CRITICAL CARE

NURSING
Course Unit 1 :
Scopes of Critical Care Nursing
 CRITICAL CARE NURSING CONCEPTS
• Critical
▫ (Crucial – Crisis – Emergency – Serious)

• Critical Care Nursing

▫ care of the seriously-ill clients
from point of injury/illness until discharge
from intensive care

▫ Deals with human responses to life-

threatening problems

▫ Comprehensive, specialized, and individualized

nursing services which are rendered to
patients with life-threatening conditions
 CRITICAL CARE NURSING CONCEPTS
• Goal:
üSurvival of the critically-ill patients
and
üRestoring QUALITY of LIFE
üHelping families of critically-ill
patients in coping with stress
 CRITICAL CARE NURSING CONCEPTS
• Role of a Critical Care Nurse:

▫ Care for clients who are very ill

▫ Provide one-to-one care

▫ Responsible of making life and death

decision

▫ At risk of injury and illness

▫ COMMUNICATION SKILL is of optimum

importance
 CRITICAL CARE NURSING CONCEPTS
• Critically-ill client
▫ Require more intensive and careful nursing care

▫ At risk for actual or potential life-threatening

health problems

▫ Examples:
▫ Post-operative clients with major surgery
▫ Illness involving vital organs
▫ Stable clients with signs of impending doom
 Classification of Critical Care Clients
▫ Level 0 : normal ward care

▫ Level I : at risk of deteriorating

= support from critical care team

▫ Level II : needs more observation or

intervention
= single failing organ
= post operative care

▫ Level III : multisystem failure

= advanced respiratory support
= basic respiratory support
 CRITICAL CARE NURSING CONCEPTS
• PRINCIPLES OF CRITICAL CARE

▫ Continuous monitoring and treatment

▫ High intensity therapies

▫ Expert surveillance and efficiency

▫ Alert to early manifestations and

recognition of parameters denoting
progress and deterioration
 CRITICAL CARE NURSING CONCEPTS
• Roles of Critical Care Nurse
• to identify sudden and subtle changes
in the condition of the patient
• to immediately provide emergency
treatment
• Frequent nursing assessment
• Round the clock monitoring

ü Care provider
ü Educator
ü Manager
ü Advocate
 CRITICAL CARE NURSING CONCEPTS
• Goals of Critical care

▫ Towards the survival of the critically-

ill patients and restoring QUALITY of
LIFE

▫ Helping families of critically-ill

patients in coping with stress
CRITICAL CARE NURSING CONCEPTS
• Common Critical Care Unit Equipments
▫ Cardiac Monitor
▫ Pulse oximeter
▫ Swanz-Ganz Catheter
▫ Arterial lines
▫ Central venous catheter
▫ Nasograstic Tube
▫ Chest tubes
▫ Endotracheal tubes
▫ Urinary catheters
▫ Tracheostomy
▫ Ventilator
ASSESSMENT FRAMEWORK
FOR
CRITICAL NURSING
ASSESSMENT FRAMEWORK
qStarts from the awareness of the nurse
of the client’s admission and continues
until transition to the next phase of care

q STAGES:
q Pre- arrival assessment

q Admission quick-check

q Comprehensive Admission Assessment

q On-going Assessment
ASSESSMENT FRAMEWORK

• PRE-ARRIVAL ASSESSMENT

q Begins when the information is received

about the pending arrival of the patient

q Abbreviated report on patient

= brief summary of px condition
= what has been performed

q Complete room set-up including verification

of proper equipment functioning
 ASSESSMENT FRAMEWORK
• PRE-ARRIVAL ASSESSMENT

q The charge nurse notifies Nurse Loise that she will be

receiving a 26-year-old man from the ER who was
involved in a serious car accident. The ED nurse caring
for the patient has called to give Nurse Loise a report.
The patient suffered a closed head injury and chest
trauma with collapsed left lung. The patient was
intubated and placed on a mechanical ventilator. IV
access had been obtained, and a left chest tube had
been inserted. After obtaining a computed
tomographic (CT) scan of the head, the patient will be
transferred to the ICU. Nurse Loise questions the ED
nurse regarding whether the patient has been
agitated, had a Foley catheter placed and whether
family had been notified of the accident.
ASSESSMENT FRAMEWORK

• PRE-ARRIVAL ASSESSMENT
• BEFORE THE ACTION BEGINS

q The charge nurse notifies Nurse Loise

that she will be receiving

ü 26-year-old man from the ER who

was involved in a serious car accident

ü patient suffered a closed head injury

and chest trauma with collapsed left
lung.
ASSESSMENT FRAMEWORK

• PRE-ARRIVAL ASSESSMENT

q The charge nurse notifies Nurse Loise

that she will be receiving

ü The patient was intubated and placed

on a mechanical ventilator.

