Critical Care Nursing Module 1 PDF

CRITICAL CARE NURSING CRITICAL CARE NURSING Prof. Christy B. Verdida, MAN, RN 1st Semester | Module 1...

CRITICAL CARE NURSING CRITICAL CARE NURSING Prof. Christy B. Verdida, MAN, RN 1st Semester | Module 1 1970s - The impact of the shortage of CCN was OUTLINE 1980s notable I. Historical Background of B. Acute and Critical Critical Care Nursing Care Nursing 1990s Increased demand for skilled critical care II. Current Trends Related to VI. Critical Care nursing nurses Critical Care Nursing Standard AIDS is pandemic Trauma A. What is Critical Care VII. Critical Care Professional Nursing? Accountability Substance abuse B. Standard in Critical VIII. Critical Care in the Care Nursing Philippines American Association of Critical Care Nurses (AACN) vision C. Skills Needed for the IX. Philosophy of Cultural for critical care nursing in the next Century: next Century Care Nursing ”A healthcare system driven by the needs of patients D. Patients in CCN Unit X. Holistic Critical Care and their families in which critical care nurses make E. Basic Requirements Nursing their optimal contribution.” for a CCN Nurse XI. Cultural and Linguistic III. Areas in CCN Competencies for Nurses TAKE NOTE! IV. Equipment Needed in XII. Complementary and Should be RN, IV Therapy trained, ACLS certification Critical Care Units Alternative therapies before becoming CCN V. Critical Care Team XIII. Issues related to A. Critical Nursing caregiver Roles II. CURRENT TRENDS RELATED TO CRITICAL CARE NURSING A. WHAT IS CRITICAL CARE NURSING I. HISTORICAL BACKGROUND OF CRITICAL CARE NURSING Specialty area in nursing that aims to promote highly specialized and excellent care ○ Needs certification 1800 Advantages of placing patients recovering ○ Should be trained and should have a licensed from surgery in a separate area of the hospital B. STANDARD IN CRITICAL CARE NURSING 1900 Three-bed-post-operative neurosurgical intensive care unit in Baltimore 1:1 or 1:2 RATIO 37 % HIGH PAY ○ John Hopkins Hospital Pre-mature infant unit in Chicago Nurse to Patient Nurses working in 55 USD hourly ratio because the hospital settings mean wage rate WWII Shock wards for critically injured patients patient requires are critical care constant attention nurses 1950 New mechanical ventilation technology and the need to group patients receiving this new C. SKILLS NEEDED FOR THE NEXT CENTURY therapy in one location, less than 60 years ago Critical thinking skills Critical care nursing was organized as a ○ Used in analyzing client issues and problems specialty ○ Thinking skills include interpretation, evaluation, inference, and explanation 1960 Focused on coronary care, nephrology, and ○ Guide clinical decisions, in the application of the intensive care nursing process to patient care ○ tool: nursing process Collaborative Skills 1965 Coronary care (1st specialty) ○ Implies shared attention to a problem in which the Neurologic unique talents and contributions of all parties are Respiratory considered Surgical ○ Interpersonal/multidisciplinary collaboration Burn Delegation Pediatric ○ Process of transferring the authority and responsibility Neonatal to another team member to complete a task while retaining accountability NCM118 Critical Care Nursing | Critical Care Nursing 1  ○ 5 rights of delegation INTENSIVE CARE UNIT (ICU) Right task Also known as critical care units (CCU), intensive therapy/ Right circumstance treatment unit (ITU) Right person (to delegate, consider legal Definition (The Medical City, 2021) aspects) ○ Special area in the hospital that provides the highest Right direction or communication (oral or level of care to patients needing extensive monitoring written; what are the expectations?) - to and intensive specialized care evaluate and monitor Right supervision and evaluation of the nurse (delegate tasks that you can CORONARY CARE UNIT (CCU) troubleshoot) Also known as telemetry unit, cardiac care unit (CCU), Computer Skills cardiac intensive care unit (Cardiac ICU) ○ Computers are used to document patient care, Definition (Manila Doctors Hospital, 2021) monitor physiologic data, and manage patient ○ An ICU mainly for patients with cardiac disorders information Example: coronary bypass surgery, heart failure ○ Patient record, referrals, nutrition, discharge, Main feature: comprehensive coronary care Procedures: availability of telemetry (way to monitor vital D. PATIENTS IN CCN UNIT signs remotely), cardiac rhythm monitoring (ECG), cardioversion, defibrillation Patients who are at risk for actual or potential life-threatening health problems Require and need intensive and vigilant care NOTE: Following patients There are different types of ICU ○ Unstable Coronary Care Unit is a step-up unit ○ Critically ill Needs hands-on and immediate care ○ Injured ○ Complex ○ Life-threatening conditions Most common reasons/ conditions CARDIAC CATHETER LABORATORY ○ Severe accident Also known as CathLab ○ Heart attack Definition (Up Duke Health System, 2021) ○ Cardiac arrest ○ Performs cardiovascular diagnostic imaging ○ Stroke procedures ○ Head injuries ○ Performs specific minimally invasive advanced ○ Others: burns, shock, MODS cardiac interventional procedures Procedures: Angiogram, angiography, angioplasty (PTCA) E. BASIC REQUIREMENTS FOR A CCN NURSE intra aortic balloon pump, Swans Ganz catheter, pacemaker Requirements: insertion/ implantation ○ Nursing degree program ○ Active license (US, PH) NEUROLOGY ICU (NEURO ICU) ○ ACLS certification Also known as the neurology ward, the acute stroke unit ○ Experience with other units Definition (Up Duke Health System, 2021) Critical Care Registered Nurse (CCRN) ○ An ICU/ ward devoted to the care of the patients with ○ Specialty certification for nurses issued by AACN who immediately life-threatening neurological problems/ provide direct care to acutely or critically ill patients disorder ○ Requirements for eligibility ○ Hospital units take care of stroke patients for Practicing RN or APRM diagnosis, treatment, and rehabilitation US-based facility/ standard (acute/ critical care nursing) STEP DOWN UNITS Completed 2000 hours of direct care Passed the CCRN examination Also known as the neurology ward, acute stroke unit Intermediate care units ○ Provide intermediate level of care for patients with illness severity not warranty ICU care but who are III. AREAS IN CCN unstable enough to be treated in the ward Critical care units Transition units: transition care between ICU and general ○ Job prospects and employment setting in critical care MS ward/ regular floor nursing specialties Patients: close monitoring, frequent assessment, serious, Units/ areas/ department less critical injuries (Prin, 2014) ○ ICU STEP UP: higher level of care for patients deteriorating on a ○ CCU ward ○ CathLab STEP DOWN: lower level of care