Module 1 Introduction to Critical Care Nursing PDF

NCM 118 UNIVERSITY OF THE EAST RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER LECTURER: PROF. CHRISTY B. VERDIDA OUTLINE Substance abuse I. “A healthca...

NCM 118 UNIVERSITY OF THE EAST RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER LECTURER: PROF. CHRISTY B. VERDIDA OUTLINE Substance abuse I. “A healthcare system driven by the needs of patients and their INTRODUCTION OF CRITICAL CARE NURSING families in which critical care nurses make their optimal contribution.” - American Association of Critical Care Nurses (AACN) SCOPE OF CRITICAL CARE PRACTICE Development of Critical Care Practice Education and CURRENT TREND RELATED TO CRITICAL NURSING Professional Activities in the Philippines Critical Care Nursing Critical care body of knowledge specialty/area in nursing that aims to promote highly ○ Critical care competencies specialized and excellent care ○ Professional organization ○ There are qualification and experience HISTORICAL BACKGROUND OF CRITICAL CARE NURSING STANDARD IN CRITICAL CARE NURSING 1800 1:1 or 1:2 Ratio ○ Advantages of placing patients recovering Nurse to patient ratio because the patient requires from surgery in a separate area of the constant attention hospital Expect a lot of contraption, monitor and Q15/Q30 ○ Florence nightingale (modern nursing monitoring to the patient theorist) inspire the nursing community as well as the midwifery 37% Nurse working in hospital settings ae critical care 1900 nurses ○ Three-bed-post-operative neurosurgical intensive care unit in Baltimore Premature High pay infant unit in Chicago 55 USD hourly mean wage rate ○ World war II - Shock wards for critically injured patients WHAT ARE THE SKILLS NEEDED FOR THE NEXT 1950 CENTURY? ○ New mechanical ventilation technology and Critical thinking skills the need to group patients receiving this new Is used in analyzing client issues and problems. therapy in one location, less than 60 years Thinking skills include interpretation, evaluation, ago Critical Care Nursing was organized as a inference, and explanation. specialty. Guide clinical decisions, in the application of nursing process to patient care. 1960 ○ Critical and intuitive knowledge (the nurse ○ Focused on coronary care, nephrology, and know the need of the patient) is needed intensive care Collaborative skills 1965 Implies shared attention to a problem in which the ○ 1st specialty coronary care unique talents and contributions of all parties are Neurologic considered. Respiratory ○ Multidisciplinary interprofessional - working Surgical with the MD depending on the specialization, Burn nutritionist, and other health care provider in Pediatric the hospital Neonatal ○ Nursing educator - coordinator of care 1970s-1980s Delegation ○ The impact of the shortage of CCN was Process of transferring the authority and responsibility notable to another team member to complete a task while ○ Lot of our fellow go to different countries as retaining the accountability early as 1970s ○ Leadership and management skills are needed 1990s 5 rights of delegation ○ Increased demand for skiles critical care 1. Risk task nurses ○ What has the nurse delegate to the other AIDS is pandemic RN? Most of the Filipino nurses ○ Repetitive and doesn’t need to much go to different country due supervision to fear of AIDS ○ E.g. Monitoring of the vital signs Trauma FIRST SEMESTER | PRELIMS 1  2. Right circumstances ○ Is a specialty certification for nurses issued ○ Health status and complexity of care and by AACN who provide direct care to acutely what it demands to the skills of the team ill or critically ill patients member Requirements for Eligibility 3. Right person Practicing RN or APRN ○ Know thy people US-based facility/standard (acute/critical care nursing) ○ Assess and verify the competency and must Complete 2000 hours of direct care be in the scope of a person’s practice Passed the CCRN examination 4. Right direction/communication WHAT ARE THE AREAS IN CRITICAL CARE NURSING? ○ Orally or by writing Critical care units ○ Expectation for the nursing aid to do the task Job prospects and employment setting in critical care nursing specialities 5. Right supervision/evaluation ○ Due to retaining the accountability Units/areas/department ○ Know how to troubleshoot ○ ICU ○ DO NOT DELEGATE A TASK YOU CANNOT ○ CCU TROUBLESHOOT ○ Cath lab ○ Neuroward Computer skills ○ Step Down units - (ICU to Private room) Computers are used to document patient care, to monitor physiologic data and to manage patient information. INTENSIVE CARE UNITS (ICU) Also known as Critical care units (CCU) Intensive therapy/treatment unit (ITU) WHO ARE THE PATIENTS WHO GO TO CRITICAL CARE NURSING UNITS? Definition (The Medical City, 2021) Patients who are at risk for actual or potential life-threatening Special area in the hospital that provides the highest health problems. They require need for intensive and vigilant level of care to patients needing extensive monitoring care and intensive specialized care Following patients ○ Unstable CORONARY CARE UNIT E.g. stroke patient with Also known as telemetry unit, cardiac care unit (CCU), cardiac manifestation