Introduction-to-CCN.pdf

Nursing Care of Clients with Life- Threatening Conditions, Acutely Ill / Multi- Organ Problems, High Acuity and Emergency Situation  Objectives Analyze the key components of providing safe, effective care in a critical care setting. Describe the critical care nurse's fundamental character...

Nursing Care of Clients with Life- Threatening Conditions, Acutely Ill / Multi- Organ Problems, High Acuity and Emergency Situation  Objectives Analyze the key components of providing safe, effective care in a critical care setting. Describe the critical care nurse's fundamental characteristics and position within the multidisciplinary team. Analyze the multidisciplinary nature of care in the intensive care unit. Demonstrate an understanding of the ethical and legal issues that arise in critical care. Prepare nursing responses to the most often expressed concerns of critically sick patients. Describe nursing interventions that address some of the most fundamental physiological demands of critically ill patients. Discuss strategies for identifying and meeting the needs of critically sick patients' relatives. What is Critical Care Nursing? The delivery of specialized care to critically ill patients—that is, ones who have life- threatening illnesses or injuries.  What is Critical Care Nursing? To be considered critical, an The delivery of specialized illness or injury must acutely care to critically ill patients— impair one or more vital that is, ones who have life- organ systems to such a threatening illnesses or degree that there is a high injuries. probability of life-threatening deterioration. - Perrin and McLeod, 2018  A nursing care that… Reflects a holistic approach in caring of patients. Places great emphasis on the caring of the bio-psycho-social- spiritual nature of human beings and their responses to illnesses rather than the disease process. Helps maintain the individual patient’s identity and dignity. The focus of caring includes preventive care, risk factor modification and education to decrease future patient admissions to acute care facilities. The framework of critical care nursing is a complex, challenging area of nursing practice. It utilizes the nursing process applying assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The critical care nursing practice is based on a scientific body of knowledge and incorporates the professional competencies specific to critical care nursing practice and is focused on restorative, curative, rehabilitative, maintainable, or palliative care, based on identified patient’s need. Professional Regulation Commission – Board of Nursing (PRC-BON) -committed to provide need-driven, effective and efficient specialty nursing care services of high standard and at international level within the obtainable resources. PRC-BON Working Group in Developing the Nursing Specialty Framework was formed in the 1996 -take on the task of setting the process-based framework and guidelines for specialty nursing services.  revisited the existing Standards of Nursing Practice to provide clear and updated Critical Care statements regarding the scopes of practice Nurses and standards of critical care nursing. 11 Core Competencies for Entry Level for Association of Safe and Quality Nursing Care the he CCNAPI Core Competencies of a Critical Care Nurse are stated according to the Philippines, levels of expected behavior defining the Inc. (CCNAPI) actual knowledge, skills and abilities in the practice of critical care by a nursing professional.  is responsible for the promotion of man’s health and welfare for national Critical Care development. Nurses It desires to support the professional Association of and personal growth and development the of initial core nurses. CCNAPI has organized itself into a national Philippines, association committed to the ideals of Inc. (CCNAPI) service to the people, equality, justice and social progress.  The International Council of nurses (ICN) views health care as the rights of every individual regardless of financial political, geographical, racial and religious THE RIGHT consideration. This right includes the right to choose or decline care, including the right to accept or refuse OF THE treatment or nourishment; informed consent; confidentiality and dignity, including the right to die CRITICALLY with dignity. It involves both the right of those seeking care and the providers. ILL PATIENT The World Federation of Critical Care Nurses (WFCCN) has considered the rights of the critically ill patients, WFCCN has agreed that the statement of the patient’s right from the ICN covers the requirement for position statement on the rights of the critically ill patients.  To promote optimal delivery of safe and quality care to the critically ill patients and their families by providing highly individualized care so that the physiological dysfunction as well as the psychological stress in the ICU are under control; To care for the critically ill patients with a holistic approach, considering the patient’s biological, psychological, cultural and spiritual dimensions regardless of diagnosis or clinical setting; Goals of Critical To use relevant and up-to-date knowledge, caring attitude and clinical skills, supported by appropriate Care Nursing technology for the prevention, early detection and treatment of complications to facilitate recovery. (CCNAPI, 2014) To provide palliative care to the critically ill patients in situations where their health status is progressing to unavoidable death, and to help the patients and families go through their painful sufferings. Common Cases in Critical