for patients transitioning ○ Neuroward out of ICU ○ Stepdown units NCM118 Critical Care Nursing | Critical Care Nursing 2  NOTE: Most common reasons/ conditions B. ACUTE AND CRITICAL CARE NURSING Patient na usually stable na but not enough to be treated in the ward ACUTE CRITICAL CARE NURSING Must welcome px and the SO regarding the guidelines in Recognize the fiscal responsibility of nurses working in a the ward resources intensive-driven environment Proper endorsement is a must Use health care interventions designed to restore, Determine the criteria of step up and step down rehabilitate, cure, maintain, or palliate for clients of all ages “After thorough assessment.. This is what I noticed with across the lifespan the patient..” The American Association of Critical Care Nurse defines Air conditioned yung room kais dapat properly align yung acute and critical nursing as the specialty that manages temperature nila. Bawal tumaas temperature nila because human responses to actual or potential life-threatening it will increase metabolic rate → worsen neurologic problems condition. Nurses rely on a body of knowledge, skills, and abilities to: ○ Restore, support, promote, and maintain the physiologic and psychosocial stability of clients AACN Roles: IV. EQUIPMENT NEEDED IN CRITICAL CARE UNITS ○ Monitor and safeguard the quality of nursing care that the patient receives ○ Act as a liaison between the patient and the patient’s CRITICAL CARE NURSING UNIT BASIC SETUP family The Medical City, 2021 ○ Multiparameter physiologic monitor linked with sophisticated centralized monitoring system ROLES AS NURSES Services Assimilate Assimilate and prioritize information in order and to take immediate and decisive CONTINUOUS MONITOR INVASIVE MONITOR prioritize evidence-based, client-focused action ECG Arterial Anticipate Anticipate and respond with confidence and Arterial pressure Venous and adapt to rapidly changing client conditions Oxygen Intra-abdominal respond intracranial Respond Respond to the unique needs of clients and 1 SLIDE families coping with unanticipated treatment as well as quality-of- life and end-to-life decisions NOTE: Oxygen are attached to the wall Establish Establish and maintain safe, respectful, Bedside equipments should be always complete and healing, and caring environments. Maintain V. CRITICAL CARE TEAM VI. CRITICAL CARE NURSING STANDARD Team consist of: It describes the practice of the nurse who cares for acutely ○ Advanced practice nurses (APNs) or critically ill patient in the healthcare environment ○ Nurse practitioners (NPs) and other specialty clinicians ○ Pharmacists VII. CRITICAL CARE PROFESSIONAL ACCOUNTABILITY ○ Respiratory therapist ○ Social worker ○ Clergy AMERICAN ASSOCIATION OF CRITICAL CARE NURSES (AACN) A. CRITICAL NURSING ROLES Created in 1969 – largest specialty organization Expanded Role Nursing Positions Focused on “creating a healthcare system driven by the ○ They seek to provide comprehensive care to the need of clients and their families, where acute and client. Rotates to role expansion within nursing in critical care nurses make their optimal contribution” general and more specifically to critical care nurses Advanced Practice Nurses CRITICAL CARE NURSES OF THE PHILIPPINES INC. ○ Advanced critical care practitioners (ACCP) are (CCNAPI) clinical professionals who have developed their skills The national organization of nurses interested in the field of and theoretical knowledge to a very high standard critical care nursing NCM118 Critical Care Nursing | Critical Care Nursing 3  It was founded in February 1977 with approved SEC ○ Is indicated by physical and emotional registration (CN 200813601), a founding member of the absence,inhumane and belittling interactions, and World Federation of Critical Care Nurses (2001) and lack of recognition of the client's uniqueness. accredited as a Provider of Continuing Professional Holistic Care Education by the Professional Regulation Commission ○ Focuses on human integrity and stresses that the (Provider Number 2009-019) body, the mind, and the spirit are interdependent and The critical care nursing practice is based on a scientific inseparable. body of knowledge and incorporates the professional competencies specific to critical care nursing practice and is focused on restorative, curative, rehabilitative, maintainable, XI. CULTURAL AND LINGUISTIC COMPETENCE FOR or palliative care, based on identified patient needs NURSES Nurses should demonstrate cultural competence by: ○ Developing an awareness of one's own culture VIII. CRITICAL CARE IN THE PHILIPPINES without letting it have an undue influence on those In the Philippines, the Professional Regulation Commission - from other backgrounds Board of Nursing (PRC-BON) is committed to provide need- ○ Demonstrating knowledge and understanding of driven, effective and efficient specialty nursing care services different cultures of high standard and at international level within the ○ Accepting that there may be differences between the obtainable resources. cultural beliefs and values of the health care provider To respond to this mission and commitment, a PRC-BON and the client Working Group in Developing the Nursing SpecialtyFramework was formed in the 1996 to take on the CULTURALLY COMPETENT CARE task of setting the process based framework and guidelines Cultural perspectives on death and dying are complex for specialty nursing services. View a discussion of advance directives as a legal device to The expanding healthcare and nursing knowledge together deny care with new and evolving healthcare sites, structures, and technologies all have contributed to the need and desire for XII. COMPLEMENTARY AND ALTERNATIVE THERAPIES specialty nursing organizations like the Critical Care Nurses Guided Imagery Association of the Philippines, Inc. (CCNAPI) to revisit the ○ Decreased side effects existing statements of its Standards of Nursing Practice to ○ Decreased length of stay provide clear and updated statements regarding the scopes ○ Reduced hospital cost of practice and standards of critical care nursing ○ Enhanced sleep This will ensure continued understanding and ○ Increased Satisfaction acknowledgment of nursing's varied specialty professional Massage contributions healthcare environment ○ Effleurage ○ Tapotement IX. PHILOSOPHY OF CULTURAL CARE NURSING ○ Teach SO how to do this para hindi time consuming The Critical Care Nurses of the Philippines, Inc. (CCNAPI) is for nurses responsible for the promotion of man's health welfare for Animal assisted therapy national development ○ Not allowed if animal is too loud in the area It desires to support the professional and personal growth Music therapy and development of initial core nurses. CCNAPI has organized itself into a national association committed to the