of hypertension and intensive care unit (Cardiac ICU) headache ○ Critically ill Definition (Manila Doctors Hospital, 2021) Kidney disease An ICU is mainly for patients with cardiac disorders Status asthmaticus ○ Injured Example: coronary bypass surgery, heart failure Traumatic injury Gunshot px Main feature: comprehensive coronary care ○ Complex Procedures: availability of telemetry (way to monitor vital signs ○ Life-threatening conditions remotely), cardiac rhythm monitoring (ECG), cardioversion, defibrillation THE PATIENT ACCORDING TO NHS UK, MOST COMMON CARDIAC CATHETER LABORATORY REASONS/ CONDITIONS required intensive care and Also known as Cath lab treatment Severe accident Definition (UP Duke Health System, 2021) Heart attack Performs cardiovascular diagnostic imaging Cardiac attack procedures Stroke Performs specific minimally invasive advanced cardiac Head injuries interventional procedures OTHERS: burns, shock, MODS Procedure: Angiogram, angiography, angioplasty (PTCA), intra WHAT ARE THE REQUIREMENTS NEEDED TO BECOME aortic balloon pump, Swans Ganz catheter Pacemaker A CRITICAL NURSE insertion/implantation Basic requirements NEUROLOGY ICU 1. Nursing degree program Also known as the neurology ward, the acute stroke unit 2. Active license (PH, US) 3. ACLS certification Definition (UP Duke Health System, 2021) 4. Experience with other units An icu/ward devoted to the care of patients with 5. IV therapy certification immediately life-threatening neurological problems/disorder Critical Care RN Hospital units take care of stroke patients for diagnosis, treatment, and rehabilitation FIRST SEMESTER | PRELIMS 2  STEP DOWN UNITS Quick assessment and vigilance is Also known as neurology ward, acute stroke unit very important The patient is improving Respond Respond to the unique needs of clients and families coping with unanticipated treatment as well as Intermediate care care units quality-of-life and end-to-life Provide intermediate level of care for patients with decisions illness severity not warranty icu care but who are Establish and maintain Establish and maintain safe, unstable enough to be treated in the wars respectful, healing and caring environment Transition units: transition care between icu and general MS ward/regular floor Patients: close monitoring, frequent assessment, serious, less ACUTE CRITICAL CARE NURSING critical injuries (Prin, 2014) Recognize the fiscal responsibility of nurses working in a STEP UP: Higher level of care for patients deteriorating in a resources intensive-driven environment ward STEP DOWN: Lower level of care for patients transitioning out of Use health care interventions designed to restore, rehabilitate, ICU cure, maintain, or palliate for clients of all ages across the lifespan WHAT ARE THE EQUIPMENT NEEDED IN CRITICAL CARE UNITS? The AACN defines acute and critical care nursing as the specialty that manages human responses to actual or potential CRITICAL CARE NURSING UNIT BASIC SETUP life-threatening problems The Medical City, 2021 ↓ Multiparameter physiological monitor linked with Nurses rely in a body of knowledge, skills and abilities to: sophisticated centralized monitoring system Restore, support, promote, and maintain the physiologic and psychosocial stability of clients Services Continuous monitor ○ Ecg AMERICAN ASSOCIATION OF CRITICAL CARE NURSE ROLE ○ Arterial pressure Monitor and safeguard the quality of nursing care that the patient ○ Oxygen receives and act as a liaison between the patient and the Invasive monitor patient’s family. ○ Arterial ○ Venous CRITICAL CARE NURSING STANDARD ○ Intra abdominal It describes the practice of the nurse who cared for acutely or ○ Intracranial critically ill patients in the healthcare environment. CRITICAL CARE TEAM CRITICAL CARE NURSES OF THE PHILIPPINES INC. The team consist of CCNAPI is the national organization of nurses interested in the Advanced practice nurses (APNs) field of critical care nursing Nurse practitioners (NPs) and other specialty clinicians Pharmacist It was founded in February 1977 with approved SEC registration Respiratory therapist (CN 200813601), a founding member of the World Federation of Social worker Critical Care Nurses (2001) and accredited as a Provider of Clergy Continuing Professional Education by the Professional Regulation Commission (Provide Number 2009-019 CRITICAL NURSING ROLES Expanded role nursing positions AACN- created in 1969 - largest specialty organization They seek to provide comprehensive care to the client. Focused on “creating a healthcare system driven by Relate to role expansion within nursing in general and the need of clients and their families, where acute and more specifically to critical care nurses critical care nurses make their optimal contribution” ○ We are the coordinator of care, leader, counselor CRITICAL CARE PROFESSIONAL ACCOUNTABILITY Critical Care Nurses Association of the Philippines, Inc. Advanced practice nurses (CCNAPI) Advanced critical care practitioners (ACCPSs) are clinical professionals who have developed their skills Critical care nursing practice is based on a scientific body of and theoretical knowledge to a very high standard knowledge