CRITICAL CARE NURSING

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CRITICAL CARE NURSING:

CRITICAL CARE NURSING

DEFINITIONS:

DEFINITIONS CRITICAL CARE : CRITICAL CARE IS A TERM USED TO DESCRIBE AS THE CARE OF PATIENTS WHO ARE EXTREMELY ILL AND WHOSE CLINICAL CONDITION IS UNSTABLE OR POTENTIALLY UNSTABLE.

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CRITICAL CARE UNIT : IT IS DEFINED AS THE UNIT IN WHICH COMPREHENSIVE CARE OF A CRITICALLY ILL PATIENT WHICH IS DEEMED TO RECOVERABLE STAGE IS CARRIED OUT.

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CRITICAL CARE NURSING : IT REFERS TO THOSE COMPREHENSIVE, SPECIALIZED AND INDIVIDUALIZED NURSING CARE SERVICES WHICH ARE RENDERED TO PATIENTS WITH LIFE THREATENING CONDITIONS AND THEIR FAMILIES.

What are the conditions considered as Critical? :

What are the conditions considered as Critical? ANY PERSON WITH LIFE THREATENING CONDITION PATIENTS WITH : ARF AMI CARDIAC TAMPONATE SEVERE SHOCK

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HEART BLOCK ACUTE RENAL FAILURE POLY TRAUMA, MULTIPLE ORGAN FAILURE AND ORGAN DYSFUNCTION SEVERE BURNS

NURSING ASSESSMENT:

NURSING ASSESSMENT IT IS THE FIRST STAGE OF NURSING PROCESS IN WHICH THE NURSE SHOULD CARRY OUT A COMPLETE AND HOLISTIC NURSING ASSESS- MENT OF EVERY PATIENT’S NEEDS, REGARDLESS OF THE REASON FOR THE ENCOUNTER.

COMPONENTS OF NURSING ASSESSMENT:

COMPONENTS OF NURSING ASSESSMENT NURSING HISTORY: Taking a nursing history prior to the physical examination allows a nurse to establish a rapport with the patient and family. Elements of the history include – Health Status Cause of present illness including symptoms Current management of illness Past medical history including family’s medical history

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Social history Perception of illness Psychological and Social Examination- Client’s perception Emotional health Physical health Spiritual health Intellectual health 3. Physical Examination : A nursing assessment includes physical examination, where the observation or measurement of signs, which can be observed or measured, or symptoms such as nausea or vertigo, which can be felt by the patient.

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The techniques used may include Inspection, Palpation, auscultation and Percussion in addition to the vital signs like temperature, pulse, respiration , BP and further examination of the body systems such as the cardiovascular or musculoskeletal systems. Documentation of Assessment: The Assessment is documented in the patient’s medical or nursing records, which may be on paper or as part of the electronic medical record which can be assessed by all members of the health care team.

CLASSIFICATION OF CRITICAL CARE UNITS:

CLASSIFICATION OF CRITICAL CARE UNITS LEVEL - I : PROVIDES MONITORING, OBSERVATION AND SHORT TERM VENTILATION. NURSE PATIENT RATIO IS 1:3 AND THE MEDICAL STAFF ARE NOT PRESENT IN THE UNIT ALL THE TIME.

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LEVEL - II : PROVIDES OBSERVATION, MONITORING AND LONG TERM VENTILATION WITH RESIDENT DOCTORS. THE NURSE-PATIENT RATIO IS 1:2 AND JUNIOR MEDICAL STAFF IS AVAILABLE IN THE UNIT ALL THE TIME AND CONSULTANT MEDICAL STAFF IS AVAILABLE IF NEEDED.

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LEVEL - III : PROVIDES ALL ASPECTS OF INTENSIVE CARE INCLUDING INVASIVE HAEMODYNAMIC MONITORING AND DIALYSIS. NURSE PATIENT RATIO IS 1:1

TYPES OF CRITICAL CARE UNIT:

TYPES OF CRITICAL CARE UNIT NEONATAL INTENSIVE UNIT (NICU) SPECIAL CARE NURSERY (SCN) PAEDIATRIC INTENSIVE CARE UNIT (PICU) PSYCHIATRIC INTENSIVE UNIT (PICU)

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CORONARY CARE UNIT (CCU) CARDIAC SURGERY INTENSIVE CARE UNIT (CSICU) CARDIOVASCULAR INTENSIVE CARE UNIT (CVICU) MEDICAL INTENSIVE CARE UNIT (MICU) MEDICAL SURGICAL INTENSIVE CARE UNIT (MSICU)

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OVERNIGHT INTENSIVE RECOVERY (OIR) NEUROSCIENCE / NEUROTRAUMA INTENSIVE CARE UNIT (NICU) NEURO INTENSIVE CARE UNIT (NICU) BURN INTENSIVE CARE UNIT (BNICU)

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SURGICAL INTENSIVE CARE UNIT (SICU) TRAUMA INTENSIVE CARE UNIT (TICU) SHOCK TRAUMA INTENSIVE CARE UNIT (STICU) TRAUMA – NEURO CRITICAL CARE INTENSIVE CARE UNIT (TNCC)

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RESPIRATORY INTENSIVE CARE UNIT (RICU) GERIATRIC INTENSIVE CARE UNIT (GICU)

PRINCIPLES OF CRITICAL CARE NURSING:

PRINCIPLES OF CRITICAL CARE NURSING ANTICIPATION : The first principle in critical care is Anticipation. One has to recognize the high risk patients and anticipate the requirements, complications and be prepared to meet any emergency. Unit is properly organized in which all necessary equipments and supplies are mandatory for smooth running of the unit. EARLY DETECTION AND PROMPT ACTION : The prognosis of the patient depends on the early detection of variation, prompt and appropriate action to prevent or combat complication. Monitoring of cardiac respiratory function is of prime importance in assessment.