ideals of service to the people, XIII. ISSUES RELATED TO CAREGIVER equality,justice and social progress Role: Client Care They contribute to the client’s well being by: ○ Providing a link to the client’s personal life X. HOLISTIC CRITICAL CARE NURSING ○ Advising the client in health care decisions or Caring functioning as the decision when the client cannot ○ Aspect between nurses and clients is most ○ Helping with activities of daily living (bathing, fundamental to the relationship and to the health care suctioning) experience ○ Providing positive, loving, and caring support Client-centered Critical cCare ○ Critical care unit is a stressful environment for clients and for their family members with the understanding that family is whomever the client designates to be at their bedside ○ CCU - because of number of alarms, 24/7 routines, unfamiliar environment, and often an uncertain prognosis Non-caring NCM118 Critical Care Nursing | Critical Care Nursing 4  REFERENCES Lecture Slides NOTES NCM118 Critical Care Nursing | Critical Care Nursing 5  CRITICAL CARE NURSING ETHICO-LEGAL ASPECTS OF CARE Prof. Christy B. Verdida, MAN, RN 1st Semester | Module 2 OUTLINE A. AMERICAN NURSES ASSOCIATION CODE OF ETHICS Sets guidelines to use when providing client care outlines I. Ethical Principles VIII. Quality and Safety II.Ethical Dilemmas Education for Nurses QSEN the nurse's responsibility to the client and the profession of A. American Nurses Competencies nursing and assist the nurse for making ethical decision Association Code of IX. Safety Work Environment making Ethics Standard B. Ethical Decision Making X. Good Samaritan Act B. ETHICAL DECISION MAKING III. Organ Donation XI. Mandatory Reporting IV. Advance Directives XII. Nursing Responsibilities A process in which the nurse, client's family, and health care A. Planning Guides for XIII. Information Technology team make decisions taking into consideration personal and Seriously ill patients A. Informatics philosophical viewpoints, The ANA code of ethics and ethical V. Legal Issues B. Data Security principles. Frequently, this requires that a balance between A. Informed Consent C. Use of Technology in science and morality VI. Legal Responsibilities Healthcare VII. 2020 Hospital National Client Safety Goals ADVOCACY A process in which the nurse assist the client to grow and develop toward self-actualization. Advocacy is critical leadership role and emphasizes the values of caring, autonomy, respect and empowerment I. ETHICAL PRINCIPLES ○ Goal: safety and welfare Autonomy ○ The right to make one’s own decisions III. ORGAN DONATION Beneficence Organ and tissue donation is regulated by state and federal ○ The obligation to do good for others laws. Facilities will have specific policies and procedure to Confidentiality follow during the process ○ The obligation to observe the privacy of another and Federal Law requires health care facilities to provide access maintain strict confidence to trained specialists who make the request to clients or ○ Respect privacy family members and provide information regarding consent, Fidelity organ and tissues that can be donated, and how burial or ○ The obligation to be faithful to agreements and cremation will be offered by donation responsibilities to keep promises Provide emotional support and answer questions ○ Our social responsibility is to help our community A document in which a client who is competent is able to Justice express wishes regarding future acceptable health care ○ The obligation to be fair (including the desire for extraordinary lifesaving measures, Non-maleficence resuscitation, intubation and artificial hydration and nutrition) ○ The obligation not to harm others and/or designate another person to make decisions when ○ Hippocrates states “First, do no harm” the client becomes physically and mentally unable to do so Paternalism ○ Assuming the right to make decision for another Veracity IV. ADVANCE DIRECTIVES ○ The obligation to tell the truth A. PLANNING GUIDES FOR SERIOUSLY ILL CLIENTS II. ETHICAL DILEMMAS Are problems for which more than one choice can be made, LIVING WILL and the choice is influenced by the values and beliefs of the Legal document that instructs health care provider and decision makers. Ethical dilemma is very common in health family members about what, if any, life sustaining treatment care, and nurses must be prepared to apply ethical theory an individual wants if at some time the individual is unable to and decision making make decisions Two contradicting ethical principles NCM118 Critical Care Nursing | Ethico-Legal Aspects of Care 1 DURABLE POWER OF ATTORNEY FOR HEALTHCARE CONFIDENTIALITY Legal document that designates another person to make The right to privacy with respect to one's personal medical healthcare decisions for the client when the client becomes information unable to make decisions independently VI. LEGAL RESPONSIBILITIES NURSING INTERVENTIONS Ensure communication to the health care team when clients SOURCES OF LAW have provided advance directives available in the medical The Constitution, statutes, administration, agencies and record). Clients who do not have advance directives must be court decisions given written information outlining rights related to health care decisions TYPES OF LAWS AND COURTS Who is the decision maker? CRIMINAL LAW V. LEGAL ISSUES Felony Serious crime A. INFORMED CONSENT Obtained after a client receives complete disclosure of all Misdemeanor Less serious crime pertinent information provided by the provider regarding the surgery or procedure to be performed CIVIL LAWS Obtained only if the client understands the potential benefits Unintentional torts Negligence – failure to act and risks associated with the surgery or procedure as nurse Malpractice – you are doings ELEMENTS things outside of your Individual giving consent must fully understand the practice procedure that will be performed, the risks involved, Quasi-intentional torts Breach of confidentiality, expected/desired outcomes, expected complications/side defamation of character effects, alternate treatments or therapies available Consent is given by a competent adult, legal guardian or a Intentional torts Assault, battery and false designated power of attorney (DPOA), emancipated or imprisonment married minor, parent of a minor, or a court order A trained medical interpreter must be provided when the STATE LAW person giving consent is unable to communicate due to a language barrier Nursing practice is regulated by state law. Each state's board of nursing has rules, regulations and standards that vary based on statutes defining practice NURSES ROLE 11 Core Competencies Witness the client's signature and ensure the provider gave ○ Safety the necessary information and that the client understood and ○ Quality is competent