and incorporates the professional competencies ○ Coordinate the care as a student nurse specific to critical care nursing practice and is focused on restorative, curative, rehabilitative, maintainable, or palliative Assimilate and prioritize Assimilate and prioritize information care, based on identify patients needs in order to take immediate and decisive evidence-based, CRITICAL CARE IN THE PHILIPPINES client-focused action Critical Care Nurses Association of the Philippines, Inc. Anticipate and respond Anticipate and respond with (CCNAPI) confidence and adapt to rapidly changing client conditions In the Philippines, the Professional Regulation Commission - Board of Nursing (PRC-BON) is committed to provide need- driven, effective and FIRST SEMESTER | PRELIMS 3  efficient specialty nursing care services of high Demonstrating knowledge and understanding of standard and at international level within the obtainable different cultures resources. Accepting that there may be differences between the cultural beliefs and values of the health care provider To respond to this mission and commitment, a and the client PRC-BON Working Group in Developing the Nursing Specialty Framework was formed in 1996 to take on CULTURALLY COMPETENT CARE the task of setting the process- based framework and Cultural perspectives on death and dying and death are complex guidelines for specialty nursing services. View of a discussion of advance directives as a legal device to The expanding healthcare and nursing knowledge deny care together with new and evolving healthcare sites, structures, and technologies all have contributed to the COMPLEMENTARY AND ALTERNATIVE THERAPIES need and desire for specialty nursing organizations like Guided imagery the Critical Care Nurses e Association of the ○ Benefits Philippines, Inc. (CCNAPI) to revisit the existing Decreases side effects statements of its Standards of Nursing Practice to Decreases length of stay provide clear and updated statements regarding the Reduced hospital cost scopes of practice and standards of critical care Enhanced sleep nursing Increases satisfaction Massage This will ensure continued understanding and Animal-assisted therapy acknowledgment of nursing's varied specialty Music therapy professional contributions healthcare environment HOLISTIC CRITICAL CARE NURSING PHILOSOPHY OF CRITICAL CARE NURSING Cultural care The expanding healthcare and nursing knowledge Individual care together with new and evolving healthcare sites, a. Assess correctly the preferences of the px structures, and technologies all have contributed to the Caring need and desire for specialty nursing organizations like a. The px will know if you are not paying the Critical Care Nurses Association of the Philippines, attention and complain due to dissatisfaction Inc. (CCNAPI) to revisit the existing statements of its of care Standards of Nursing Practice to provide clear and Complementary and alternative therapies updated statements regarding the scopes of practice a. Animal-assisted therapy and standards of critical care nursing ISSUES RELATED TO CAREGIVER This will ensure continued understanding and Role: Client care acknowledgment of nursing's varied specialty They contribute to the client’s well-being by: professional contributions healthcare environment a. Providing a link to the client’s personal life b. Advising the client in health care decisions or The Critical Care Nurses of the Philippines, Inc. functioning as the decision maker when the (CCNAPI) is responsible for the promotion of man's client cannot health and welfare for national development. c. Helping with activities of daily living (bathing, suctioning) It desires to support the professional and personal d. Providing positive, loving, and caring support growth and development of initial core nurses. CLIENT-CENTERED CRITICAL CARE CCNAPI has organized itself into a national The critical care unit is a stressful environment for association committed to the ideals of service to the clients and for their family members with the people, equality, justice and social progress understanding that family is whomever the client designates to be at their bedside HOLISTIC CARE NURSING CCU - because of number of alarms, 24/7 routines, unfamiliar environment, ad often an uncertain Caring Aspect between nurses and clients is most prognosis fundamental to the relationship and to the health care experience Non-caring Is indicated by physical and emotional absence, inhumane and belittling interactions, and lack of recognition of the client’s uniqueness. Holistic care Focuses on human integrity and stresses that the body, the mind, and the spirit are interdependent and inseparable CULTURAL AND LINGUISTIC COMPETENCE FOR NURSES Nurses should demonstrate cultural competence by: Developing an awareness of one’s culture without letting it have an undue influence on those from other backgrounds FIRST SEMESTER | PRELIMS 4 Provider and patient factors influencing medication safety The second – Guide to good prescribing: a practical manual can relate to either the health care professional providing – is a learning resource which uses case scenarios to outline care or