ü IV access had been obtained, and a

left chest tube had been inserted

ü computed tomographic (CT) à ICU

ASSESSMENT FRAMEWORK
• PRE-ARRIVAL ASSESSMENT

q Nurse Loise goes to check the patient’s

room prior to admission and begins to do a
mental check of what will be needed.

Ø “The patient is intubated so…

Ø I’ll connect the AMBU bag to the

oxygen source,

Ø check for suction catheters and

make sure the suction systems are
working.
ASSESSMENT FRAMEWORK

• PRE-ARRIVAL ASSESSMENT

Ø The pulse oximeter and the ventilator

are ready to go.

Ø I have an extra suction gauge to

connect to the chest tube system.

Ø I’ll also turn on the ECG monitor and

have the ECG electrodes ready to
apply.
ASSESSMENT FRAMEWORK
• PRE-ARRIVAL ASSESSMENT

q Nurse Loise goes to check the patient’s

room prior to admission and begins to do a
mental check of what will be needed.

q The arterial line flush system and

transducer are also ready to be connected.

q The IV infusion devices are set up.

q This patient has an altered LOC, which

means frequent neuro checks and potential
insertion of an ICP catheter for monitoring.
ASSESSMENT FRAMEWORK
• PRE-ARRIVAL ASSESSMENT

q Nurse Loise goes to check the patient’s

room prior to admission and begins to do a
mental check of what will be needed.

q I have my pen light handy, but I better

check to see if we have all the equipment
to insert the ICP catheter in case the
physician wants to perform the procedure
here after the CT Scan.

q I think I’m ready.”

 ASSESSMENT FRAMEWORK
• ADMISSION QUICK CHECK
q General appearance
q consciousness

q Aiway
q Instruct the client to talk

q Rise and fall of chest

q Rate, rhythm, depth, symmetry

q Breathing
q Check for tongue obstruction
 ASSESSMENT FRAMEWORK
• ADMISSION QUICK CHECK ASSESSMENT
• THE FIRST FEW MINUTES

q Circulation
q Check pulse, HR, Temp

q ECG

q Peripheral perfusion

q color, temp., moisture of skin,

capillary refill
 ASSESSMENT FRAMEWORK
• ADMISSION QUICK CHECK ASSESSMENT
• THE FIRST FEW MINUTES

q Cerebral perfusion
q functional integrity of the brain

q LOC

q alert

q aware of surroundings

q GCS

q follows commands
 ASSESSMENT FRAMEWORK

• ADMISSION QUICK CHECK ASSESSMENT

• THE FIRST FEW MINUTES

q Chief Complaint
q obtained from patient

q family, friends or bystanders

q absence of history source

q PE

q onset, precipitating factors and severity

 ASSESSMENT FRAMEWORK
• ADMISSION QUICK CHECK ASSESSMENT
• THE FIRST FEW MINUTES

q Drugs and Diagnostic tests and

Disability
q meds prior to admission

q Rx

q OTC

q ellicit

q current meds
 ASSESSMENT FRAMEWORK
• ADMISSION QUICK CHECK ASSESSMENT
• THE FIRST FEW MINUTES

q Drugs and Diagnostic tests

q review diagnostic test results

q serum electrolytes

q glucose

q CBC with platelets

q Coagulation studies

q ABG

q Chest x-ray

q ECG
 ASSESSMENT FRAMEWORK
• ADMISSION QUICK CHECK ASSESSMENT
• THE FIRST FEW MINUTES

q Equipment
q Vascular and drainage tubes for location

and patency
q connect to appropriate monitoring or

suction devices
q Note:

q amount

q color

q consistency

q odor of drainage secretions

ASSESSMENT FRAMEWORK
• Comprehensive Admission Assessment
q In-depth assessment
q Past medical History

q Past hospitalizations

q Medications

q Allergies

q Social history

q Interaction processes

q Vices

q Psychosocial assessment

qBehavior

qEmotion culture
ASSESSMENT FRAMEWORK
• Comprehensive Admission Assessment
q Physical Assessment

q Nervous system

q GCS scoring

q Pupil assessment

q LOC

q Trauma

q Cardiovascular system

q Check for pulses

q Check perfusion
ASSESSMENT FRAMEWORK
• Comprehensive Admission Assessment
q Physical Assessment
q Respiratory system

q Breathing pattern

q Arterial blood gas result

q Auscultation

q Secretions

q Urinary system

q Amount

q Color

q Odor

q Dx: BUN/Crea/UA
ASSESSMENT FRAMEWORK
• Comprehensive Admission Assessment
q Physical Assessment

q Gastrointestinal system

q Nutrition and hydration status

q Contour and symmetry of abdomen

q IAPePa

q Integumentary System

q Check the integrity

q Ulcer stages:

q Stage I Stage II
q Stage III Stage IV
ASSESSMENT FRAMEWORK
 ASSESSMENT FRAMEWORK