to sign, notify the provider if clarification is ○ Management of resources needed ○ Legal responsibilities Check, be vigilant in checking the document ○ Collaboration (C) Thorough documentation includes reinforcement of ○ Education information given by the provider any irregular occurrences ○ Confidentiality ○ What is not written is not done ○ Legal responsibility CLIENTS ROLE STATE LAW PATIENT BILL OF RIGHTS Nurse practice act, quality safety and regulatory issues Right to human care and treatment in critical care ○ Quality and safety issues AMERICAN WITH DISABILITIES ACT (ADA) ○ Quality and safety regulations Eliminates discrimination against Americans who have Check if hospital is following such physical or mental disabilities regulations ○ Quality and safety resources NCM118 Critical Care Nursing | Ethico-Legal Aspects of Care 2  VII. 2020 HOSPITAL NATIONAL CLIENT SAFETY GOALS INFORMATICS Use information and technology to communicate and manage knowledge, mitigate error, and support decision making. Some of the hospitals use informatics for documentation. Laptop use. Chart of patient is still hard copy IX. SAFETY WORK ENVIRONMENT STANDARD ​Identify client correctly ○ Identify yourself Improve staff communication ○ Collaborative care Use medication safely ○ High alert medications Use alarms safely Prevent Infection Identify client safety risks Prevent Mistakes in surgery ○ Checklist for surgery VIII. QUALITY AND SAFETY EDUCATION FOR NURSES QSEN COMPETENCIES PATIENT-CENTERED CARE Recognize the client or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for the client's preferences, values, and needs. There is a standard STANDARD DESCRIPTION I Skilled Communication TEAMWORK AND COLLABORATION Nurses must be proficient in communication Function effectively within nursing and interprofessional skills as they are in clinical skills teams, fostering open communication, mutual respect, and decision-making to achieve quality client care. II True Collaboration Practice, implementing, research Nurses must be relentless in pursuing and fostering true collaboration EVIDENCE-BASED PRACTICE You should be honest Integrate best current evidence with clinical expertise and Referral to laboratory, dietician, etc. client/family preferences and values for delivery of optimal health care. III Effective Decision Making Nurse must be valued and committed partners in making policy, directing and evaluating QUALITY IMPROVEMENT clinical care, and leading organizational Use data to monitor the outcomes of care processes and operations use improvement methods to design and test changes to Respect their decision continuously improve the quality and safety of health care systems IV Appropriate Staffing Common issue: understaffing SAFETY Staffing must ensure the effective match Minimize risk if harm to clients and providers through both between patient needs and nurse competencies system effectiveness and individual performance NCM118 Critical Care Nursing | Ethico-Legal Aspects of Care 3  A nurses who are able to recognize rights and V Meaningful Recognition Nurses must be recognized and recognize responsibilities in legal matters are better able to protect others for the value each brings to the work of themselves against liability or loss of licensure the organization REMEMBER! One of the most vital and basic functions of a professional VI Authentic Leadership nurse is the duty to intervene when the safety or Nurse leaders must full embrace the imperative of a health work environment, authentically live well-being of a client or another person is obviously at risk it, and engage others*** Know the people; being open to discussions regarding concerns XIII. INFORMATION TECHNOLOGY Characteristics Computer skills ○ Flexible ○ Transparency A. INFORMATICS The use of information technology as a communication and information-gathering tool that support clinical X. GOOD SAMARITAN ACT decision-making and scientifically based nursing practice Health care providers are protected from potential liability if (A) Allows candidates to test Nursing Licensure (NCLEX) volunteering away from their place of employment, as long with rapid results as the nurses action s are not grossly negligent (B) Permits verification of licensure online for nurses and other healthcare professionals (C) Informatics: Technology resources are used to gather XI. MANDATORY REPORTING data in a systematic way to support clinical decision making and scientifically, based nursing practice ABUSE (D) Client Care: Electronic documentation, medication A nurse is mandated to report abuse or vulnerable dispensing and client education resources populations (children, older adults). Any suspicion of abuse (E) Professional Education ( medications, diseases) must be reported based on procedures and treatments) (F) Client portals: Allows integration of e-health and COMMUNICABLE DISEASES A complete list is available from the cdc. Report to the public collaboration between client and health care providers health department to ensure appropriate medical treatment and plan for prevention and control including public B. DATA SECURITY education Passwords are necessary to prevent improper access to computers and medication systems. IMPAIRED COWORKER Only individuals who have a professional relationship with a A nurse who suspects of coworker using drugs or alcohol client may access the client's personal health information. while working has the duty to report to the appropriate per HIPAA Regulations supervisory personnel according to the institutional policy Computer terminals must be logged off or locked when not in immediate use MALPRACTICE (PROFESSIONAL NEGLIGENCE) Monitor screens must be shielded or situated so that The failure of a person with professional training to act in a unauthorized individuals cannot see the information reasonable and prudent manner within the identified scope of practice and or within the guidelines identified by the state C. USE OF TECHNOLOGY IN HEALTH CARE regulating agency Documentation Databases for teaching and learning NEGLIGENCE Electronic health record The omission to do something that a reasonable person Mobile application would do, or doing something that a reasonable person Telehealth/ telemedicine would not do Negligence can be mitigated by following practice standards, communicating effectively with the health care team, and REMEMBER! accurate / timely documentation A nurse should not share computer passwords with another person,including coworkers and family members Nurses should instruct clients to review valid and credible XII. NURSING INTERVENTIONS websites,the author, institution, and credentials should be reviewed NCM118 Critical Care Nursing | Ethico-Legal Aspects of Care 4  REFERENCES Lecture Slides NOTES NCM118 Critical Care Nursing | Ethico-Legal Aspects