to the patient being treated. the principles of selection of first-line medications, followed by a step-by-step overview of the process of rational 3.1 Health care professionals treatment (98). Even the most dedicated health care professional is fallible Several studies indicate that training, experience and and can make errors (93). The act of prescribing, dispensing practice help to reduce prescribing errors by hospital doctors and administering a medicine is complex, normally involving (99, 100). However, there is no room for error during several health care professionals, with the patient prescribing and thus it is important to train future doctors in necessarily being a part of, and in the centre of, what should the science of prudent prescribing, as rightly highlighted by be a “prescribing partnership” (Figure 5). Patients should Woods (101). This is so that prescribers are competent to expect that the health care professionals responsible for their provide accurate and appropriate prescriptions upon care will communicate directly with them as well as with each graduation. This approach may also be adopted in relation to other (94). In broad terms, the prescribing process involves non-medical prescribers in countries where it is applicable. the prescriber in deciding whether any particular medication or combination of medications is indicated. Whenever Health care professionals are also involved in ensuring safe feasible, the expected benefits and possible risks should be storage, preparation, dispensing, administration and discussed with the patient, following which the appropriate monitoring of medications. These different steps of the dose and duration of the chosen medication should be medication use process are no longer the sole domain of any prescribed, dispensed and then administered to the correct single health care professional group. However, it is vital that patient. there is good communication between different groups of health care professionals. Interprofessional educational Errors most commonly occur during the administration step initiatives may help health care professionals to learn to work of the medication use process, but can occur at any time, better together in multidisciplinary teams to promote patient including: storage, prescription, preparation, dispensing and safety. Certainly communication problems within and monitoring (95). between health care professionals, and between them and their patients, are often major factors predisposing to Poor prescribing has been described to take three forms prescribing errors (100), as well as other errors involving (96): dispensing and administration. Overprescribing occurs when a medication is prescribed whose risk of harm exceeds its likely Resource-limited settings are often characterized by a lack of benefit (overall or relative to another medication) in electronic support systems for prescribing or dispensing, a particular individual. Thus, every prescription overcrowding of patients, staff shortages and inadequate requires the exercise of good prescribing skills to monitoring. In such circumstances poor prescribing assess individual risk–benefit practices, such as the use of error-prone abbreviations, Underprescribing occurs when a medication is not increase the risk of medication errors. prescribed whose likely benefit greatly exceeds the risk of harm. The acquisition of sound therapeutic Different health care professionals may elicit different knowledge and skills by the prescriber is the key to information about a patient’s medication history. The optimal minimizing this risk. medication histories are often achieved through proper Misprescribing occurs when either the wrong training of workforce and use of appropriate tools. In one medication is prescribed or the wrong dose, route, study in an emergency department, physicians omitted frequency or duration of administration is chosen. It medicines or doses more often in comparison with their may occur as part of a medication error. pharmacist colleagues, probably because the latter used a structured form to collect the information (102). Differences All of these forms of potentially inappropriate prescribing can in obtaining a medication history may also occur between contribute to an unfavourable risk–benefit ratio, and reduce, specialties within a single health care profession. In one or even negate, the benefits of these medications to the study, hospitalized patients, over 65 years of age, being patient. Poor medication adherence (see Annex 1) may also treated by internal physicians were more likely to receive result in failure to benefit from the prescribed medication. neuroleptic agents for long-term hypnotic use than those However, avoidance of harm is only one aspect of treated by geriatricians (103). appropriate prescribing. It is important that the right medicine reaches the right patient. In addition, significant health care 3.2 Patients costs can be avoided by using medicines more appropriately, thus achieving better and more cost-effective health care. It is well known that adverse drug events occur most often at These aspects of care are highlighted in two informative