Introduction to Critical CareModern critical care is provided to patients by a multidisciplinary team of health care professionals who have in-depth education in the specialty field of critical care. Critical care is provided in specialized units or departments, and importance is placed on the continuum of care, with an efficient transition of care from one setting to another. Critical care patients are at high risk for actual or potential life-threatening health problems. Those who are more critically ill require more intensive and vigilant nursing care. Critical care unit is a specially designed and equipped facility staffed by skilled personnel to provide effective and safe care for dependent patients with a life threatening problem

Critical care units, also Intensive called care or intensive therapy departments, are sections within a hospital that look after patients whose conditions are life-threatening and need constant, close monitoring and support from equipment and medication to keep normal body functions going. They have higher levels of staffing, specialist monitoring and treatment equipment only available in these areas and the staff are highly trained in caring for the most severely ill patients. Some hospitals have areas called high dependency units (HDU) and some specialist units have high dependency areas within the ICU. Hospitals differ in what they call these areas but their role and expertise is the same

CCUS CAN BE CLASSIFIED AS:Level 0 : Patients whose needs can be met through normal wardLevel 1: Patients at risk of their condition deteriorating, or higher levels of care whose needs can be met on advice and support from the critical care team.Level 2: Patients requiring more detailed observation or intervention, single failing organ system or postoperative care, and higher levels of care.Level 3 : Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure.High dependency can refer to level 1 or 2 whereas critical care usually means level 2 or 3

ORGANIZATIONAL MODELS FOR ICUs:the open model allows many different members of the medical staff to manage patients in the ICU.the closed model is limited to ICU-certified physicians managing the care of all patients; and the hybrid model, which combines aspects of open and closed models by staffing the ICU with an attending physician and/or team to work in tandem with primary physicians.

CRITICAL CARE NURSINGspecialty 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 acutely and critically ill patients and their families receive optimal care

SEVEN Cs OF CRITICAL CARE NURSINGCompassion Communication (with patient and family). Consideration (to patients, relatives and colleagues) and avoidance of Conflict. Comfort: prevention of suffering Carefulness (avoidance of injury) Consistency Closure (ethics and withdrawal of care).

ROLES & RESPONSIBILITIESRespect andsupport the right of the patient or patients designated surrogate to autonomy and informeddecision making.Intervene when the best interest of the patient is in question. Helpthepatientobtainnecessarycare. Respectthevalues,beliefs,andrightsofthepatient. Provide education and support help to the patient or patients designatedsurrogatetomakedecisions. Representthepatientinaccordancewiththepatientschoices. Support the decisions of the patient or patients designated surrogate ortransfercaretoanequallyqualifiedcriticalcarenurse. Intercedeforpatientswhocannotspeakforthemselvesinsituationsthatrequireimmediateattention. Monitorandsafeguardthequalityofcarethatthepatientreceives. Act as a liaison between the patient and the patients family and otherhealthcareprofessionals.

HOLISTIC CRITICAL CARE NURSINGCaringConcern has been voiced about the diminished emphasis on the caring component of nursing in this fast-paced, highly technologic health care environment.It has been said that keeping the care in nursing care is one of our biggest challenges.The critical care nurse must be able to deliver high-quality care skillfully, using all appropriate technologies, while incorporating psychosocial and other holistic approaches as appropriate to the time and condition of the patientThe caring aspect between nurses and patients is most fundamental to the Relationship and to the health care experience

Individualized CareThe differences between nurses and patients perceptions of caring point to the importance of establishing individualized care that recognizes the uniqueness of each patients preferences, condition, and physiologic and psychosocial status. An important aspect in the care delivery to and recovery of critically ill patients is the personal support of family members and significant others. The value of patient- and family-centered care should not be underestimated.It is important for families to be included in care decisions and to be encouraged to participate in the care of the patient as appropriate to the patients personal level of ability and needs.

Cultural CareCultural diversity includes not only ethnic sensitivity but also sensitivity and openness to differences in lifestyles, opinions, values, and beliefs.Unless cultural differences are taken into account, optimal health care cannot be provided. More attention has been directed recently at determining the physiologic differences and those of disease development and progression among various ethnic groups.Cultural competence is one way to ensure that individual differences related to culture are incorporated into the plan of care.Nurses must possess knowledge about biocultural, psychosocial, and linguistic differences in diverse populations to make accurate assessments. Interventions must then be tailored to the uniqueness of each patient and family.

