necessary.

 Hospice care in the United States is a specific form of palliative care limited to the last
six months of life (determined by a doctor's diagnosis). Hospice care is offered 24 hours
day, and can be provided at an individual's home, a hospice care facility, or a hospital
nursing home. The focus of hospice care is to provide pain management and medical
emotional support, and spiritual counselling for the dying patient, and similar emotional
and spiritual help and support for family members. Hospice teams typically include
medical doctors, nurses, social workers, psychologists, nursing assistants, trained
volunteers, and spiritual advisors.

DRUGS USED IN CRITICAL CARE UNIT

General practitioners need the knowledge, skills, drugs and equipment for managing medical
emergencies. Critical Care Medicine (CCM) is a specialty that involves the management of
patients with life threatening, frequently complex medical and surgical illness. Drugs which
require immediate administration within minutes post or during a medical emergency are called
emergency or life saving drugs.

Policy:
1. Patients admitted to the ICU must have a complete drug history documented:
a) Premorbid and current medications
b) Previous adverse drug reactions and allergies
c) Note potential drug interactions
2. Charting of drugs and infusions is to be done by ICU medical staff.
a) Parent clinics must not write on the ICU flowchart
b) Therapeutic changes suggested by the home team must be communicated to the
appropriate ICU medical staff.
 3. All changes or additions to drug and fluid orders must be written and signed for on
flowchart.
a) Nursing staff must be notified of such changes
b) Verbal orders alone are neither sufficient nor legal
4. All drugs, infusions and fluids are reviewed and transcribed at least daily.
5. Printed 'sticky' labels for commonly used infusions and drugs should be used where
possible.
6. Standardization of infusion concentrations is essential for the prevention of drug errors.
7. Vasoactive or hypertonic infusions (eg. TPN) must be administered through a dedicated
lumen of a CVC or PICC.
8. Vasoactive infusions must not be used in the general wards, other than for patients in
ICU and who are being continuously monitored.
9. All antibiotics written on the ICU flowchart must also have an indication of date started
and due date for review and/or completion.
10. Patients cleared for discharge from ICU must have all appropriate drugs, infusions and
fluids prescribed on the standard hospital forms, prior to discharge.
11. Patients discharged on TPN must have their details entered in the TPN folder.
12. Any proposed changes to specialty type drugs, e.g. Immunosuppressives,
anticoagulants, antiplatelet agents, etc. should be discussed with home teams.

Principles of drug prescription in Intensive Care

 Ideally, drugs should only be prescribed where proven benefit has been demonstrated.
 Drugs should be prescribed according to Unit protocols and guidelines.
 Ensure that the drug doses are correct: seek advice if unsure.
 The risks and benefits of starting any drug must be carefully considered.
 Critically ill patients have altered pharmacokinetics and pharmacodynamics, with the
potential for toxicity and drug interactions.
 Where possible:
 Use drugs that can be titrated or prescribed to an easily measured endpoint.
 Use drugs that can be measured to monitor therapeutic drug levels.
 Avoid drugs with narrow therapeutic indices (e.g. digoxin, theophylline),
particularly in patients with associated hepatic or renal dysfunction.
 Cease a drug if there is no apparent benefit.
 If two drugs are of equal efficacy, choose the cheaper drug as the cost of drugs
in ICU is significant.

Cardiovascular Drugs
1. Inotropes: Inotropes (specifically catecholamines) are frequently used in ICU. There are
varied prescription practices and preferences for these drugs, mostly based upon the reported
pharmacological effects of the different agents.

General Principles
i. Defence of blood pressure in critically ill patient’s forms the basis of haemodynamic
resuscitation and organ perfusion.
ii. Hypovolemia is the most common cause of hypotension and low cardiac output in ICU
and must be assiduously monitored and corrected.
 iii. The main indications for the use of inotropes are to increase myocardial contractility,
heart rate and/or vascular tone.
iv. The use of inotropes requires regular haemodynamic monitoring.
v. No single inotrope (or mixture of inotropes) has been shown to be superior to another.
vi. There is marked inter-individual variation in the response to inotropes. This is partly
due to pre-existing chronic illness, genetic variation, and coadministration of other
drugs, dynamic qualitative and quantitative changes in adrenergic receptor kinetics.
Inotropic Agents used in ICU:
 Noradrenaline
 Adrenaline
 Dobutamine
 Dopamine
 Isoprenaline

2. Vasopressor Agents: Vasopressors usually act directly on the peripheral vasculature and
are primarily used to acutely elevate blood pressure. The catecholamines have variable effects
on the peripheral vasculature. The most common cause of hypotension in ICU patient is
hypovolemia. Pressor agents should not be used as an alternative to fluid resuscitation.

Vasopressor Agents used in ICU:

 Metaraminol
 Ephedrine
 Vasopressin

3. Antihypertensive Agents: The most common cause of hypertension in ICU patients is

sympathetic drive due to pain, agitation or delirium. These should be treated with adequate
sedation and analgesia. Patients in the recovery phase of acute renal failure are often
hypertensive. Hypertension following an intracranial event (haemorrhagic or ischemic) is
common and the underlying mechanism dictates therapy.

Antihypertensive and Vasodilator Agents used in ICU:

 Glyceryl trinitrate
 Sodium nitroprusside
 Phentolamine
 Amlodipine
 Captopril
 Metoprolol
 Clonidine

4. Antiarrhythmic Drugs: Prior to administration of antiarrhythmic agents, optimize

correction of the following: Hypovolaemia, Metabolic abnormalities, hypoxemia, hypo/
hyper-carbia, myocardial ischemia or cardiac failure (especially post-cardiac surgery), sepsis,
pain and agitation. All antiarrhythmic drugs are potentially arrhythmogenic. Virtually all
depress myocardial contractility.

