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King Saud University college of nursing

critical care nursing lecture1

Introduction to critical care nursing

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Learning Outcome 1

• Define critical care nursing

• Define critical care nurse

• Define critical care patient

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Critical-care nursing

• is that specialty within nursing that deals specifically with human responses to life-threatening problems.

• A critical-care nurse is a licensed professional nurse who is responsible for ensuring that all critically ill patients and their families receive optimal care

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Critical-care nursing

• The first intensive care units emerged in the 1960s as a means to provide care to very sick patients who needed one-to-one care from a nurse.

• The first critical care unit were CCU and recovery room

• It was from this environment that the specialty of critical-care nursing emerged.

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Critical-care nursing

• Critical-care nurses rely upon a specialized body of knowledge, skills, and experience to provide care to patients and families and create environments that are healing, humane, and caring.

• Foremost, the critical-care nurse is a patient advocate.

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Nurse as Patient Advocate

• Support autonomous decision making and decisions made; respect values; represent patient based on these choices

• Intervene in patient’s best interests; intercede for those who cannot advocate for selves; help patients get care

• Educate patient and family members• Ensure safe, quality care• Serve as liaison between patient, family, and

providers• Help the patient obtain necessary care

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critically ill patients

• AACN Definition• American Association of Critical Care Nurses

defines critically ill patients as• “those who are at high risk for actual or potential

life threatening health problems. The more critically ill the patient is, the more likely he or she is to be highly vulnerable, unstable and complex, thereby requiring intense and vigilant nursing care.”

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Learning Outcome 3

• Discuss the concerns expressed by critically ill patients

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1. Concerns of critically ill patients

• Noise, lights, and alarms• Being thirsty• Having tubes in their mouths and nose• Not being able to communicate• Being restricted by tubes/lines• Being unable to sleep• Not being able to control themselves

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Critical Care Environment

• Noise levels

• Light 24 hours/day

• Movement of people and equipment

• Lack of privacy

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Learning Outcome 4

• Compare and contrast the use of enteral and parenteral nutrition in the critically ill patient.

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COMMON PROBLEMS OF CRITICAL CARE

PATIENTS• Nutrition:– The primary goal of nutritional support is to

prevent or correct nutritional deficiencies. – This is usually accomplished by the early

provision of enteral nutrition (i.e., delivery of calories via the gastrointestinal [GI] tract) or parenteral nutrition (i.e., delivery of calories intravenously).

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1. Enteral Nutrition

• Delivery of nourishment by feeding tube in the gastrointestinal tract

• Delivered through a large bore nasal or oral gastric tube (short-term use)

• Small bore feeding tubes or gastrostomies (long-term use)

• Preferred route for nutritional supplementation• Lower rates of infection• Composed of proteins, calories, vitamins, and

minerals• Standard formulas

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Enteral Feeding

• . Common Problems with Early Enteral Feeding

• High gastric residual volumes

• Bacterial colonization of the stomach

• Increased risk of aspiration pneumonia

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Parenteral nutrition • Infusion of nutrients using a venous catheter located in a large,

usually central vein• Used when nutrition supplement is needed and enteral feedings

cannot be initiated within 24 hours of ICU admission• Formulated by providing dextrose, lipids, protein, electrolytes, water,

and vitamin elements• Specific components of the infusion is prescribed for each patient

• should be considered only when the enteral route is unsuccessful in providing adequate nutrition or contraindicated (e.g., paralytic ileus, diffuse peritonitis, intestinal obstruction, pancreatitis,

GI ischemia, intractable vomiting, and severe diarrhea).

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Common Problems Associated with Parenteral Nutrition/Nurse Interventions

• Gut mucosal atrophy

• Overfeeding

• Hyperglycemia

• Increased risk of infectious complications

• Increased mortality

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Learning out come 5

•Identify common problems in critical care unit and there management

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Anxiety:

– The primary sources of anxiety for patients include the perceived or anticipated threat to physical health, actual loss of control or body functions, and an environment that is foreign.

– Assessing patients for anxiety is very important and clinical indicators can include agitation, increased blood pressure, increased heart rate, patient verbalization of anxiety, and restlessness.

– To help reduce anxiety, the nurse should encourage patients and families to express concerns, ask questions, and state their needs; and include the patient and family in all conversations and explain the purpose of equipment and procedures.

– Antianxiety drugs and complementary therapies may reduce the stress response and should be considered.

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Pain:

– The control of pain in the ICU patient is paramount as inadequate pain control is often linked with agitation and anxiety and can contribute to the stress response.

– ICU patients at high risk for pain include patients (1) who have medical conditions that include ischemic, infectious,

or inflammatory processes; (2) who are immobilized; (3) who have invasive monitoring devices, including endotracheal

tubes; (4) and who are scheduled for any invasive or noninvasive

procedures.– Continuous intravenous sedation and an analgesic agent are

a practical and effective strategy for sedation and pain control.