• ON-GOING ASSESSMENT
q subsequent assessments are used to;

q determine trends
q evaluate response to therapy
q identify new potential problems
q changes from the comprehensive
baseline assessment
 ASSESSMENT FRAMEWORK

• ON-GOING ASSESSMENT
q Done periodically

q Unstable patients:
q every 15 mins

q Stable patients:
qevery 2-4 hours
CRITICAL CARE
NURSING
Course Unit 2 :
Ethical and Legal Considerations in
Critical Care Nursing
Foundations for Ethical Decision Making
1. Professional codes and standards
2. Institutional policies
3. Legal standards
4. Principles of ethics
a. Beneficence
b. Nonmaleficence
c. Autonomy
d. Privacy
e. Confidentiality
f. Fidelity
g. Veracity
 ETHICS
§ Moral principles that govern a person’s
behavior or the conducting of an activity

§ Moral
= what societies sanction as right and
acceptable

§ Principle
= fundamental / basic truth
= serves as the foundation for a system
of belief or behavior
 PRINCIPLES OF ETHICS
• BENEFICENCE • PRIVACY
üDo what is BEST for
the health of a patient üFree from unjust
ü Acting in the patient’s access by others
best interest
• NON MALEFICENCE • CONFIDENTIALITY
üDo no harm = NO BAD üProtection of
üCareful consideration of information
risks vs benefits
üDemands informed
consent if a risky
procedure is attempted
 PRINCIPLES OF ETHICS
• AUTONOMY • FIDELITY
ü Respect for üAgreement to keep
persons promises
ü Honoring patient’s
decision
• JUSTICE • VERACITY

ü To do what is fair üBeing truthful or

and equitable honest
A 39 year old white male with a past medical history of renal
cell carcinoma, currently stage 1, is seen in the Oncology
office. He says that he does not want to engage in cancer
suppression therapy. And does not want to hear about
Chemotherapy or Radiation or resection. He is content to die.
The patient is judged to have full capacity in making this
decision. Which of the following is the best response?

A. “ I respect your decision, but tell me how you arrived

at this decision.?”
B. “ I respect your decision, but medically there is hope
to treat this.”
C. “I respect your decision, but it is my obligation to tell
you that this is not the best course of action.”
D. We will not proceed with any further treatment.”
E. “I will be forced to discuss your choice with the ethics
committee.”
A 56-year-old hispanic female is found to have elevated
LFTs on routine screening. She is recommended to undergo
a liver biopsy. As part of the informed consent process, she
is explained all of the pertinent information. The
explanation of risks vs benefits, in this situation, is carefully
balancing which ethical principles?

A. Non maleficence vs Autonomy

B. Non maleficence vs Justice
C. Non maleficence vs Beneficience and Autonomy
D. Non maleficence vs Beneficience and Justice
E. Non maleficence vs Beneficience
A 28 year old black male with a past medical history of GERD
is seen in the ED waiting room for bloating and gas. He is
concerned that he has a bowel obstruction. He is triaged by
the ED staff and waits in the waiting room for the next 3.5
hours. He sees other patients, who arrived after him, go
straight back to the ED. In this situation, is the ethical
principle of justice being upheld for the patient forced to
wait in the waiting room?

A. No, this patients treatment is not equal

B. No, this patients treatment is not equitable
C. Yes, triage is an exception to justice
D. Yes, this patients treatment is equal
E. Yes, this patients treatment is equitable
 CONTEMPORARY ISSUES
• Informed Consent
q aka
q Operative permit
q Surgical consent

q Patient’s autonomous decision about

whether to undergo certain diagnostic
procedure, therapeutic measures, or
surgical procedure
 CONTEMPORARY ISSUES
▫ Informed Consent
q PURPOSE:
q The client understands the nature of

the treatment and its advantages and

disadvantages
qTo indicate that NO COERCION was made

before signing
qTo PROTECT the client against
unauthorized procedure
qTo PROTECT the surgeon and the hospital
against legal actions
 CONTEMPORARY ISSUES
• Informed Consent q Obtained: MD
q Secured :RN
q INCLUDES: q Given : Pt