Evidence-based practice (EBP) The use of the best available research data from well-designed studies coupled with experiential knowledge and characteristics, values, and patient preferences in clinical practice to support clinical decision making.The use of research ndings in clinical practice is essential to promote optimal outcomes and to ensure that nursing practice is effective.Practice based on intuition or information that does not have a scientic basis is not in the best interest of patients and families.

Barriers to Evidence-Based Practice (EBP)Lack of knowledgeLack of research skills, resources, or bothLack of organizational support and management commitmentLack of timeLack of incentive to change behaviorLack of condence in personal ability to change practiceLack of authority to change practice

Strategies for promoting EBPUse of protocols, clinical pathways, and algorithmsIncreasing clinicians awareness of available resources:Databases such as PubMed, CINAHL, HINARI and MEDLINE; Web sites such as UpToDate, which offers real-time evidence-based recommendations for patient care, and the Cochrane Library, a source of high-quality, independent evidence to inform healthcare decision making; and professional nursing organizations, such as the AACN, which publishes research-based Practice AlertsCreating an organizational culture that supports EBP:Identifying EBP champions, Incorporating EBP activities into nurses roles, allocating time and money to the process, promoting multidisciplinary collaboration among researchers and practitioners

HEALTHY WORK ENVIRONMENTThe health care environment is stressful, and increasing challenges in the areas of financial constraints, regulatory requirements, consumer scrutiny, quickly changing technologies and treatment regimens, and workforce diversity contribute to conflicts and difficulties on a daily basis.In this environment, it is essential to offer support for health care providers that can mitigate these challenges and ensure a healthy place to work.Unhealthy work environments lead to medical errors, suboptimal safety monitoring, ineffective communication among health care providers, and increased conflict and stress among care provider

Healthy Work Environment StandardsStandard I: Skilled CommunicationNurses must be as proficient in communication skills as they are in clinical skills.Standard II: True CollaborationNurses must be relentless in pursuing and fostering true collaboration.Standard III: Effective Decision MakingNurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations.Standard IV: Appropriate StaffingStaffing must ensure the effective match between patient needs and nurse competencies.Standard V: Meaningful RecognitionNurses must be recognized and must recognize others for the value each brings to the work of the organization.Standard VI: Authentic LeadershipNurse leaders must fully embrace the imperative of a healthy work environment, authentically live it, and engage others in its achievement.

The Patients and FamilysExperience With Critical IllnessThe patients experience in a critical care unit has lasting meaning for the patient and family.Often, it is the caring and emotional support given by the nurse that is remembered and valued.Research has found that although many patients recall negative experiences, they also recall neutral and positive experiences.Negative experiences were related to: fear, anxiety, sleep disturbance, cognitive impairment, and pain or discomfort. Positive experiences were related to feelings of being safe and secure and were often attributed to the care provided by nurses, specically nurses technical competence and effective interpersonal skills.The need to feel safe and the need for information are predominant themes

Managing Stress and AnxietyPatients admitted to the critical care unit are subject to multiple physical, psychological, and environmental stressors, as are their family members.The body responds to these stressors by activating the hypothalamic pituitaryadrenal axis. The resultant increase in catecholamine, glucocorticoid, and mineralocorticoid levels leads to a cascade of physiological responses known as the stress responseIn critically ill patients, prolonged activation of the stress response can lead to immunosuppression, hypoperfusion, tissue hypoxia, and other physiologic effects that impair healing and jeopardize recovery.

Anxiety, pain, and fear can initiate or perpetuate the stress response. Anxiety is an emotional state of apprehension in response to a real or perceived threat that is associated with motor tension, increased sympathetic activity, and hypervigilance.Feelings of helplessness, loss of control, loss of function or self-esteem, and isolation can produce anxiety, as can a fear of dying. Left untreated or undertreated, anxiety can contribute to the morbidity and mortality of critically ill patients.

Common Stressors in CCUsThreat of deathUncertainty about future and fear of permanent residual health deficits Pain, discomfort, and physical restrictionsLack of sleepLoss of autonomy and control over ones body, environment, privacy, and daily activitiesUnfamiliar environments with excessive light, noises, alarms, and distressing eventsWorry about finances, potential job loss, and stress on loved onesSeparation from family, friends, and meaningful social roles and workLoss of dignity, embarrassing exposures, and a sense of vulnerabilityBoredom broken only by brief visits, threatening stimuli, and procedural touchLoss of ability to express oneself verbally when intubatedUnfamiliar bodily sensations due to bed rest, medications, surgery, or symptomsUnanswered spiritual questions and concerns about meaning of the events and life

Minimizing stress and anxietyFostering trust: When patients or family members mistrust caregivers, they are more anxious because they are unable to feel safe and secureDisplaying a condent, caring attitude; demonstrating technical competence; and developing effective communication techniques are strategies that help the nurse to foster trusting relationships with both patients and family members.