Care Units Traumatic injuries from such events as automotive collisions, falls, gunshots Cardiovascular disorders, such as heart failure and acute coronary syndromes (unstable angina and myocardial infarction [MI]) Surgeries, such as abdominal aortic aneurysm repair and carotid endarterectomy Respiratory disorders, such as acute respiratory failure and pulmonary embolism GI and hepatic disorders, such as acute pancreatitis, acute upper GI bleeding, and acute liver failure Renal disorders, such as acute and chronic renal failure Cancers, such as lung, esophageal, and gastric cancer Shock caused by hypovolemia, sepsis, and cardiogenic events (such as after MI) Levels of Care (CCNAPI, 2014)  Levels of Care (CCNAPI, 2014) Should be capable of providing a high standard of general critical care for patients who are stepping down from higher levels of care or requiring single organ support/support post- operatively; Capable of providing sustainable support for mechanical ventilation, renal replacement therapy, invasive hemodynamic monitoring and equipment for critically ill patients of various specialties such as medicine, surgery, trauma, neurosurgery, vascular surgery; Has a designated medical director with appropriate intensive care qualification and a duty specialist available exclusively to the unit at all times; The nurse in-charge and a significant number of nursing staff in the unit have critical care certification; and A nurse: patient ratio is 1:1 for all critically ill patients.  Is a tertiary referral unit, capable of managing all aspects of critical care medicine (This does not only include the management of patients requiring advanced respiratory support but also patients with multi-organ failure); Has a medical director with specialist critical / intensive care qualification and a duty specialist available exclusively to the unit and medical staff Levels of with an appropriate level of experience always Care present in the unit; (CCNAPI, A nurse in-charge and most nursing staff have 2014) intensive care certification; and A nurse: patient ratio is at least 1:1 for all patients at all times. The Critical Care Environment  Also known as Intensive Care Unit (ICU) or Intensive Treatment Unit (ICU) A special department of the hospital or healthcare facility that provides intensive care medicine Caters to patients with severe or life- threatening illnesses and injuries, which require constant care, close supervision from life support equipment and medication in order to ensure normal bodily functions. Staffed by highly trained physicians, nurses, respiratory therapists and other members of the healthcare team who specialize in caring for critically ill CRITICALCARE UNIT(CCU) patients Categorization of CCU By Age Group Open System The admitting and other attending Neonatal doctors make Pediatric decisions without Adult consulting or communicating with By Specialty a Critical Care Specialist. Medical Respiratory Surgical Neurosurgical Closed System Cardio-thoracic Trauma Patient care is Cardiac provided by a By System Operation dedicated ICU Open System team that includes a Closed System critical care physician. What to expect in the ICU? Critically ill patients with various attachments and monitoring devices Common equipment in an ICU include: mechanical ventilators to assist breathing through an endotracheal tube or a tracheostomy tube cardiac monitors for monitoring Cardiac condition; Other devices for the constant monitoring of bodily functions A web of intravenous lines, feeding tubes, nasogastric tubes, suction pumps, drains, and catheters, syringe pumps A wide array of drugs to treat the primary condition(s) of hospitalization.  are registered nurses, who are trained and qualified to practice critical care Critical nursing. They possess the standard critical care Care nursing competencies in assuming specialized and expanded roles in caring Nurses for the critically ill patients and their family. personally responsible and committed to continuous learning and updating of his/her knowledge and skills.  A critical care nurse is a licensed professional Roles of Critical nurse who is responsible for ensuring that acutely and critically ill patients and their Care Nurses families receive optimal care. Care Provider A. Direct patient care Detects and interprets indicators that signify the varying conditions of the critically ill with the assistance of advanced technology and knowledge; Plans and initiates nursing process to its full capacity in a need driven and proactive manner; Acts promptly and judiciously to prevent or halt deterioration of patients’ condition when conditions warrant, and Coordinates with other healthcare providers in the provision of optimal care to achieve the best possible outcomes. A. Indirect patient care – Care of the Family Understands family needs and provide information to allay fears and anxieties Assists family to cope with the life-threatening situation and/or patient’s impending death.  A critical care nurse is a licensed professional Roles of Critical nurse who is responsible for ensuring that acutely and critically ill patients and their Care Nurses families receive optimal care. Extended roles as critical care nurses Critical care nurses have roles beyond their professional boundary. With proper training and in accordance with established guidelines, algorithms, and protocols that are continuously reviewed and updated, critical care nurses also perform procedures and therapies that are otherwise done by doctors. Such procedures and therapies are: a. Sampling and analyzing arterial blood gases; b. Weaning patients off ventilators; c. Adjusting intravenous analgesia / sedations; d. Performing and interpreting ECGs; e. Titrating intravenous and central line medicated infusion and nutrition support; f. Initiating defibrillation to patient with ventricular fibrillation or lethal ventricular tachycardia; g. Removal of pacer wire, femoral sheaths and chest tubes, and h. Other procedures deemed necessary in their respective institutions under a clinical protocol.  