critical care nursing [Autosaved].pptx

DEFINITION OF TERMS Critical care : is a term used to describe care for patients who are extremely ill and whose clinical condition is unstable. Critical care unit: is a specially designed and equipped facility staffed by skilled personnel to provide effective and safe care for dependent patients...

DEFINITION OF TERMS Critical care : is a term used to describe care for patients who are extremely ill and whose clinical condition is unstable. Critical care unit: is a specially designed and equipped facility staffed by skilled personnel to provide effective and safe care for dependent patients with a life-threatening problem Critical care nursing Caring for high-acuity patients requiring intensive monitoring and organ support therapies. The nurse will be able to apply knowledge, skills, and critical thinking in the holistic approach to caring for these acutely unwell patients and their family 4 Levels of Acuity ICU team Specially trained nurses (critical care nurses) Physicians Respiratory therapists Care managers Physical and occupational therapists Other providers Special Skill of Critical Care Nurse 1. Critical thinking skills: Using the nursing process as a guide for problem-solving. 2. Collaborative skills 3. Delegation skills 4. Computer skills Conditions Related to Critical Care Heart problems. Lung problems. Organ failure. Brain trauma. Blood infections (sepsis) Drug-resistant infections. Serious injury (car crash, burns 7 C”s OF CRITICAL CARE Compassion Communication Consideration of(patients , relatives and colleagues) and avoidance of conflict Comfort: protection of patient from suffering  Carefulness : Avoidance of injury Consistency (of observation and care) Closure (Ethics and withdrawal of treatment) STRESSORS IN THE CRITICAL CARE SETTING 1. Threat of Death 2. Threat of survival but with significant residual Ex. stroke patient 3. Pain or discomfort 4. Lack of sleep 5. Loss of autonomy over most aspects of life 6. Loss of dignity 7. Loss of usual roles and arena in which usual coping mechanisms serve the patient 8. Separation from family and friends 9. Boredom (broken only by brief visits, threatening stimuli, and frightening thoughts) 10. Loss of ability to express self verbally when undergoing intubation THE RIGHT OF THE CRITICALLY ILL PATIENT 1. Right to choose or decline care, including the right to accept or refuse treatment or nourishment 2. Informed consent 3. Confidentiality 4. Dignity, including the right to die with dignity. Goals of Critical Care Nursing To promote optimal delivery of safe and quality care to the critically ill patients and their families by providing highly individualized care To care for critically ill patients with a holistic approach To use relevant and up-to-date knowledge, caring attitude and clinical skills, supported by appropriate technology for the prevention, early detection and treatment of complications to facilitate recovery.- To provide palliative care to critically ill patients in situations where their health status is progressing to unavoidable death CRITICAL CARE NURSING STANDARDS 1. Describing and measuring the expected level of practice and professional performance for progressive and critical care registered nurses. 2. Ensuring nursing practices are consistent with the delivery of effective critical care services. 3. Covering care for acutely and critically ill patients across different age groups. 4. Extended roles beyond professional boundaries. 5. Serving as educators and patient advocates. MAJOR COMPONENTS OF CRITICAL CARE The critically ill patient The critical care environment The critical care nurse ROLES AND RESPONSIBILITIES OF CRITICAL CARE NURSE Assessing a patients condition and planning and implementing patient care plans Provides direct comprehensive bedside care to patients Treating wounds and providing advanced life support Assisting physicians in performing procedures  Able to attach equipment on patients as ordered and interpret the data , graphs on monitors etc. Observing and recording patients vital signs Ensuring that ventilators , monitors and other types of medical equipment function properly Administering intravenous fluids and medications  Collaborating with fellow members of the critical care team Responding to life-saving situations, using nursing standards and protocols for treatment Acting as patient advocate Documents appropriately Ensures patient safety  Follows the policies and procedures of the unit and the institution Is an expert in nursing knowledge and practice Promotes quality assurance in nursing Providing education and support to families RESPONSIBILITIES OF A CRITICAL CARE NURSE 1. Being an advocate 2. Uses sound clinical judgement 3. Demonstrates caring practices 4. Collaborates with multidisciplinary team 5. Provides patient and family teaching 6. Demonstrates an understanding of cultural diversity 7. Fosters leadership at all times 8. Optimizes talents &resources 9. Promotes ethical decision-making 10. Promotes innovation and creativity, including research 6 Principles Of Critical Care Nursing 1. Efficiency-You can increase your efficiency with the practical use of resources and by complying with the relevant code of ethics. Effective interpersonal communication skills and basic knowledge of technology can also improve efficiency. 