qName of Procedure
q Name of MD

q Name of witness (RN)

q Date

q Potential

complication/Disfigure
ment
 CONTEMPORARY ISSUES

• Informed Consent

q 3 MAJOR ELEMENTS:

q No Coercion/Voluntary
q Sound Mind

q Ultimate Decision Maker

= patient
 CONTEMPORARY ISSUES
• Informed Consent
q REQUISITES FOR VALIDITY:
q Written consent made by the client

q No signs of pressure
q No sedation
q 24 hours before elective surgery
q Legal age and mentally capable
q 2 surgeons signed the consent in
emergency
q Emancipated minor*

q Authorized representative*
 CONTEMPORARY ISSUES
• Informed Consent
qEMANCIPATED MINOR:
ü a legal mechanism
ü a minor before attaining the age of majority is
freed from control by their parents or guardians
ü parents or guardians are free from responsibility
for their child
ü age?
ü Don’t want to live with parents and parents
don’t mind
ü Can handle own money
ü Can have a legal way to make money
ü It is good for person
 CONTEMPORARY ISSUES
• Informed Consent
q AUTHORIZED
q EMANCIPATED MINOR: REPRESENTATIVE:
q A college student living q Minor
q Unconscious
away from home
q Psychologically
q In military service
incapacitated
q Pregnant
q Anybody who has given birth
 CONTEMPORARY ISSUES
• Informed Consent
q EXEMPTIONS:

q Experts agreed that the care is

EMERGENCY

q Life-threatening condition

q The client is unconscious and authorized

representative cannot be reached
 CONTEMPORARY ISSUES
• Advanced Directive
q Statements made by the individual with

decision-making capacity that describe the

care or treatment he/she wishes to receive
when no longer competent

q Two forms:
q Treatment directive (living will)

q Proxy Directive (Durable Power of Attorney)

 CONTEMPORARY ISSUES
• End-of-Life-Issues
q Nutrition and Hydration
q Given thru NGT, IV, or duodenal feedings,
or gastrostomy

q CONTINUE
q Nutrition and hydration status expedites

the patients return to an acceptable level of

functioning
q DISCONTINUE

q Non-beneficial
 CONTEMPORARY ISSUES
• PATERNALISM

▫ when a health care professional makes for a

patient without the explicit consent of the patient

Deliberate restriction of autonomy by health

care professionals based on the idea that they
know what is best for the client

▫ Refers to instances in which the principles

of beneficence overrides autonomy
 CONTEMPORARY ISSUES
• Pain Management

q One of the main components of

palliative care
q Done if there is a decision to forego

life- sustaining treatment

q“should provide interventions to relieve

pain and other symptoms in the dying
patient even when those interventions
entails risks of hastening death”

q ANA (Code for Nurses)

 Laws on Critical care Nursing
1. Scope of Nursing practice based on R.A. 9173
(Philippines Nurses Act of 2002
= provide protection and improvement of nursing
profession
= relevant nursing education
= humane working conditions
= better career prospects
= dignified existence for nurses
2. Nurses’ Code of Ethics
= guiding outline for how nurse’s should behave
ethically
 Laws on Critical care Nursing
3. Patient’s Bill of Rights and Obligations
= appropriate health and medical care of good
quality
4. Dying Patient’s Bill of Rights
= “I have the right to be treated as a living human
being until I die”
5. Senate Bill 586:
= An Act Providing Palliative and End-Of-Life Care,
Appropriating Funds therefore and for other
purposes
 The Process of Ethical Analysis
1. Assessment
a. Identify the problem – clarify the competing
ethical claims, conflicting obligations, and personal
and professional values; acknowledge the emotional
and communication issues
b. Gather data – distinguish the morally relevant
facts, including medical, nursing, legal, social, and
psychological facts; clarify patient’s religious and
philosophical beliefs and values
c. Identify the individuals involved in the problem’s
development and who should be involved in the
decision making; discern factors that may impede the
patient’s ability to make the decision
 The Process of Ethical Analysis
2. Plan
a. Consider all options and avoid restricting
choices to the most obvious
b. Identify the pros and cons (“harms and
goods’)
c. Analyze if plan is in accordance with ethical
theories and principles
d. Look into institutional policies and/or
procedures that address the issue
 The Process of Ethical Analysis
3. Implementation
– choose a plan and act (anticipate objections)

4. Evaluation
a. Outline the results
b. Identify what harm or good occurred as a
result
c. Identify necessary changes in the institutional
policy(ies) or other strategies to avoid similar
issues in the future