Antiarrhythmic used in ICU:

 Amiodarone
 Digoxin
 Metoprolol
 Phenytoin
5. Thrombolytic Therapy: Thrombolytic therapy is standard in the management of AMI,
wherever primary angioplasty is not performed. Thrombolytic is administered in consultation
with the duty cardiologist. The patient should be advised of the potential risks and benefits.

Thrombolytic used in ICU:

 Tenecteplase TNK
 Alteplase

6. Antiplatelet Agents: An antiplatelet drug (antiaggregant) is a member of a class of

pharmaceuticals that decrease platelet aggregation and inhibit thrombus formation. They are
effective in the arterial circulation, where anticoagulants have little effect.

Antiplatelets used in ICU:

 Aspirin
 Clopidrogel
 Reopro
 Tirofiban

Respiratory Drugs
 Bronchodilators: Bronchodilators work by relaxing and expanding the smooth
muscle of the airways making it easier to breathe. Three types of bronchodilators are
commonly used treatment of emphysema: beta adrenergic agonists, anticholinergics
and methylxanthines.

Bronchodilators used in ICU:

 Salbutamol
 Hydrocortisone
 Theophylline
 Ipratropium MDI

Sedative and Analgesic Drugs: A sedative is a substance that induces sedation by reducing
irritability or excitement. An analgesic is any member of the group of drugs used to relieve
pain. Adequate analgesia and anxiolytics are primary goals in the management of the critically
ill patient.

Sedative and analgesics used in ICU:

 Propofol
 Fentanyl
 Morphine and Midazolam
 Diazepam
 Haloperidol
 Chlorpromazine

Muscle Relaxants: A muscle relaxant is a drug which affects skeletal muscle function and
decreases the muscle tone. It may be used to alleviate symptoms such as muscle spasms, pain,
and hyperreflexia. These agents have a limited role in ICU and must not be used unless the
patient is adequately sedated (heavy sedation).
Muscle Relaxants used in ICU:
 Suxamethonium
 Rocuronium
 Vecuronium

Anticoagulant Drugs: An anticoagulant is a substance that prevents coagulation (clotting) of

blood. Anticoagulants reduce blood clotting. This prevents deep vein thrombosis, pulmonary
embolism, myocardial infarction and stroke.

Anticoagulants used in ICU:

 Warfarin
 Heparin
 Enoxaparin
 Prostacyclin

Diuretics: A diuretic provides a means of forced diuresis which elevates the rate of urination.
There are three types of diuretics: thiazide, loop and potassium-sparing. All diuretics increase
the excretion of water from bodies, although each class does so in a distinct way. Each works
by affecting a different part of your kidneys, and each may have different uses, side effects and
precautions.

Diuretic Agents used in ICU:

 Furosemide
 Acetazolamide
 Spironolactone
 Mannitol

Gastrointestinal Drugs: The following drugs and medications are in some way related to, or
used in the treatment of gastrointestinal conditions.
 Metoclopramide
 Erythromycin
 Ondansetron
 Ranitidine
 Pantoprazole
 Tropisetron

Antibiotics: The word antibiotic comes from the Greek anti-meaning ‘against’ and bios
meaning ‘life’.' Antibiotics are also known as antibacterials, and they are drugs used to treat
infections caused by bacteria. Antibiotics target microorganisms such as bacteria, fungi and
parasites. A broad-spectrum antibiotic can be used to treat a wide range of infections. A narrow-
spectrum antibiotic is only effective against a few types of bacteria. There are antibiotics that
attack aerobic bacteria, while others work against anaerobic bacteria. Aerobic bacteria need
oxygen, while anaerobic bacteria don't.

Although there are well over 100 antibiotics, the majority come from only a few types of drugs.
These are the main classes of antibiotics.
 Penicillins such as penicillin and amoxicillin
 Cephalosporins such as cephalexin (Keflex)
 Macrolides such as erythromycin, clarithromycin and azithromycin
 Fluoroquinolones such as ciprofloxacin, levofloxacin and ofloxacin
  Sulfonamides such as co-trimoxazole (Bactrim) and trimethoprim (Proloprim)
 Tetracyclines such as tetracycline (Sumycin, Panmycin) and
doxycycline(Vibramycin)
 Aminoglycosides such as gentamicin (Garamycin) and tobramycin (Tobrex)

General indications for antibiotics

1) Prophylaxis for invasive procedures and operations
Proven Indications:
a. Abdominal surgery which involves a breach of the colonic mucosa (traumatic or
elective), or draining an infected cavity
b. Selected obstetrical and gynaecological procedures:
i. Caesarean section with ruptured foetal membranes
ii. Vaginal hysterectomy
c. Insertion of a prosthetic device
d. Compound fractures
e. Amputation of gangrenous limb
Unproven but Recommended:
a. Lacerations penetrating into periosteum or into joint cavities
b. Crush injuries
c. Insertion of a neurosurgical shunt
d. Cardiac valve replacement
e. Arterial prosthesis

2) Empirical antibiotics where infection is likely prior to definitive bacteriological

diagnosis:
 Obtain as many cultures as possible before antibiotics commenced.
 In sick patients "best guess" antibiotics should be commenced prior to results
 When gram stain or culture results return, antibiotic cover should be rationalised to
specific treatment for isolated organisms.

3) Specific infections where the organisms is known.