2. Appropriate medical intervention- administering systematic medication and maintaining the required life support systems 3. Professionalism-providing high-quality care while upholding accountability, respect and integrity. This also includes demonstrating professional behaviour, communicating clearly and maintaining a positive 4. Safety and non-maleficence-This principle emphasizes the importance of increased safety standards in the physical care environment to reduce risks for patients and healthcare providers. Non-maleficence refers to providing quality care and avoiding intentional harm during treatment 5. Respect and care- listening to patients' concerns with sensitivity and respecting their opinions. Critical care nursing aims to promote quality of life rather than just survival. You can achieve this by helping patients gain control of their health through habits and thoughts that promote self-care 6. Fair allocation-treating everyone fairly when providing medical attention. As a CCN, you are responsible for treating all patients with respect regardless of age, ethnicity, race, religious beliefs, sexual orientation or economic status. The fair allocation also requires you to ensure compliance, assign all medical resources, and use medical equipment fairly and justly. What are the conditions considered Critical? Any person with life-threatening condition Patients with : Acute renal failure AMI Cardiac tamponade Severe shock Heart block Poly trauma Multiple organ failure and organ dysfunction Severe burns Where is critical care provided? Accident & Emergency Units High Dependency Units Intensive Care Units Coronary Care Units Recovery Anaesthetic Rooms Operating Theatres NURSING ASSESSMENT It is the first stage of nursing process → nurse should carry out a complete and holistic nursing assessment of every patient’s needs, regardless of the reason for the encounter COMPONENTS OF NURSING ASSESSMENT 1.NURSING HISTORY: Taking prior to the physical examination → allows a the nurse to establish a rapport with the patient and family. Elements of the history include: – Health Status Cause 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- Client’s perception Emotional health Physical health Spiritual health Intellectual health 3. Physical Examination : Observation Measurement of signs → can be observed or measured, or symptoms → nausea or vertigo, which can be felt by the patient The techniques used Inspection Palpation Auscultation Percussion in addition to the vital signs and further examination of the body systems such as the cardiovascular or musculoskeletal systems. Documentation of Assessment Is documented in the patient’s medical or nursing records→ On paper or part of the electronic medical record → can be assessed by all members of the health care team CLASSIFICATION OF CRITICAL CARE UNITS LEVEL - I Provides monitoring, observation, and short-term ventilation. The patient ratio is 1:3and the medical staff are not present in the unit all the time. LEVEL - II Provides observation, monitoring, and long-term ventilation with resident doctors. The nurse-patient ratio is 1:2; junior medical staff is available in the unit all the time, and consultant medical staff is available if needed. Ethical Issues in Critical Care Key ethical (moral) principles include autonomy, beneficence, non-maleficence, justice, and paternalism. Other related ethical concepts include integrity, best interests, informed consent, and advance directives. All are applicable to critical care practice. Some of these principles and how they relate specifically to critical care nursing practice are discussed individually in this chapter. Others are incorporated in broader issues, such as brain death and organ donation Autonomy According to the principle of autonomy, critical care patients are entitled to be treated as self-determining. Where the patient is incompetent, healthcare professionals ought to act so as to respect the autonomy of the individual as much as possible, for example by attempting to discover what the patient’s preference would have been in the current circumstances. Beneficence and Non-maleficence The principle of beneficence requires that nurses act in ways that promote the well-being of another person; this incorporates the two actions of doing no harm and maximizing possible benefits while minimizing possible harms (non-maleficence). It also encompasses acts of kindness that go beyond obligation. In practice , this means that although the caregiver’s treatment is aimed to ‘do no harm ,’ there may be times when to ‘maximize benefits’ for positive health outcomes, it is considered ethically justifiable that the patient be exposed to a ‘higher risk of harm.’ For example, in the coronary care unit (CCU) , a patient may require a central venous catheter (CVC) to optimize fluid and drug therapy, but this is not without its own inherent risks (e.g., infection, pneumothorax on insertion). Evidence-based protocols exist for caregivers/nurses for both the safe insertion of a CVC and subsequent care so as to minimize possible harm to the patient. Justice Justice may be defined as fair, equitable and appropriate treatment in light of what is due or owed to an individual. The fair, equitable and appropriate distribution of health care, determined by justified rules or ‘norms’, is termed distributive justice. There are various well-regarded theories of justice. In health care, egalitarian theories generally propose that people be provided with an equal distribution of particular goods or services. However, it is usually recognized that justice does not always require equal sharing of all possible social benefits. In situations where there is not enough of a resource to be equally distributed, often guidelines or policies (e.g. ICU admission policies) may be developed in order to be as fair and equitable as possible. Patients’ Rights Patients’ rights are a subcategory of human rights. ‘Statements of patients’ rights’ relate to particular moral interests that a person might have in healthcare contexts, and hence require special protection when a person assumes the role of a patient. Consent In principle, any procedure that involves intentional contact by a healthcare practitioner with the body of a patient is considered an invasion of the patient’s bodily integrity and, as such, requires the patient’s consent. A healthcare practitioner must not assume that a patient provides valid consent because the individual has been admitted to a hospital. All treating staff (nurses, doctors, allied health, etc) are required to facilitate discussions about diagnosis, treatment options, and care with the patient to enable the patient to provide informed consent. When specific treatment is to be undertaken by a medical practitioner, the responsibility for obtaining consent rests with the medical practitioner; this responsibility may not be delegated to a nurse. Consent to treatment A competent individual has the right to decline or accept healthcare treatment. Consent is considered valid when the following criteria are fulfilled; consent must: be informed (the patient must understand the broad nature and effects of the proposed intervention and the material risks it entails) be voluntarily given encompass the act to be performed be given by a person legally competent to do so. To be competent, an individual must: be able to comprehend and retain information believe it (i.e. they must not be impervious to reason, divorced from reality, or incapable of judgment after reflection) be able to weigh that information up (i.e. consider the effects of having or not having the treatment) make a decision based on that ability. End-of-Life Decision Making A common ethical dilemma found in critical care is related to the opposing positions of ‘maintaining life at all costs’ and ‘relieving suffering associated with prolonging life ineffectively’. Patients that would probably have previously died can now be maintained for prolonged periods on life support systems, even if there is little or no chance of regaining a reasonable quality of life. Assessment of their ‘post-critical illness’ quality of life is complex, emotive and forms the basis of significant debate, compounded by the nuances of each individual patient’s case. Hence, decisions regarding withdrawal and withholding of life support treatment(s) are not made without substantial consideration by the Withdrawing/Withholding Treatment The withholding or withdrawal of life support is considered ethically acceptable and clinically desirable if it reduces unnecessary patient suffering in patients whose prognosis is considered hopeless (often referred to as ‘futile’) and if it complies with the patient’s previously stated preferences. Life support includes the provision of any or all of ventilatory support, inotropic support for the cardiovascular system and haemodialysis, to critically ill patients. Withholding/withdrawal of life support are processes by which healthcare therapy or interventions either are not given or are forgone, with the understanding that the patient will most probably die from the underlying Decision-Making Principles Despite significant advances in medical technology and therapeutics, approximately 20% of patients admitted to ICUs do not survive and the majority of those