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Impaired communication:

– Inability to communicate can be distressing for the patient who may be unable to speak because of sedative and paralyzing drugs or an endotracheal tube.

– The nurse should explore alternative methods of communication, including the use of devices such as notepads or computer keyboards.

– Nonverbal communication is important. Comforting touch with ongoing evaluation of the patient’s response should be provided.

– Families should be encouraged to touch and talk with the patient even if the patient is unresponsive or comatose.

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Delirium

• Sudden onset of disturbances in cognition, attention, and perception

• Manifest as hyperactive, hypoactive, or mixed

• Mixed type is most prevalent in ICU

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Delirium

– Delirium in ICU patients ranges from 15% to 40%.• Demographic factors predisposing the patient to delirium include

1.advanced age,

2. preexisting cerebral illnesses,3.Environmental factors that can contribute to delirium include sleep

deprivation, anxiety, sensory overload, and immobilization.4.Physical conditions such as hemodynamic instability, hypoxemia,

hypercarbia, electrolyte disturbances, and severe infections can precipitate delirium.

5. Certain drugs (e.g sedatives, furosemide, antimicrobials) have been associated with the development of delirium

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Management of Delirium

• The ICU nurse must identify predisposing factors that may precipitate delirium and improve the patient’s mental clarity and cooperation with appropriate therapy (e.g., correction of oxygenation, use of clocks and calendars).

• If the patient demonstrates unsafe behavior, hyperactivity, insomnia, or delusions, symptoms may be managed with neuroleptic drugs (e.g., haloperidol).

• The presence of family members may help reorient the patient and reduce agitation.

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Management of Delirium

• Treatment includes medication and environment and supportive strategies

• Treatment with sedatives alone can worsen delirium

• Decrease drugs that contribute to delirium or discontinue them

• Limit unnecessary noise• Provide patients with eyeglasses or hearing

aides

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Sleep problems:

– Patients may have difficulty falling asleep or have disrupted sleep because of noise, anxiety, pain, frequent monitoring, or treatment procedures.

– Sleep disturbance is a significant stressor in the ICU, contributing to delirium and possibly affecting recovery and can decreases patient immunity

– The environment should be structured to promote the patient’s sleep-wake cycle by clustering activities, scheduling rest periods, dimming lights at nighttime, opening curtains during the daytime (natural light), obtaining physiologic measurements without disrupting the patient, limiting noise, and providing comfort measures.

– Benzodiazepines like Diazepam (Valium)lorazepam (Ativan) and benzodiazepine-like drugs (Zolpidem) can be used to induce and maintain sleep.

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Learning Outcome 6

• Discuss ways to identify and meet the needs of families of critically ill patients.

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ISSUES RELATED TO FAMILIES

• Family members play a valuable role in the patient’s recovery and should be considered members of the health care team.

• They contribute to the patient’s well-being by:– Providing a link to the patient’s personal life– Advising the patient in health care decisions or

functioning as the decision maker when the patient cannot

– Helping with activities of daily living– Providing positive, loving, and caring support

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ISSUES RELATED TO FAMILIES

• To provide family-centered care effectively, • the nurse must be skilled in crisis intervention.

– Interventions can include active listening, reduction of anxiety, and support of those who become upset or angry.

– Other health team members (e.g., , psychologists, ) may be helpful in assisting the family to adjust and should be consulted as necessary.

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ISSUES RELATED TO FAMILIES

• The major needs of families of critically ill patients have been categorized as

• informational needs, • reassurance needs, • and convenience needs.

– Lack of information is a major source of anxiety for the family.– The family needs reassurance regarding the way in which the patient’s

care is managed and decisions are made and the family should be invited to meet the health care team members, including physicians, nurses ,dietitian, respiratory therapist, social worker, and physical therapist, .

– Rigid visitation policies in ICUs should be reviewed, and a move toward less restrictive,

– Research has demonstrated that family members of patients undergoing invasive procedures, including cardiopulmonary resuscitation, should be given the option of being present at the bedside during these events.

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Needs of Families of Critically Ill Patients

• Personnel care about the patients• Believe there is hope• Waiting room near the patient• Called when changes in the patient occur• Know the prognosis• Have questions answered honestly• Know specific facts about patient’s progress• Be allowed to see the patient frequently

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Needs of Families of Critically Ill Patients

• Provide information• Discuss patient goals• Written instructional guidelines to provide

information about critical care• A way to contact the nurse• Consistency in the nurse• Open visiting hours• Assess to telephones, bathrooms, and food• Good communication• Relaxed waiting area near the patient

04/20/23 IMAD THULTHEEN CRITICAL CARE NURSING

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Visual Map Critically Ill Patient Summary