Providing informationAnxiety can be greatly relieved with simple explanations. Critically ill patients and their family members need to know what is happening at the moment, what will happen to the patient in the near future, how the patient is doing, and what they can expect.Many patients also need frequent explanations of what happened to them. These explanations reorient them, sort out sequences of events, and help them distinguish real events from dreams or hallucinations.

Ensuring privacy. Ensuring privacy while sensitive or condential information is being exchanged can markedly reduce the anxiety of a patient or family member. Healthcare providers are not always mindful of their surroundings when discussing condential details of a patients case. The nurse can direct healthcare providers and family members to a quiet room away from the general waiting area to afford privacy when discussing specic patient information.

Allowing control Nursing measures that reinforce a persons sense of control help increase autonomy and reduce the overpowering sense of loss of control that can increase anxiety and stress.The nurse can help the patient and family exert more control over the environment by providing order and predictability in routines; using anticipatory guidance; allowing the patient and family to make choices whenever possible; involving the patient and family in decision making; and explaining procedures thoroughly, including why the procedure is needed.

Strategies For Communicating With Patients And Family MembersBe patient. What is routine for caregivers can be stressful and new to patients and family members.Repeat information as many times as necessary. Stress reduces concentration, memory, and comprehension, especially in unfamiliar situations.Assess patient and family knowledge level and prior experience with critical care.Use understandable language and interpret medical terms, without talking down.Asking clarifying questions to help validate understanding.Use a welcoming, open communication style. Critical care units can feel intimidating to people unfamiliar with the environment.Offer frequent updates regarding patients condition, even if not asked.Engage in conversations of meaning with patients and family members, even if brief. Often critical care conversations are reduced to conveying only technical aspects of care.

Conti.Honor privacy and provide space for family conferences.Speak to patients, even if they are unconscious. This conveys caring to family and words may comfort the patient, even if there is no response.Use communication boards or other devices with patients unable to speak.Give patients time to respond and ask questions patient can likely answer easily.Speak slowly and look at patients when communicating. Gestures, lip movements, and facial expressions convey important messages.

SPIRITUAL CHALLENGES IN CRITICAL CAREMany of the psychosocial issues - anxiety, self-concept, body image, self-esteem, coping, dignity, and relationships with othersare rooted in the spiritual dimension of life, the seat of a persons deepest meanings and ground of being. Ones spiritual dimension encompasses those elements of life that provide meaning, purpose, hope, and connectedness to others and a higher power.Providing spiritual care is essential for patient recovery in critical care units.

Spiritual Distressa disruption in the life principle that pervades a persons entire being and that integrates and transcends ones biologic and psychosocial nature.Threats of physiologic or psychologic illness, prolonged pain, and suffering can challenge a persons spirituality.Separation from ones meaningful religious or spiritual practices and rituals, coupled with intense suffering, can induce spiritual distress for patients and their families.Patients experiencing spiritual distress may question the meaning of suffering and death in relation to their personal belief system.Some individuals in spiritual despair may question their existence, verbalize their wish to die, or display anger toward Unresolved spiritual distress is interpreted in the body as a stressor.

Hope and HopelessnessConsidered to be a spiritual process, hope is an energy that arises out of a sense of being meaningfully connected to ones self, others, and powers greater than the self. With hope, a person is able to transition from a state of vulnerability to a point of being able to live as fully as possible.Hopelessness is a subjective state in which an individual sees extremely limited or no alternatives and is unable to mobilize energy on his or her own behalf. Feelings of hopelessness can greatly hinder recovery. Conditions that increase a persons risk for feeling hopeless include a loss of dignity, long-term stress, loss of self-esteem, spiritual distress, and isolation, all of which can be present in a critical care experience

Loss of Control and PowerlessnessMany patients admitted to a critical care unit have experienced a rapid onset of illness or an injury and have not had time to adjust to the limits of their changed circumstances. They have to adapt quickly to a loss of control.Patients who have a pervasive sense that they can do nothing to change or control their circumstances are at risk for feeling powerless.Critically ill people can experience powerlessness due to the constraints of their health and the care environment, a loss of meaningful interpersonal interactions with their usual support system, inability to maintain cultural or religious beliefs and practices, or by adopting a helpless coping style.