die in ICU after the forgoing of life-prolonging therapies (as opposed to after cardiopulmonary resuscitation). Lack of communication creates a potential for patients to undergo burdensome and expensive treatments that they may not desire. Some doctors do not communicate with patients or families or document decisions because of the lack of clear laws for end-of-life practices and the fear of litigation. Many families want to be involved but some individual family members do not want to be involved in end-of-life decisions. Individuals commonly want their family to decide for them, although the judgement of intensive care professionals concerning which treatment should be given may well differ from that of patients and families The decision-making process Quality of Life Often, quality of life is considered to consist of both subjective and objective components, based on the understanding that a person’s wellbeing is partly related to both aspects; therefore, in any overall account of the quality of life of a person, consideration is given to both independent needs and personal preferences.9 Subjective components refer to the experience of personal satisfaction or happiness, or the attainment of personal informed desires or preferences. Conversely, objective components refer to factors outside the individual, and tend to focus on the notion of ‘need’ rather than desires (e.g. the level to which basic needs are met, such as avoiding harm, and Best Interests Principle The best interests principle is a guiding principle for decision making in health care, and is defined as acting in a way that best promotes the good of the individual. This principle is referred to when one person makes a decision on behalf of another person (e.g. when a doctor makes a decision to cease life-sustaining treatment for a particular patient). This situation particularly arises when the patient is incompetent and is therefore unable to participate in the decision-making process Patient Advocacy Terms such as ‘medical agent’, ‘medical power of attorney’ and ‘enduring guardian’ are relatively common in relation to patient advocacy. A medical agent is someone chosen by an individual (e.g. a partner, child, good friend who must be over 18 years old) to make medical decisions on behalf of that person in a situation where the individual becomes incompetent (i.e. when an individual lacks decisional capacity). Substituted Judgement Principle A substituted judgment is where an ‘appropriate surrogate attempts to determine what the patient would have wanted in his/her present circumstances.’ The person making the decision should, therefore, attempt to utilize the values and preferences of the patient, implying that the proxy decision maker would need an in-depth knowledge of the patient’s values to do so. Making a substituted judgment is relatively informal in the sense that the patient usually has not formally appointed the proxy decision maker. Rather, the role of proxy tends to be assumed on the basis of an existing relationship between proxy and patient. Difficulties related to this principle include that making an accurate substituted judgement is very difficult and that the proxy might not be the most appropriate person to have taken on the role Advance Directives For individuals wanting to document their preferences regarding future healthcare decisions with the onset of incompetence, there are ‘anticipatory direction’ and ‘advance directive’ forms available. Advance directives can be signed only by a competent person (before the onset of incompetence), and can be either instructional (e.g. a living will) or proxy (the appointment of a person(s) with enduring power of attorney to act as surrogate decision maker), or some combination of both. Advance directives can therefore inform health professionals how decisions are to be made, in addition to who is to make them. Medical Futility Futility is a concept that has widespread use in healthcare ethics guidelines for the cessation of treatment, particularly with reference to ‘do-not- resuscitate’ orders and the withdrawal of lifesaving or sustaining treatment. Treatment is considered futile if it merely preserves permanent unconsciousness or cannot end dependence on intensive health care What Is an Ethical Dilemma? An ethical dilemma exists if there are two (or more) morally correct actions that cannot be followed. The result is that both something right and something wrong occur. In these situations, there are both ethical conflict and ethical conduct issues. The most common ethical dilemmas encountered in critical care are forgoing treatment and allocating the scarce resources of critical care Early Indicators For Ethical Dilemmas Signs of conflict among health care (HC) team members, family members, HC team, and family Signs of patient suffering Ethical and Legal Issues in Critical Care Nursing Signs of nurse distress Signs of ethics violation Signs of unrealistic expectations Signs of poor communication Steps in Ethical Decision Making 1. Identify the health problem. 