of Care 5  BUNDLES OF CARE & INFECTION CRITICAL CARE NURSING PREVENTION AND SAFETY Prof. Christy B. Verdida, MAN, RN 1st Semester | Module 3 OUTLINE CLINICAL DEFINITION CLABSI occurs when these criteria exist: I. Bundle ○ Clinical signs of infection II. Specific Interventions: ○ No alternate source of bloodstream infection A. Central Line-Associated Bloodstream Infection (CLABSI) ○ Positive blood culture from a peripheral vein with one B. Catheter-Associated Urinary Tract Infection (CAUTI) or any of the following: C. Ventilator-Associated Pneumonia (VAP) Catheter tip culture that matches grown from D. Surgical Site Infection (SSI) the blood E. Methicillin-Resistant Staphylococcus Aureus (MRSA) At least three folds high number of organisms grown from the catheter versus the peripheral blood culture on I. BUNDLE simultaneously drawn culture Bundles – a team effort; multidisciplinary (collaboration with Growth from the catheter-drawn blood other healthcare workers) culture occurs at least two hours before the A structured way of improving the process of care and growth of the same organism from a patient outcome percutaneously-drawn blood culture A small and straightforward set of evidence-based practices, generally 3-5 that when performed collectively and reliably, SURVEILLANCE DEFINITION have been proven to improve patient outcome An infection that originates from or is related to a central In order for bundle implementation to be successful, each venous catheter element of the bundle must be implemented collectively with ​A laboratory-confirmed infection where a CVC is in place for complete consistency to achieve the most favorable ≥2 calendar days prior to a positive culture and is also in outcomes place the day of or day prior to culture “ALL OR NOTHING APPROACH” Examples 1: Contribute to: ○ PICC placed June 1 ○ infection ○ Patient febrile June 3 ○ PICC in place ○ Cultures positive for Staphylococcus aureus Example 2: ○ PICC placed June 2nd ○ Removed June 5th ○ Patient febrile June 6th ○ Cultures positive for Coagulase-Negative Staphylococci RISK FACTORS PATIENT PROVIDER DEVICE CHARACTERISTICS CHARACTERISTICS CHARACTERISTICS Immunocompromise Emergency insertion Site of insertion d host Excessive device Number of lumens Severe skin burns or manipulation Indication for use protein calorie Incompetent malnutrition adherence to safe II. SPECIFIC INTERVENTIONS Prolonged hospital insertion practices stay prior to Failure to remove placement unnecessary device A. CENTRAL-LINE ASSOCIATED BLOODSTREAM Low nurse-patient ratio ( catheter hub INFECTION (CLABSI) care) An infection that originates from or related to central catheter BUNDLES FOR PREVENTION OF CLABSI NCM118 Critical Care Nursing | Bundles of Care Infection Prevention and Safety 1  INFECTION (CAUTI) Defined as Urinary Tract Infection in a patient with current urinary catheterization or has been catheterized for the past 48 hours 5-10cc balloon INDWELLING CATHETER/ FOLEY CATHETER Closed sterile system with a catheter and retention balloon that is inserted through the urethra suprapubic to allow for bladder drainage. Catheter is left in place INTERMITTENT CATHETERIZATION INSERTION BUNDLE Involves a brief insertion of catheter into the bladder through Have a process in place to ensure adherence to infection the urethra to drain urine at intervals prevention If a patient can't know the 3 temp. (tap, hot, cold) then ​Hand hygiene prior to catheter insertion or manipulation he/she has neurogenic bladder Avoidance of the femoral vein for central vein access in adult If there is urinary retention, may cauti clients ​Standardized insertion packs EXTERNAL CATHETERIZATION Use of ultrasound guidance for insertion of internal jugular Urine containment device that fits over or adheres to the Use maximal skin barrier precautions during CVC insertion genitalia and is attached to urinary drainage bag most Use alcoholic chlorhexidine antiseptic, betadine, hydrogen common " condom catheter" peroxide SOURCES OF MICROORGANISMS Metal – opening, meatus MAINTENANCE BUNDLE (AFTER INSERTION) Daily review of central line necessity Rectal or vaginal colonization Disinfect catheter hubs, ports, connectors etc. before using Contaminated hands of healthcare personnel or equipment the catheter Prompt removal of unnecessary lines/ non essential CAUTI PREVENTION Urinary catheter use catheters ○ Insert catheter only for appropriate indications Change transparent dressing and disinfect sites with ○ Consider using alternatives to indwelling urethral chlorhexidine every 5-7 days or immediately after dressing is catheterization soiled. Change gauze dressing every 2 days or earlier if soiled, PROPER TECHNIQUES IN URINARY CATHETER loose or damp. INSERTION Daily chlorhexidine washes for ICU patients over 2 months Perform hand hygiene immediately before and after insertion of age or manipulation of the catheter Replace administration sets within 96 hours. Immediately if Only properly trained persons who know the correct aseptic used for blood products or lipids technique are given responsibilities. Ensure appropriate nurse to patient ratio in ICU Insert catheter using aseptic technique and sterile equipment Non-acute care setting: clean technique for intermittent CDC SOCIO ADAPTIVE INTERVENTIONS: NOT JUST catheterization is accepted. ABOUT HAVING A BUNDLE Secure indwelling catheters after insertion Clinician education Unless clinically indicated: consider using the smallest bore Designated Physician and Nursing Team Leader catheter possible, consistent with good drainage Central-line cart in each ICU If intermittent catheterization is used, perform at a regular Insertion Checklist intervals Nurse empowerment to stop procedure if best practices are Consider using portable ultrasound device to assess urine not followed volume in patients undergoing intermittent catheterization Adherence to best practices To frontline staff, feedback provided regarding rates of PROPER TECHNIQUES FOR URINARY CATHETER CLABSI MAINTENANCE Maintain a closed drainage system. B. CATHETER-ASSOCIATED URINARY TRACT Maintain unobstructed urine flow NCM118 Critical Care Nursing | Bundles of Care & Infection Prevention and Safety 2  Use standard precautions, including use of gloves and gown ○ Oral care as appropriate, during manipulation of catheter or collection Safe enteral nutrition container ○ Suction before feeding Changing indwelling catheter or drainage bags at routine. ABCDE Bundle (ASSESSMENT) Unless clinical indication exists, DO NOT use systemic ○ Awakening trial for ventilated patient antimicrobials routinely to prevent CAUTI ○ Spontaneous Breathing trials Do not clean the periurethral area with antiseptic to prevent ○ Coordination between RN and RT CAUTI while the catheter is in place. Routine hygiene is ○ Standard Delirium assessment