the extremes of life (in the very young and in older people). WHO publications. The first – The pursuit of the responsible In older people, it is the group of frail patients who are likely use of medicines: sharing and learning from country to be receiving several medications concomitantly, adding to experiences – highlights examples of how certain countries the risk of adverse drug events. In addition, the harm of have positively addressed specific important areas of some of these medication combinations may sometimes be prescribing (97) synergistic and be greater than the sum of the risks of harm of the individual agents. In neonates (particularly premature neonates), elimination routes through the kidney or liver may FIRST SEMESTER | PRELIMS 5 not be fully developed (104). In children as well as in older recipients, clinically significant medication errors (defined as persons, the impact of any resulting harm may be much those that contribute to hospital admission) were associated more serious. The very young and those of old age are also with more post-transplant readmissions, significantly higher less likely to tolerate adverse drug reactions, either because costs for those readmissions, overall length of stay, and risk their homeostatic mechanisms are not yet fully developed of graft failure (109). (e.g. in the young, especially neonates and infants) or may have deteriorated (e.g. in older people). Therefore it is likely In a study of 50 people with liver disease (in this case that outcomes involving high-risk (high-alert) medications will cirrhosis), 27 (54%) had one or more discrepancies between be more severe in these groups. what the patient reported they were taking and their medical record. These discrepancies were more common in older Medication errors in children, where doses may have to be patients, those who were on five or more conventional calculated in relation to body weight or age, are a source of medications, or those having a low to medium adherence major concern. ranking. Concordance between the two lists was lowest for respiratory medicines (0%), and complementary and Prescribing errors resulting from miscalculations have been alternative medicines (14.5%) (110). reported in a paediatric intensive care setting (105). In the PRACtICe study in primary care, the risk of medication errors 3.3 Strategies to reduce medication errors related to was greater in those below the age of 15 years and in those provider and patient factors aged over 64 years (40). Health care professionals Age also appears to be a major predictor of the risk of James Reason has noted that there should be a systems medication errors among older people. In a study of more approach to counter the effects of human fallibility. This than 1400 adult inpatients, 26% of whom experienced at approach concentrates on the conditions under which people least one clinically significant medication error; age and the work and endeavours to build the defences required to avert number of prescribed medications were the two major errors or limit their effects (93). The Clinical Human Factors predictors of the risk of experiencing a medication error Group has identified four major themes – design, teamwork, (106). Sears et al. showed that self-reported medication incident investigations, and working in the real world – that errors were more likely in females than males (107). are important components of a resilient systems approach to safety, and these can be usefully applied to medication Polypharmacy safety (111). The number of prescribed medications was the second major factor predicting risk of experiencing a medication error in Education adult inpatients (106). The risk of medication (prescribing or The importance of safe medication practice should be monitoring) errors in the PRACtICe study was related to the conveyed at an early stage in training of health care number of unique medication items prescribed, reinforcing professionals, and embedded in training curricula. WHO has the important contribution of polypharmacy to the increased developed a set of evaluation tools designed to complement risk of harm (40). the WHO Patient safety curriculum guide for medical schools, published in 2009 (112). Within the first two years of Multimorbidity its circulation, the guide had been implemented in curricula Multimorbidity (see Annex 1) is becoming more prevalent as around the world. A multiprofessional version of the guide life expectancy increases in many countries around the was subsequently produced in 2011 for students of dentistry, world. A meta-analysis that included 75 studies from primary medicine, midwifery, nursing and pharmacy (113). care demonstrated that mentalphysical multimorbidity was associated with an increased risk for “active patient safety As more groups of health care professionals are embracing incidents” and prescribing errors (108). the role of prescribers, they should be made aware of the importance of establishing an accurate medication history, High-risk medical conditions covering both prescribed (conventional and/or traditional and Certain medical conditions predispose patients to an complementary