2. Define the ethical issue. 3. Gather additional information. 4. Delineate the decision maker. 5. Examine ethical and moral principles. 6. Explore alternative options. 7. Implement decisions. 8. Evaluate and modify actions. Ventilators: A ventilator, sometimes known as a “breathing machine,” assists a patient with breathing in part or entirely. Ventilators are used to assist breathing or the lungs’ ability to operate. The device uses a mask that fits snugly or a tube that is placed into the trachea to pressure air into the lungs. To assist the body to receive sufficient oxygen and expel carbon dioxide, this respiratory assistance may be used. ICU patients occasionally require the assistance of a ventilator because they are not alert enough or powerful enough to breathe safely on their own. Monitors: Patients in the ICU who are severely unwell necessitate careful supervision. The “Vital Signs” of several patients in the ICU, which include heart rate and rhythm, blood pressure, and respiration rate, are shown on a computerized monitor. These monitors are visible to the ICU care team from both the main unit desk and the patient’s bedside, enabling them to respond rapidly to any changes that may arise. Dialysis Machines: A dialysis machine, sometimes known as an “artificial kidney,” is a medical procedure used to alleviate this issue, waste and some toxins from the blood in place of the kidneys. A customized IV is inserted into a big vein in the neck or thigh to collect the blood for dialysis. Blood exits the IV, travels through the dialysis unit, gets filtered, and is subsequently reintroduced to the body. Dialysis can replace a portion of the kidneys’ functions, but it typically does not promote kidney recovery after injury. However, the sort of dialysis used for ICU patients is often utilized for brief periods of time, whereas some individuals beyond the hospitals need it for years. IV Pumps: The use of an intravenous catheter is required to provide a large number of the drugs and treatments provided in the ICU into the bloodstream directly (IV). The ICU doctors and nurses can administer these drugs using a programmed IV pump in the form of ongoing stream (infusions) or supplementary dosages (boluses). When an alert goes off, you’ll frequently observe the nursing staff setting doses, attaching medications to IV pumps, and taking care of the patients. Feeding Tubes: Patients who are very unwell and unable to eat can receive nutrients and fluids through feeding tubes. The tube is frequently put into the stomach using the nose (nasogastric or NG tube). The skin may occasionally be used to insert feeding tubes straight into the stomach (gastronomy tube or PEG). Each patient in a serious condition receives the optimum nutrition with the assistance of the ICU dieticians when selecting a liquid food composition. The patient’s stomach is filled with this liquid meal combination utilizing a computerized pump that is inserted into the feeding tube. Crash Cart: A crash cart must be used in an ICU when a patient’s condition suddenly deteriorates. Many facilities, such as hospitals, ambulatory surgical centers, emergency care centers, etc., have crash carts accessible. Equipment and medications are both included in a crash cart. It is a crucial piece of equipment, and the cart also has other tools. Namely: IV start packs with bag valve masks Angiocaths, IV tubing, and gauze preparing alcohol Defibrillator and monitor Nasal syringe adapter The training of the cart is listed on a checklist. ECG Electrodes: The electrocardiogram (ECG) is a graph that shows the timing of a person’s cardiac electrical activity.. They identify a cardiac cycle’s electrical activity. The self- adhesive circular patches and the thin paper stickers are the two electrode types that are most frequently utilized Urine Catheter: The discharge of urine is collected using this specific piece of equipment. Using this, the staff assesses the patient’s steadiness and overall health for additional medical purposes.  Tubes used in ICU 1. Nasogastric Tube: In critical care, a nasogastric tube is the most typical form of feeding tube utilized. The nurse or doctor inserts these lengthy, thin tubes into the patient’s nose, down the esophagus (the food pipe), and then into the stomach. 2. Intravenous feeding: If the feeding cannot be absorbed through the stomach, sustenance is given via a central line inserted into the veins. Since there is a possibility of infection and stomach feeding is more physiological, this approach is typically not the preferred option for feeding. 3. Nasojejunal tube: A nasojejunal tube may be implanted if there are issues with the nasogastric tube as a result of feed intake. These tubes resemble nasogastric tubes, except the jejunum—a portion of the small intestine— instead of the stomach—is where the tube’s head is located. 