program appropriate. ○ Early Mobilization and Ambulation of Critically ill Unless obstruction Is anticipated, bladder irrigation is not patients is advised recommended. Any foreign body will cause infection NOT RECOMMENDED: ○ Routine irrigation with the bladder with antimicrobial METHODS PROPOSED TO REDUCE VAP RATES due to resistance Noninvasive ventilation as much as possible ○ Routine instillation of antiseptic or antimicrobial ○ O2 mask solutions into the urinary bags, no clamping ○ Nasal cannula ○ Clamping indwelling catheters prior to removal is not Avoid prolonged use of paralytic agents of paralytic agents necessary. or IV sedation May possibility na mag back flow and infection Extubate, remove NG tubes ASAP Assess for urge to urinate Evaluate HOB >= 30 degrees ○ Prevent aspiration pneumonia C. VENTILATOR-ASSOCIATED PNEUMONIA VAP Maintain adequate cuff pressure Ventilator Evaluate need & use of stress ulcer prophylaxis ○ Device use to support, assist or control respiration Evaluate need for transport out of ICU through the application of positive pressure to the Avoid unnecessary reintubation airway when delivered via artificial airway. Kinetic Rx, chest physiotherapy Ventilator Associated Pneumonia No circuit changes ○ ​A pneumonia where a patient is on mechanical Careful drainage of tube condensate ventilation for more that 2 calendar days, (48-72 Single use products/devices hours) with the day of ventilator placement as day 1 Proper disinfection Continuous aspiration of subglottic secretions POTENTIAL RESERVOIRS: NOSOCOMIAL PNEUMONIA Hand hygiene PATHOGENS Use of gloves Oropharynx Oro, the suctions the more secretions Trachea Practice aseptic technique Stomach Respiratory therapy equipment D. SURGICAL SITE INFECTION (SSI) Paranasal Are infections of the incision or organ or space that occur Sinuses after surgery Sanctuary (above cuff below cords) The most common preventable infection today Endotracheal intubation decreases the cough reflex, An SSI typically occurs within 30 days after surgery impedes mucociliary clearance, injures the tracheal epithelial, provides a direct conduit for bacteria from URT to TYPES the LRT Superficial incisional SSI ○ occurs just in the area of the skin where the incision PREVENTION OF VENTILATOR-ASSOCIATED PNEUMONIA was made (BUNDLE) Deep incisional SSI Elevate the head of the bed between 30-45 degrees ○ occurs beneath the incision area in muscle and the Peptic ulcer disease prophylaxis, H2 Blocker, Sucralfate, tissues surrounding the muscles Proton pump Inhibitor Organ or space SSI ○ Omeprazole ○ can be in any area of the body other than skin, ○ Pantoprazole muscle, and surrounding tissue that was involved in Venous Thromboembolism (VTE) Prophylaxis the surgery. This includes a body organ or space ○ Clexane between organs ○ Compression stockings Use of oral chlorhexidine SSI BUNDLE NCM118 Critical Care Nursing | Bundles of Care & Infection Prevention and Safety 3  Parenteral antimicrobial prophylaxis Glycemic control Normothermia Oxygenation Antiseptic prophylaxis Blood transfusion PARENTERAL ANTIMICROBIAL PROPHYLAXIS Administer preoperative antimicrobial agents only when indicated Administer the appropriate parenteral prophylactic antimicrobial agents before skin incision in all cesarean section procedures. In clean and clean-contaminated procedures, do not administer additional prophylactic antimicrobial agent doses after the surgical incision is closed in the operating room Antibiotic prophylaxis should be administered 60 minutes prior to incision Re-dosing is administered for prolonged procedures in patient with major blood loss and excessive burns E. METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) GLYCEMIC CONTROL Resistant to antibiotics Implement glycemic control and use blood glucose target Staphylococcus aureus levels below than 200 mg/d in patients with or with out ○ Bacteria found in people’s skin diabetes In hospital setting, MRSA can cause: ○ Bloodstream infection NORMOTHERMIA ○ Pneumonia Maintain perioperative normothermia ○ Surgical site infection Maintain oxygen that is why i should be normothermia before ○ Sepsis surgery ○ Death OXYGENATION For patients with normal pulmonary function undergoing GA with ET intubation, administer increase FiO2 during surgery and after extubation in the immediate postoperative period ANTISEPTIC PROPHYLAXIS Advise patient to shower or bathe (full body) with soap or antiseptic agent on at least night before the operative day Perform intraoperative skin preparation with an alcohol-based antiseptic agent unless contraindicated. BLOOD TRANSFUSION Do not withhold transfusion of necessary blood products from surgical patient as a means to prevent SSI This is for recovery of client How is MRSA spread in healthcare setting ○ Direct contact with an infected wound or from contaminated hands usually those of healthcare providers ○ Mandatory to wash hands to prevent infection STRATEGIES TO PREVENT HOSPITAL-ONSET S. AUREUS NCM118 Critical Care Nursing | Bundles of Care & Infection Prevention and Safety 4  Implement interventions to reduce device and procedure ○ Monitor facility HO SA BSI counts and target units related health care infections with the highest number for evaluation ○ CLABSI ○ Evaluate and Train all healthcare personnel on ○ SSI prevention practices of HO SA BSI ○ VAP ○ Audit and conduct competency based assessment for ○ Hemodialysis blood stream prevention practices like: infection control practices Hand Hygiene observations ○ Dapat meron kayong DATA for continuous quality Catheter / Vascular access observation monitor and do research as nurses Staff education and competency Patient education/engagement Catheter reduction REFERENCES Chlorhexidine for skin antisepsis Lecture Slides Catheter hub disinfection Antimicrobial ointment Implement source control strategies for high risk patients NOTES during high risk periods ○ Table: Summary of Source Control Strategies by Central Venous Catheter or Midline Catheter Presence and Unit Type Pt Type ICU Non-ICU Patient ICU Non-ICU Type CVC or Topical chlorhexidine Topical chlorhexidine Midline gluconate (at least gluconate (at least 2%) Catheter 2%) + Intranasal + Intranasal Present antistaphylococcal antistaphylococcal antibiotic /antiseptic al antibiotic/antiseptic (e.g.mupirocin or (e.g.mupirocin or iodophor) (core iodophor) strategy) (supplemental strategy) No CVC Topical chlorhexidine None (note that source or Midline gluconate (at least control strategies may Catheter 2%) + intranasal apply to pre-operative present antistaphylococcal surgical patients outside antibiotic/antis the ICU) eptic (i.e. mupirocin or iodophor) (core strategy) Implement ​interventions to prevent transmission or MRSA in acute care ○ Place patients colonized or infected with MRSA in private rooms ○ Use