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COLLABORATIVE PRACTICE : Critical Care, which has originated as technical sub-specialized body of knowledge has evolved into a comprehensive discipline requiring a very specialized body of knowledge for the physicians and nurses working in the critical care unit fosters a partnerships for decision making and ensures quality and compassionate patient care. Collaborate practice is more and more warranted for critical care more than in any other field. COMMUNICATION : Intra professional, inter departmental and inter personal communication has a significant importance in the smooth running of unit. Collaborative practice of communication model

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unlike the traditional practice model enhances better outcome as far as patient, nurse, physician and hospital are concerned. This model centres around the patient, fosters individual clinical decision making, uses integrated medical records and join review of care. Prevention of Infection : Nosocomial infection cost a lot in the health care services. Critically ill patients requiring intensive care are at a greater risk than other patients due to the immunocompromised state with the antibiotic usage and stress, invasive lines, mechanical ventilators, prolonged stay and severity of illness and environment of the critical unit itself.

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Crisis Intervention and Stress Reduction : partnerships are formulated during crisis. Bonds between nurses, patients and families are stronger during hospitalization. As patient advocates, nurses assist the patient to express fear and identify their grieving patttern and provide avenues for positive coping.

ORGANIZATION OF ICU:

ORGANIZATION OF ICU DESIGN OF ICU : Should be at a geographically distinct area within the hospital, with controlled access. There should be a single entry and exit. However, it is required to have emergency exit points in case of emergency and disaster. There should not be any through traffic of goods or hospital staff. Supply and professional traffic should be separated from public/visitor traffic.

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Safe, easy, fast transport of a critically sick pt should be a priority in planning its location. Therefore, the ICU should be located in close proximity or ER, OT, trauma ward etc. Corridors, lifts and ramps should be spacious enough to provide easy movement of bed/trolley of a critically sick patient. Close, easy proximity is also desirable to diagnostic facilities, blood bank, pharmacy etc. BED STRENGTH: It is recommended that total bed strength in ICU should be between 8-12 and not less than 6 or not more than 24 in any case.

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2. 3-5 beds per 100 hospital beds for a Level III ICU or 2 to 20% of the total no of hospital beds. 1 isolation bed for every ICU beds. BED AND ITS SPACE: 150-200 sq.ft per open bed with 8 ft in between beds. 225-250 sq.ft per bed if in a single room. Beds should be adjustable, no head board, with side rails and wheels. Keep bed 2 ft away from head wall.

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ACCESSORIES : 3 O 2 outlets, 3 suction outlets (gastric, tracheal and underwater seal), 2 compressed air outlets and 16 power outlets per bed. Storage by each bedside. Hand rinse solution by each bedside. Equipment shelf at the head end. Hooks and devices to hang infusions/ blood bags, extended from the ceiling with a sliding rail to position. Infusion pumps to be mounted on stand or poles. Level II ICUs may require multi channel invasive monitors.

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ventilators, infusion pumps, portable X ray unit, fluid and bed warmers, portable light, defibrillators, anaesthesia machines and difficult airway management equipments are necessary. STAFFING : Medical Staff – the best senior medical staff to be appointed as an Intensive Care Director or Intensivist . Less preferred are other specialists from anaesthesia / medicine who has clinical commitment elsewhere. Junior staff are intensive care trainers and trainees on deputation from other disciplines. Nursing staff – The major teaching tertiary care ICU requires trained nurses in critical care.

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The no of nurses ideally required for such unit is 1:1 ratio, however it might not be possible to have such members in our set up. So 1 nurse for 2 patients is acceptable. The no of trained nurses should also be worked out by the type of ICU, the workload and work statistics and type of patient load. 3. Allied Services – Respiratory services, Nutritionist, Physiotherapist, Biomedical engineer, technicians, computer programmer, clinical pharmacist, social worker / counsellor and other support staff, guards and grade IV workers.

CRITICAL CARE NURSE :

CRITICAL CARE NURSE Factors to be considered in recruiting Critical Care Nurses are: Intra and interpersonal factors Technical Qualifications. Educational background Clinical Experience.

PRIME RESPONSIBILITIES OF A CRITICAL CARE NURSE:

PRIME RESPONSIBILITIES OF A CRITICAL CARE NURSE Continuous monitoring Keep ready emergency trolley / crash Cart Efficient Individualized Care. Counseling and information to family. Application of policies and procedures Proper records of all activities Maintain infection control principles. Keep update with advance information.

QUICK REFERENCE PROTOCOL FOR MANAGING EMERGENCY IN ICU:

QUICK REFERENCE PROTOCOL FOR MANAGING EMERGENCY IN ICU Quickly review the patient - Identity, History , Physical Exam. Be with the patient, ask for help. Place the patient in a suitable position. Attach the cardiac monitor and call for crash cart. Maintain ABC Along with expert team Introduce IV, CV line and TPI

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Administer medication as needed. Carry on Investigations - ABG, ECG, Urea, Creatinine , Blood Sugar, Cardiac enzymes. Maintain Fluid and Electrolytes . Record right things at right time rightly.