4. Percutaneous endoscopic gastrostomy (PEG) tube: The skin of the abdomen is penetrated to introduce a PEG tube into the stomach. These tubes are placed if the patient requires nourishment for an extended period of time or poses a high danger of aspirating food particles into the lungs. Ventilators – The Breath of Life Defibrillators – Shocking the Heart Back to Rhythm Defibrillators are the last line of defense against life- threatening cardiac 🫀 rhythms. They deliver a controlled electric ⚡️shock to reset the heart’s rhythm. They are able to do this because the device can read the electrical activity of the patient’s heart. Pads are placed on the patient, an energy level is selected (this depends on the situation), and a shock is delivered to the patient. Defibrillators can both shock a patient’s heart and also provide cardiac monitoring during urgent/emergent situations. Hemodialysis Machines – Filtering Life Hemodialysis machines are lifelines for patients with kidney failure. They filter waste products from the blood, maintaining electrolyte balance. These may be referred to as a “dialysis machine” by patients and/or loved ones. A special tube is used to connect these devices to the patient, often referred to as a “dialysis catheter” that must be inserted by a specialist (this isn’t something a nurse does) directly into the blood vessels. There are two types of hemodialysis machines: A continuous renal replacement (CRRT) and intermittent hemodialysis. There is a third type, peritoneal dialysis (PD). However, this is most often used in the pediatric patient population, and studies evaluating PD vs. CRRT in the adult ICU population showed CRRT to be much more effective and have a significantly lower mortality rate. Tips for Nurses with Hemodialysis Monitor closely for signs of hypotension and hypoglycemia Understand the anticoagulation protocol for CRRT. Monitor activated partial thromboplastin time (aPTT) or other relevant parameters as per protocol. Frequent Lab Monitoring: Check electrolytes, blood gases, and other relevant labs as per protocol. Adjust CRRT parameters based on results. Prevent Complications: Monitor for potential complications such as circuit clotting, air embolism, or access site infection. Prevent Hypothermia: Patients on CRRT may be at risk for hypothermia due to exposure to room-temperature replacement fluids. Keep the patient warm Top Medications Given in the ICU Sedatives Sedatives are drugs that are used in the ICU to enable patients to endure certain procedures or remain calm. When administered, patients slowly close their eyes and appear to be sleeping. Medical professionals are then able to do certain invasive things that the patient would be unable to tolerate otherwise. Some common sedatives used in the ICU include: Propofol – ventilator always required Midazolam Dexmedetomidine These medications are often administered by an ICU nurse as a drip. The physician will order the medication and the ICU nurse will give it in a patient’s vein through a normal IV catheter or a central venous catheter. Pain Medications Pain is a common symptom for many ICU patients. Pain medications are used to help manage pain and keep patients comfortable. Please note, sedatives are not the same as pain medications. Some common pain medications used in the ICU include: Morphine Fentanyl Hydromorphone Ketamine Acetaminophen The ABCDEF Bundle in Critical Care The ABCDEF bundle helps guide well-rounded patient care and optimal resource utilization resulting in more interactive ICU patients with better controlled pain, who can safely participate in higher-order physical and cognitive activities at the earliest point in their critical illness. Assess, Prevent, and Manage Pain, Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT), Choice of analgesia and sedation, Delirium: Assess, Prevent, and Manage, Early mobility and Exercise, Family engagement and empowerment Vasopressors Vasopressors are one of the common ICU medications that are used to increase blood pressure in patients with hypotension. While the choice of drug depends on the cause and situation at hand, often physicians will order that patients get IV fluids first before starting vasopressors Some common vasopressors used in the ICU include: Norepinephrine Epinephrine Vasopressin Antibiotics Antibiotics are used to treat infections in the ICU. Patients may present to the ICU with an active infection, or they may acquire one while in the ICU. Patients in the ICU are at increased risk for infections due to the use of invasive devices such as central venous and urinary catheters, ventilators, and any other invasive devices. Some common antibiotic medications used in the ICU include: Vancomycin Meropenem Piperacillin-tazobactam