dedicated patient-care equipment ○ Single use disposable items ○ If common use equipment is unavoidable, clean and disinfect ○ Provide regular competency based training on use of PPE and monitor adherence ○ Place patient with excessive wound drainage on contact precaution and in private room Develop infrastructure to support hospital-onset SA BSI prevention ○ Develop multi-disciplinary workgroup to identify and implement strategies NCM118 Critical Care Nursing | Bundles of Care & Infection Prevention and Safety 5  BASICS IN EMERGENCY CRITICAL CARE NURSING NURSING CARE Prof. Janelle P. Castro, PhD, MSN, RN 1st Semester | Module 4 OUTLINE III. STANDARDS OF CARE GUIDELINES A general guide I. Definitions V. Triage Process A. Emergency NUrsing VI. Triage Documentation Each patient situation presents a unique set of clinical II. Nursing Focus in A. Elements of factors and requires nursing judgment Emergency Situations Comprehensive Whenever a patient with a potentially life threatening III. Standards of Care Triage condition, proceed with the following: Guidelines Documentation ○ Remove the patient from potential source of danger – live IV. Triage VII. Additional Notes electrical current, water, fire A. Triage Acuity Rating ○ Go through the primary emergency assessment Systems B. Canadian Triage and ○ Call for help as soon as possible pls help Acuity Scale (CTAS) ○ Assist with transport and further assessment and care as C. Emergency Severity needed Index (ESI) IV. TRIAGE A method of prioritizing patient care according to the type of I. DEFINITIONS illness or injury and the urgency of the patient's condition Higher acuity rating = more toxic Note: Mass casualty incident includes human resources as ○ In CCU and ward patients considerations; disaster nursing Acuity rating 1 = requiring resuscitation ○ In emergency department A. TRIAGE ACUITY RATING SYSTEMS A. EMERGENCY NURSING The delivery of specialized care to a variety of ill or injured patients who may: ○ Be unstable ○ Have complex needs Some may have minor needs; health is the choice of a person – some patients may think that they're condition is considered an “emergency” All patients that go to the ER believes that they have a condition that requires complex needs ○ Require intensive and vigilant nursing care Overcrowding in the ER ○ Importance of integration of UHC Not everyone can afford or has access to healthcare ○ Not all patients that go to the ER require intensive care II. NURSING FOCUS IN EMERGENCY SITUATIONS B. CANADIAN TRIAGE AND ACUITY SCALE (CTAS) Based on Australian triage scale PREHOSPITAL Mandates that every patient presenting for care should be at Assume position of responsibilities least visually assessed within 10 minutes of presentation Supervision of both EMS and non-EMS personnel during The ED RN assigns acuity based on chief complaint and a acute care provisions focused subjective and objective assessment ○ Supervise the scene and the bystanders Nagmamarunong na bystanders; people who want to help but do not know the procedure CTAS Level 1 Patients need to be seen by a physician immediately 98% of the time INTRAHOSPITAL Assist in life support care NCM118 Critical Care Nursing | Basics in Emergency Nursing Care 1  CTAS Level 2 Patients need to be seen by a physician Example: Conscious within 15 minutes 95% of the time sedation CTAS Level 3 Patients need to be seen by a physician within 30 minutes 90% of the time V. TRIAGE PROCESS CTAS Level 4 Patients need to be seen by a physician within 60 minutes 85% of the time CTAS Level 5 Patients need to be seen by a physician within 120 minutes 80% of the time C. EMERGENCY SEVERITY INDEX (ESI) Categorizes patients initially by acuity amd then by expected resource consumption Resource needs are defined as the number of resources a patient is expected to consume in order for a dispositions decision ( discharge, admission , transfer) Research has demonstrated that this is a valid and reliable system ACROSS-THE-ROOM ASSESSMENT Rapid Triage Assessment ○ Should be completed within 60 to 90 seconds when necessary, a comprehensive assessment should be consistently performed within 2 to 5 minutes Use of Nurses’ Senses ○ Nurses use their own senses to gather vital information SIGHT SMELL HEARING Sick or not sick Stool, urine, vomit Breathing Obvious Ketones Speech RESOURCES NOT RESOURCES deformities or Alcohol, amputations cigarettes Labs (blood, urine) History and physical Dress Poor hygiene X-rays Point of care testing Chronic illness Pus CT-MRI-Sonogram-Angiogra Activity level Chemicals phy Obvious blood on clothing, skin IV Fluids Saline or heplock Breathing Skin color IV or IM or Nebulized PO medications Level of medications Tetanus immunization consciousness Prescription refills Special consultation Phone call to PCP PEDIATRIC ASSESSMENT TRIANGLE Simple procedure = 1 Simple wound care APPEARANCE WORK OF CIRCULATION Example: Foley cath Crutches, splints, slings BREATHING OR SKIN insertion Complex procedure = 2 NCM118 Critical Care Nursing | Basics in Emergency Nursing Care 2  Muscle tone Nasal flaring Pallor Position of patient relative to the Intractability or Retractions Mottling motorcycle consolability Abnormal airway Cyanosis Lock or gaze Bicycle Crash Helmet use sounds Speech or crying Collided with a vehicle or object Position of Thrown or run over comfort Impact speed Landed on which body parts NOTE: PEDIATRIC ASSESSMENT (CC) If the patient is assessed to be in need of immediate Mnemonic: CIAMPEDS care, skip the other processes and proceed with the triage care (Triage care → Triage interview) C Chief Complaint I Immunizations, Isolation TRIAGE INTERVIEW Should begin with the nurse confirming the patient's identity, A Allergies introducing himself or herself to the patient and explaining the purpose of the triage process M Medications Gathering vital information is critical for making appropriate P Past medical history, Parent’ or caregivers’ triage decisions impression of the child’s condition CHIEF COMPLAINT E Events surrounding the illness “What brings the patient to the ER?” Based on the patient's own words D Diet, Diapers Don’t change the cc to medical diagnosis without adequate cues S Symptoms associated with the illness or injury When a patient is transported by ambulance, much of the triage information can be obtained from prehospital TRIAGE VITAL SIGNS & PHYSICAL EXAM providers, but it is important to acknowledge the patient and to verify information TRIAGE VITAL SIGNS Vital signs provide additional data to support the triage acuity TRIAGE QUESTIONS rating decision Focused physical exam should be based on the patient's MECHANISM TRIAGE QUESTIONS current injury or illness OF INJURY PHYSICAL EXAM Motor Vehicle Speed of the vehicle The triage performs a focused assessment related to the Collision Direction of