Holistic Psychosocial-spiritual CareIn addition to having sophisticated knowledge of anatomy and physiology, the pathophysiology of disease processes, and appropriate nursing interventions, the holistic critical care nurse also needs the knowledge, wisdom, and skills to interpret the internal human responses to experiences of serious illness or injury.Essential skills that underlie nursing interventions for psychosocial-spiritual care include:using communication patterns based on compassion and care, practicing dignity-enhancing care, supporting patient coping, using a family-centered focus, and engaging spiritual resources.

Nursing Interventions for Care of the Family in CrisisConvey feelings of hope and condence in the familys ability to deal with the situation.Try to perceive the feelings that the crisis evokes in the family.Demonstrate concern about the patient and family and a willingness to help.Speak openly to the patient and the family about the critical illness.Discuss all issues as they relate to the patient specically, avoiding generalizations.Be realistic and honest about the situation, taking care not to give false reassurance.

ContiEnsure that the family receives information about all signicant changes in the patients condition.Mitigate feelings of powerlessness and hopelessness by involving families in decision making and patient care.Advocate for the adjustment of visiting hours to accommodate the needs of the family.Locate space near the unit where the family can be alone and have privacy.Recognize the patients and familys spirituality, and suggest the assistance of a spiritual advisor if there is a need.

PATIENT AND FAMILY EDUCATIONPatient education is a process that includes the purposeful delivery of health-related information to promote changes in behavior that will optimize health practices and assist the individual in attaining new skills for living.This concept can be overwhelming in the fast-paced, technology-rich setting of the critical care environment.The bedside nurse must incorporate the abundant educational needs of the patient or family into the education plan and be aware of the requirements of regulatory agencies and the legalities of documenting the teaching-learning encounter.

BenefitsClarification of patients understanding and perceptions of their chronic illness and care decisionsImproved health outcomes relative to self-management techniques, such as symptom managementPromotion of informed decision making and control over the situationDiminished emotional stress associated with an unfamiliar environment and unknown prognosisImproved adaptation to stressful situationsImproved satisfaction with the care receivedImproved relationship with the health care teamPromotion of self-concept

The Education ProcessSTEP 1: ASSESSMENTEducation provided should be appropriate to the patients condition and should address the patients identified learning needs.Learning needs can be defined as gaps between what the learner knows and what the learner needs to know, such as survival skills, coping skills, and ability to make a care decision.Identification of actual and perceived learning needs directs the health care team to provide need-targeted education.Educational needs of the patient and family can be categorized asinformation only (environment, visitation hours, get questions answered);Informed decision making (treatment plan, informed consent); or Self-management (recognition of problems and how to respond).Learning needs may change from day to day, shift to shift, or minute to minute. Educational needs are influenced by how the patient or the family perceives or interprets the critical illness.

Factors Affecting the Learning ProcessInformation must also be gathered on factors that affect the education process and impair the ability of the patient or family to respond. These factors include:desire and motivation; physical or cognitive limitations; cultural and religious views of illness or health; emotional barriers; and barriers to effective communication.

STEP 2: EDUCATION PLAN DEVELOPMENTDetermining What to Teach: Education must be ongoing, interactive, and consistent with the patients plan of care and education level.Learning needs in the critical care unit, can be separated into four different categories to help set teaching priorities in each phase of the hospitalization:Initial contact or first visit, with a focus on immediate needsContinuous care Transfer to a different level of carePlanning for aftercare, discharge planningWriting Goals or Outcomes: An outcomes statement helps clarify to the teacher and the learner what is to be taught, what is to be learned, what is to be evaluated, and what is to be documented. Developing Interventions: Interventions describe how a nurse will become involved in providing education to the patient or the family

STEP 3: IMPLEMENTATIONAfter the assessment is completed and the education plan is developed, need-targeted education can commenceSetting up the Environment: The optimal environment for learning is one that is nonthreatening, comfortable, open, and honest.Many factors concerning the CCU environment can be threatening or anxiety producing. Use various teaching strategies

STEP 4: EVALUATIONThe intent of evaluation is to determine the effectiveness of the educational interventions. The nurse must use his or her clinical judgment and knowledge of adult-learning principles to determine how well the learner has met the expected outcomes and objectives. STEP 5: DOCUMENTATIONDocumentation of education is necessary to communicate educational efforts to members of the health care team, patients and families, and regulatory agencies. The nurse should recognize that informal teaching at the bedside is education.

Factors that affect the teaching-learning processLack of an accurate assessmentSetting unrealistic goalsNot involving the patient or the family in the processOverloading the learner with informationRelying too heavily on resourcesHaphazard and nondirected teaching; lack of an education plan of careTeaching at the wrong time, hurried teaching, not paying attention to the learnerLack of trust and rapport between the teacher and learnerLack of communication among health care providersLanguage-related communication barriers