A critical care nurse is a licensed professional Roles of Critical nurse who is responsible for ensuring that acutely and critically ill patients and their Care Nurses families receive optimal care.  A critical care nurse is a licensed professional Roles of Critical nurse who is responsible for ensuring that Care Nurses acutely and critically ill patients and their families receive optimal care. Competencies Clinical Inquiry of Critical critical care nurse should be engaged in the ongoing process of questioning and evaluating practice and providing informed practice. Care Nurses Clinical Judgement clinical reasoning which includes clinical decision- making, critical thinking, and a global grasp of the situation, coupled with nursing skills acquired through a process of integrating formal and experiential knowledge Caring Practices nursing activities that create a compassionate, supportive, and therapeutic environment for patients and staff, with the aim of promoting comfort and preventing unnecessary suffering  Advocacy and Moral Judgement respecting and supporting the basic rights and beliefs of the critically ill patient Systems Thinking Competencies managing the existing environmental and system resources for the benefit of patients of Critical Facilitator and their families of Learning Care Nurses creatively modify or develop patient/family educational programs and integrate family/patient education throughout the delivery of care Response to Diversity sensitivity to recognize, appreciate, and incorporate diversity into the provision of care Collaboration working with others in a way that promotes each person’s contributions toward achieving optimal and realistic patient/family goals.  To develop, foster and maintain a level of knowledge about the norms, values, beliefs, patterns of illness, health and care needs of the people; CHALLENGES To analyze and evaluate critical care nurses specialty skills and their evolving roles; OF CRITICAL To review current studies and researches and to examine contextual issues that will enable CARE evaluation and synthesis of new knowledge, traditional techniques, religious and cultural NURSES influences to be applied in nursing practice, particularly evidence- based nursing practice, and To exercise professional judgments expected of them in the critical care clinical setting.  TRAINING OF NURSES FOR CRITICAL CARE SERVICES ORIENTATION PROGRAM / PRECEPTORSHIP AND MENTORING PROGRAM NURSES’ EDUCATION IN-SERVICE TRAINING PROGRAM CRITICAL CARE NURSING PROGRAM (POST GRADUATE SPECIALTY PROGRAM) CONTINUING PROFESSIONAL EDUCATION (CPE)  The following are categorization of critical care nursing education: 1. Post Graduate Courses Post graduate courses are part of higher education taken after a Bachelor’s Degree that are accredited from the Commission on CRITICAL CARE Higher Education (CHED) or the Professional Regulation Commission—Board of Nursing (PRC-BON). NURSING Certification Course PROGRAM (POST 1. GRADUATE Certification courses provides recognition and designation earned by a professional nurse after completing with satisfaction the SPECIALTY requirements of the course and has earned qualification to PROGRAM) perform a job or task. The certification courses should be recognized and accredited by the Professional Regulation Commission— Board of Nursing (PRC- BON) or other authorized accrediting body. This shall include but not limited to the following: Advanced Cardiac Life Support Pediatric Advanced Cardiac Life Support Newborn Resuscitation Continuous Renal Replacement Certification Advanced Intravenous therapy Stroke Nursing Nursing Responsibilities  Critical care specialty addresses the management and support of patients with severe or life- threatening illness. The goal of critical care nursing is to promote optimal adaptation of critically ill patients and their families by providing highly STANDARDS individualized care, so that the critically ill patients OF CRITICAL adapt to their physiological dysfunction as well as the psychological stress in the Critical Care Unit or CARE Intensive Care Unit (ICU). NURSING Care standards for critical care nursing provide PRACTICE measures for determining the quality of care delivered, and also serve as means for recognizing the competencies of nurses in intensive care specialty.  1. The critical care nurse functions in accordance with legislation, common laws, 11 organizational regulations and by-laws, which affect nursing practice. STANDARDS 2. The critical care nurse provides care to OF CRITICAL meet individual patient needs on a 24-hour CARE basis. NURSING 3. The critical care nurse practices current critical care nursing competently. PRACTICE 4. The critical care nurse delivers nursing care in a way that can be ethically justified.  5. The critical care nurse demonstrates accountability for his/her professional 11 judgment and actions. 6. The critical care nurse creates and STANDARDS maintains an environment which promotes OF CRITICAL safety and security of patients, visitors and CARE staff. NURSING 7. The critical care nurse masters the use of all essential equipment, available services PRACTICE and supplies for immediate care of patients.  