impact Patient position within the vehicle patient's chief complaint Use of restraints Assess only parameters pertinent to the chief complaint or Airbag deployment patient; this is not a system-by-system or head-to-toe Ejection Rollover examination Fatalities The more non specific the symptom, the more difficult the Ambulatory at the scene entrapment or assessment prolonged extrication FOCUSED PHYSICAL ASSESSMENT AT TRIAGE Penetrating Type of object (knife, bullet, impaled object) Injury Left in place, removed, broken off Respiratory / Respiratory rate, rhythm, depth Fall From how high Cardiac Work of breathing; accessory muscle Landed on which body part(s) use What kind of landing surface Why the patient fell Skin color, temperature, moisture, turgor, mucous membrane status Impact speed Oxygen saturation; peak expiratory Motorcycle Helmet use flow rate Crash Other protective clothing Peripheral edema Thrown Skidded, pinned, or run over NCM118 Critical Care Nursing | Basics in Emergency Nursing Care 3  Breath sounds Position of comfort Chest excursion Level of Consciousness Gastrointestin Abdominal distension, tenderness, al / rigidity, scars, bruising Genitourinary / Circulation, sensation Musculoskelet Motor function, strength al (compare Deformity, wounds side to side) Edema, discoloration Endocrine Skin color, turgor; mucous membrane status Fingerstick blood glucose Level of consciousness Neurologic Facial symmetry, droop, ptosis, drooling Grip strength, pronator drift Speech clarity and articulation Level of consciousness Behavior Pupil size, shape, equality, response to RESUSCITATION Patients who need immediate nursing light and medical attention Motor function and sensation in all extremities EMERGENT Patients who need immediate nursing Glasgow Coma Scale score; mental assessment and rapid treatment status Fingerstick blood glucose Oxygen saturation URGENT Patients who need quick attention but can wait as long as 30 minutes for assessment and treatment Psychiatric Appearance; grooming Speech Affect LESS URGENT Patients can wait up to 1 hour for Behavior: bizarre appropriate assessment and treatment Thought: content and process Memory; orientation NON-URGENT Patients can wait up to 2 hours Potential for danger to self or others (possibly longer) for assessment and treatment Skin Description of wounds: size, location, depth, cause, age, bleeding Contamination; foreign body KINDLY ANSWER THIS: Signs of infection: general or local What if a patient-ambulatory but has a BP of 220/150 -is Rashes, bites, stings other lesions assigned a triage level of 4? And a patient who is having severe menstrual cramps assigned a triage level of 3? Eye Inflammation, drainage, trauma, foreign What is the implication? body, tearing, photophobia Visual acuity: Snellen eye chart, light and dark, shapes VI. TRIAGE DOCUMENTATION Triage assessment documentation should be clear, be concise, and support the assigned severity rating. Each TRIAGE ACUITY RATING hospital needs to have a triage policy that includes Based on the chief complaint and on subjective and documentation requirements objective data, triage nurses use their knowledge, Many EDs now use computerized documentation systems experience, and triage guidelines to assign a severity rating. This decision will be derived logically from the information A. ELEMENTS OF COMPREHENSIVE TRIAGE obtained DOCUMENTATION Date and time of arrival at the emergency department Patient age Chief complaint NCM118 Critical Care Nursing | Basics in Emergency Nursing Care 4  Triage interview time ○ Environment Allergies (medications, food, latex) Check areas of injury Current medications (prescription, over-the-counter, Allergic reactions → starting of anaphylactic shock supplements) Triage severity rating Vital signs REFERENCES First aid measures Lecture Slides Reassessments Assessment of pain History of current complaint NOTES Subjective and objective assessment Significant medical history Last menstrual period Last tetanus immunization Diagnostic procedures initiated Medications administered at triage Signature of registered nurse Consider including the following ○ Mode of arrival ○ Use of an interpreter VI. ADDITIONAL NOTES ABCDE ○ Airway Hindi diretso intubate. Assess the breathing sounds like stridor. COPD px: 88-90 normal O2 SAT because they can cause CO2 retention pag tumaas → Respiratory Acidosis Priority airway for oxygenation Normal blood sugar: 80-100 Stress hyperglycemia: 120 above; hindi sometimes pinapansin sa CCU ward ○ Breathing Provide adequate o2 High flow O2: risk for dry nose so di masyado mataas yung O2 stat but mataas yung PaO2. Use a cotton applicator and nasal spray. Wag basta basta tanggalin yung high flow O2 because baka mag bleed yung nose. ○ Circulation ○ Disability Determine neuro status, get GCS Alert Pain Unresponsive Independent nursing intervention: get CBG bc hypoglycemic → decrease sensorium (brain attack) Stress hyperglycemia- physiologic stress LOC Awake Confused Lethargic Disoriented Obtunded Stuporous NCM118 Critical Care Nursing | Basics in Emergency Nursing Care 5  CRITICAL CARE NURSING PATIENT ASSESSMENT Prof. Janelle P. Castro, MSN, RN, PhD 1st Semester | Module 5 OUTLINE Interventions: ○ Oxygen therapy I. Primary Assessment ○ Use of airway adjuncts A. Initial Assessment – ABCDE Mnemonic ○ Suction as indicated II. Secondary Assessment A. FGHI Mnemonic ○ Remove foreign objects that may obstruct breathing ○ Treat life-threatening conditions CIRCULATION I. PRIMARY ASSESSMENT Assessment: The first step in the primary assessment is to determine if ○ Pulse and blood pressure the patient is conscious ○ Bleeding or hemorrhage Identify life-threatening problems ○ Capillary refill and color of skin and mucous ○ Airway membranes ○ Breathing ○ Cardiac rhythm ○ Circulation Interventions: Appropriate interventions are required before proceeding to ○ Start CPR, medications and defibrillation or secondary assessment synchronized cardioversion ○ Control hemorrhaging ○ Establish IV access and fluid therapy A. INITIAL ASSESSMENT – ABCDE MNEMONIC ○ Treat life threatening conditions A Airway DISABILITY Assessment: B Breathing ○ Neurologic assessment Level of consciousness C Circulation Pupils Motor and sensory function D Disability AVPU (awake, verbal, pain, unresponsive) Interventions: E Exposure and Environment ○ Institute cervical spine immobilization AIRWAY EXPOSURE AND ENVIRONMENT Assessment: Assessment: ○ Airway patency ○ Environmental exposure Interventions: Extreme cold or heat ○ Institute cervical spine immobilization until z-rays Injuries determine whether the patient has CSI Interventions: ○ Position the patient ○ Examine patient to determine extent of injuries ○ Open the airway – make sure the neck is midline and ○ Institute appropriate therapy (warming therapy or stabilized