medicines) and non-prescribed medications increased risk of adverse drug reactions, particularly renal or (including self-prescribed, over-the-counter, food hepatic dysfunction and cardiac failure (where both kidney supplements, and traditional and complementary medicines). and liver can be compromised together). In part this is Similarly, a history of allergy to any previous medication because the liver and kidney are the two main organs should be elicited. Interprofessional education in this area involved in the metabolism and excretion of medications from can be used to improve communication within different the body, so if the normal doses of a certain medication are professional teams. used during liver or kidney failure, dose-related ADRs (type A reactions) may occur. Hepatic and renal diseases are often Core prescribing competencies are relevant to all the also chronic conditions in which polypharmacy is common, prescribing health care professionals who are faced with and this can predispose patients to drug–drug interactions or addressing the increasing burden of complex polypharmacy drug–disease interactions. Other conditions that predispose among people with multimorbidity (114). Several studies people to a high risk of medication-related harm include have shown that training using the WHO Guide to good pregnancy and poor hydration status (98). prescribing (98) was associated with increased prescribing competency in a wide range of settings (115). In the United Medication errors may lead to significant harm in patients Kingdom, a prescribing safety assessment has to be passed with renal disease. In a study of 200 renal transplant to ensure that all new medical prescribers, whether trained in FIRST SEMESTER | PRELIMS 6 the United Kingdom or elsewhere, meet a similar basic disabilities, including (but not only) in the hospital (121). prescribing standard before they begin clinical practice Caregivers also have an important role and can make similar (116).Prescribing, dispensing, administration and monitoring errors to those made by professionals (122). of medicines should be the subject of audit and clinical review by health care professionals, and consideration may be given to those using resources emphasizing medication safety as part of clinical revalidation or relicensing. Medication reconciliation Prescribing errors often occur at transitions of care. Pharmacy-led medication reconciliation on hospital admission may also have economic benefits (117). Patients Many of the patient factors discussed earlier (e.g. age, multimorbidity) are relatively static. Patients should be supported by an effective prescribing team working in close partnership to ensure they are aware of the purpose of all medications taken, their likely benefits and potential risks (94). Useful aide-memoire tools for patients are available, such as 5 questions to ask about your medications when you see your doctor, nurse, or pharmacist (118) and 5 Moments for Medication Safety (119): The 5 Moments for Medication Safety is a patient engagement tool developed to support implementation of the third WHO Global Patient Safety Challenge: Medication Without Harm. It focuses on 5 key moments in the medication use process, where action by the patient, family member or caregiver can greatly reduce the risk of harm associated with the use of medications. The five moments are: starting a medication, taking my medication, adding a medication, reviewing my medication and stopping my medication. Each moment, in turn, includes 5 critical questions, some of them being self-reflective for the patient and some requiring support from a health professional to be answered and reflected upon correctly (119). Application of the 5 Moments for Medication Safety tool may vary depending on the country or local context and specific setting. It may be applied in targeted population groups (for example, older people, children, pregnant and breastfeeding women) or in targeted patient groups (for example, patients with chronic conditions, cancer or mental health conditions). It is important to highlight that principles of co-production of resources and partnership with patients and caregivers should be applied in relation to developing systems for all the guidance for high-risk (high-alert) medications discussed earlier. Medication Safety, Standard 4, developed by the Australian Commission on Safety and Quality in Health Care states that the patient should be provided with patient-specific medication information that includes treatment options, benefits and associated risks (50). The format of the information provided should meet the needs of patients and caregivers while being easily understandable. Finally, the medication plan should be discussed with the patient and the patient should agree to follow that plan, with the emphasis on joint decision-making. Limited language proficiency, lower levels of education and misperceptions of illness severity are more likely to lead to patients having reduced knowledge regarding their prescribed medications (120). It is also important to recognize the particular needs of people with intellectual FIRST SEMESTER | PRELIMS 7