8. The critical care nurse protects the patients from developing environmental 11 induced infection. 9. The critical care nurse utilizes the nursing STANDARDS process in an explicit systematic manner to OF CRITICAL achieve the goals of care. CARE 10. The critical care nurse carries out health NURSING education for promotion and maintenance of health. PRACTICE 11. The critical care nurse acts to enhance the professional development of self and others.  Being Being in Common thirsty pain concerns of Having tubes Not being and lines in able to their body control that restrict the themselves their movement Not being Critically Ill Being able to unable to communica sleep te Being unable to fulfill family roles Essentials in Patient Care: Communication Sedated Patients Provide orientation or translate medical information State procedural and task intentions Provide reassurance Apologize and/or recognize discomfort Obtain a response Provide intentional and unintentional distractions Provide social information to colleagues Essentials in Patient Care: Communication Responsive Patients If with limitation to verbal communication, provide communication tools such as letter boards, speaking valves, and prosthetic larynxes Recognize nonverbal cues like nodding and hand movements Limit the use of restraints Be educated about the frustration that mechanically ventilated patients experience when they are attempting to communicate their needs and desires. Essentials in Patient Care: Communication Responsive Patients When communicating with ventilated patients, you should: Routinely ask patients about their feelings and their state of mind. Ask permission before beginning nursing care and procedures. Evaluate patients’ understanding of the information conveyed to them by asking simple yes/no questions. Demonstrate attention to the needs of their patients by informing them of their surroundings, plan of care, and when they will return after leaving the bedside. Approach each patient with a kind, patient manner; take the time to investigate and understand what the patient is communicating; and respond to the patient’s communicated needs. Essentials in Patient Care: Pain Assessment Patient self-report. Search for a potential cause of a change in patient behavior. Surrogate report of a patient’s pain or patient’s behavior change. Observation of patient behaviors when patient self-report is not possible. Facial expressions Body Movements Muscle Tension Compliance with ventilation Physiologic parameters Essentials of Patient Care: Pain For acute pain, analgesics should be administered intravenously for Management - immediate onset of action to General Principles prevent the imprinting of the painful for Administration experience on the nervous system. of Pain or Sedative Subsequent doses may be given intravenously or orally on a regular Medications schedule around the clock. Continuous pain management is essential since duration and efficacy of analgesic intervention may be as important as timing for treatment of pain.  Intravenous infusions of analgesics start to act immediately; however, they will not provide Essentials of Patient significant analgesia until the infusion reaches Care: Pain “steady state.” Management - At the initiation of an infusion and when the General Principles infusion rate is increased, loading doses must be administered in order to provide immediate for Administration analgesia and maintain the desired analgesia until of Pain or Sedative the infusion reaches steady state. Medications In response to anticipated painful procedures (e.g., turning) the patient might receive an additional bolus. Adjustment of dose as indicated (e.g., elderly patients, impaired renal function) Essentials of Patient Care: Provision Assess all intravenous lines for patency and of Physiologic Needs - Sleep level all transducers, placing the head of the bed in the desired position before the patient is settled for sleep. Obtain vital signs. Assess the patient for pain or discomfort and provide medication as needed. Decrease noise in the patient’s environment as much as possible. Assess the patient’s normal sleep patterns and habits. Attempt to duplicate as many of these as possible. Ensure ventilator settings are in synchrony with the patient’s breathing pattern. If it is necessary to disrupt the patient’s sleep, try to space procedures so that the patient is able to obtain at least 2 to 3 hours of uninterrupted sleep at a time. Essentials of Patient Care: Provision of Physiologic Needs - Nutrition Perform assessment and history taking Determine nutritional requirements Assist in feeding as necessary. Be mindful of enteral and parenteral feedings Coordinate nutritional care with a nutritionist/dietician Evaluate effectiveness of nutritional therapy Essentials of Patient Care: Provision of Physiologic Needs - Mobility Adherence to progressive mobilization plan (turning to sides, passive/active ROM, movement against gravity, dangling and balancing, transferring to a chair, chair positioning, then ambulating.) Collaboration with physical and occupational therapists The Needs of Families of the Critically Ill Support Comfort Proximity Information Assurance  For optimum patient outcomes, The critical care is delivered by a Multidisciplinary multidisciplinary team whose Team members trust each other and communicate and collaborate well. Working in Critical Care Environments Communication Optimal patient care is not possible without skilled communication, and errors are frequent in situations where communication between healthcare providers and patients and their families is impaired. Use of SBAR and/or DATAS communication tool Use of CUS method and/or the Two- challenge Rule to resolve concerns Working in Critical Care Environments Collaboration Collaboration is a process, not a single event, and it requires that members of the healthcare team develop a pattern of sharing knowledge and responsibility for patient care. This ultimately affects patient outcomes. Building the Team Nurses have an important role on the multidisciplinary team in helping the team to recognize that the overall goal is related to the patient’s values and quality of life preferences as well as assisting in the establishment of the daily patient goals and the treatment plan Working in Critical Care Environments Negotiating Respectfully Managing Conflict Wisely Nurses should contribute Encountering conflict can be to teams from positions of stressful but acknowledging it strength by being innovative and managing it well is the and by demonstrating cornerstone to successful integrity in collaboration collaboration. It is important and to achieve collaboration to distinguish between there must be some form emotional conflict and task conflict. of power sharing Rapid Response Team Also known as Medical Emergency Team (RRT) A team of nurses and other health care professionals (respiratory therapists, pharmacists, emergency department personnel, and others) who bring critical care expertise to the bedside. The teams may or may not include physicians. The key goal is to act before “failure to rescue” occurs and a patient has suffered a cardiac or respiratory arrest. Managing the Critically Ill Clinical Practice Protocols Pathways Guidelines Best Critical Care Evidenced- Practices Research Based Care Ethical and Legal Issues in the Delivery of Critical Care  A situation that gives rise to conflicting moral claims, resulting in disagreements about choice for action. Exist when there is a conflict between the duties, rights, or values of the people involved in the situation Ethical dilemmas are usually described in terms of right or wrong, duty or obligation, rights or responsibilities, and good or bad. Ethical Dilemma Determining ü What ethically justified goals can be identified? What Ought to be done ü What are the ethically justified alternatives for action or what are the Identify the significant information choices? ü Are there practical constraints to following Recognize what ethical any of them? reasoning system are you ü What arguments can be using and identify the ethical viewpoints of those constructed in favor of these alternatives (this involved in the dilemma includes considering the probable consequences)? Ask yourself ü How can these arguments be evaluated? ü What ought to be done?  Informed Consent Use of Restraints Common Legal End-of-Life Issues and Ethical Advance directives Limitation of therapy Withdrawal of therapy Issues Euthanasia Organ donation Cultural Considerations Negligence Standards of Care Some Factor that affect the Well-being of Critical Care Nurses Moral Distress Compassion Fatigue Job Satisfaction  Resolving these factors: Moral Distress Moral Distress +A nurse would know the right thing to do, yet institutional constraints such as lack of resources or personal authority would prevent her from doing it What We Can Do: +Ask-Affirm-Assess-Act: The 4 A’s to Rise Above Moral Distress +Conscientious Refusal Resolving these factors: Moral Distress Resolving these factors: Compassion Fatigue + State of tension and preoccupation with the suffering of those being helped that is traumatizing for the helper + Term used to describe the combined effect of secondary traumatic stress and burnout + Secondary traumatic stress is primarily a response to caring for people who are suffering, whereas burnout is often a response to other stressors such as poor morale in the work environment.  Resolving these factors: Signs and Symptoms: Compassion Fatigue Intrusive thoughts or images of patients’ situations or traumas Difficulty separating work life from personal life Lowered tolerance for frustration and/or outbursts of anger or rage Dread of working with certain patients Depression Increase in ineffective and/or self- destructive self-soothing behaviors Hypervigilance Decreased functioning in What We Can Do: Standards nonprofessional situations of Self-Care Loss of hope Recommendations Recommendations Resolving these Job Satisfaction an important component of nurses' lives factors: Job that can impact on patient safety, staff morale, productivity and performance, Satisfaction quality of care, retention and turnover, commitment to the organization and the profession with additional replacement costs and further attempts to hire and orientate new staff Factors affecting job satisfaction: Working Environment, Policies and Practice, Caring Organization Appreciation, Pay, Age, Promotion, Feel of Belongings What Can We Do: Address issues or concerns relating to the above-mentioned factors  Become a Or get certified critical care (Certified nurse through Critical Care learning by Nurse [CCRN]). doing Do you have what it takes? References Perrin, K., & MacLeod, C. (2018). Understanding the Essentials of Critical Care Nursing (3rd ed.). Pearson. Burns, S., & Delgado, S. (2018). AACN Essentials of Critical Care Nursing, Fourth Edition (4th ed.). McGraw-Hill Education / Medical. Critical Care Nurses Association of the Philippines, Inc. (2014). Critical care nursing guidelines, standards and competencies. https://www.ccnapi.org/news- and-events/critical-care-nursing-guidelines-standards-and-competencies/