CRITICAL CARE NURSING

1. CRITICAL CARE NURSING
BY:
MRS.KEERTHI SAMUEL
ASST.PROFESSOR
VIJAY MARIE COLLEGE OF NSG

2. INTRODUCTION
 Critical care Nursing is a specialty within nursing that deals
specifically with human responses to life threatening
problems.
 The care of seriously ill clients from point of injury or illness
until discharge from intensive care .
 Critical care deals with human responses to life threatening
problems –trauma /major surgery

3. DEFINITIONS
CRITICAL CARE
 Term used to describe as the care of
patients who are extremely ill and whose
clinical conditions is unstable or potentially
unstable.
CRITICAL CARE UNIT
 Defined as the unit in which comprehensive
care of a critically ill patient which is deemed
to recoverable.
 It is a specially designed and equipped with
skilled staff and personnel to provide
effective and safe care for patients with life
threatening problem that is potentially
reversible.

4. DEFINITIONS
CRITICAL CARE NURSE
 Critical care Nurse is a licensed
professional who is responsible for
ensuring that acutely and critically ill
patients and their families receive optimal
care.
CRITICAL CARE NURSING
 Critical care Nursing is a specialty within
nursing that deals specifically with human
responses to life threatening problems.

5. 7 C’S OF CRITICAL CARE
Compassion
Communicati
on
Consideration
Patient,
relatives ,
colleagues
Comfort
Protect
patient from
suffering
Carefulness
Avoid injury
Consistency
Observation
and care
Closure
(ethics/withdr
awal of
treatment)

6. LEVELS OF CCU’S
LEVEL-I CCU
 High dependency units which could be either
separate or attached to a general ward
 Short term cardio respiratory support.
 Resuscitation , short term mechanical ventilation
and simple invasive cardiovascular monitoring for
< 24 hours.
 Duty medical officer will be present whenever
needed
LEVEL-II CCU
 Located in general hospital , undertake prolonged
ventilation.
 Provides a high standard of general intensive care,
including complex multisystem life support.
 Ex: Myocardial Infarction,Single failing organ, Post
operative care etc…
 DMO is present throughout and physician will be
available on call.
 Nurse patient ratio will be 1:2

7. LEVELS OF CCU’S
LEVEL-III CCU
 Tertiary referral unit for Intensive care patients
 Provides comprehensive critical care including complex multi system life
support for an indefinite period.
 Nurse patient ratio will be 1:1
 Commitment to academic research and education
 Physician will be present throughout.
 Ex: Hemodialysis, Neuro surgery patients, MODS,

8. ORGANIZATIONAL MODELS FOR ICU
OPEN MODEL CLOSED MODEL HYBRID MODEL
Allows many different
members of the medical
staff to manage patients in
the ICU
Is limited to ICU certified
physicians , intensivists
managing the care of all
patients
Combines open and closed
by staffing the ICU with
and attending physician
/team to work in
association with primary
physicians

9. PRINCIPLES OF CRITICAL CARE NURSING
 Anticipation
 Early detection and prompt action
 Collaborative practice
 Communication
 Prevention of infection
 Crisis intervention and stress reduction
 Expertise
 Supportive care

10. STAFFING IN ICU
MEDICAL STAFF:
• Director,and experienced
Intesivist to provide
patient care,
administration, teaching,
audits etc
TRAINED NURSING
STAFF
• 1:1 for ventilated patients
, 1:2 for other patients
and a Nurse in charge
with ICU qualification
ALLIED HEALTH
AND ANCILLARY
STAFF
• Respiratory
therapist,physiotherapist,
dietician,biomedical
engineer, computer
programmer,social
worker, counseller,
house keeping staff etc.

11. ORGANIZATION OF CCU
 Design of CCU
 Location
 Bed strength
 Bed space
 Staffing –
 Medical staff
 Nursing Staff
 Allied Services
 Central Nursing station

12. PLANNING OF CCU- LOCATION
 Decided based on type of patient treated
 Ex: if the unit is used for care of surgical patients it is best cited near the
operating /recovery room.
 Other specialized unis prefer to have them as part of their own
department where the patient care is based on the concept of
progressive care. That is from intensive care to intermediate care and
then to general patient care area.
 If only one CCU in the whole hospital it should be centrally located and
should be easily accessible to all departments in the hospital.

13. PLANNING OF CCU- NUMBER OF BEDS
 Estimation of bed need is done by considering the
 number of patients seeking CCU care
 Average length of stay in unit
 Occupancy rate
 Considering all this one lakh population needs 14-15 beds.
 Number of additional beds is calculated by knowing the average daily
census of patients needing CCU care and desired bed availability.
ADC= no.of admissions to CCU X length of stay in CCU
365

14. PLANNING OF CCU- NUMBER OF BEDS
 Applying the formula ,a hospital with 500 intensive care admissions
with average 7-8 days stay per year result in an estimate 9-11 beds.
 Another way to estimate is to quote the figure for 1 bed for 100
general patients.
 Ideally the number of beds in one unit should not exceed 10-12 and
the minimum should be 4 catering to both the sexes.
 Beds can be organized into general beds or specialized beds.
 6-8 beds is the ideal size to be served by one nursing station. Max 10-
12 beds can be accommodated.

15. PLANNING A CCU- DESIGN
 Critical care unit can be X-shaped,U shaped or semi circle so as to have good
observation..
 Individual rooms are recommended to minimize cross infection, reduce noise
level and provide privacy for conscious patients. This would require more staff for
the unit.
 Separate cubicles are preferred when privacy is required.
 Nurses station which is nerve center of the unit, should be close enough to
patients to permit observation of the patient.
 The proximity of the nurses station to the patient saves the energy for nurses and
influences patients confidence.
 Emergency call system of nurses has o be there for every bed

16. PLANNING A CCU- LIGHTING
 CCU s need continuous observation.
 Unit should be well lit.
 Background illumination from ceiling should be color corrected.
 Lighting should be as natural as possible.
 Portable spotlight should be available.
 Each bed should be provided with a night lamp so that clients
can be aware of diurnal variations

17. PLANNING A CCU- TEMPERATURE & HUMIDITY
 Units should be air conditioned for sake of patients, equipment, staff.
 Temperature to be adjusted to 68-72 degree F.
 Adequate air exchange should be there for 20 times per hour
 Air conditioners should have humidity control to provide comfort.
 Isolation rooms should incorporate non recirculating air control that
maintains slightly positive pressure for reverse isolation or slightly negative
pressure for conventional isolation.
 Wall thermometers should be ideally placed to check the efficiency of AC
systems

18. OTHER FACILITIES IN CCU
1. NURSES STATION:
 It should be planned permitting direct visual
observation of patients with facilities for charting,
telephone, placement of patient record and central
cardiac monitoring systems.
2. Hand washing:
 facilities convenient to nurses station, drug distribution
area,pantry, clean and dirty utility area and individual
rooms especially in isolation rooms.
 Taps should be elbow operating or peddle operating.

19. OTHER FACILITIES IN CCU
3. CHANGING ROOM:
 It should be separate for both men and women
 Shoe rack and individual cupboards for storing personal items of
nursing and other personnel has to be there in the changing rooms
4. WORKROOM:
 Clean workroom appropriates with working storing for clean and
sterile supplies.
 This includes work counter and storing personal effects of nursing
and other personnel.
5. STAFF TOILET ROOM

20. OTHER FACILITIES IN CCU
6. SLUICE ROOM:
 Where the facilities for flushing the bedpans and
automatic bedpan washers are situated.
7. DRUG DISTRIBUTION STATION:
 Where medicine trolley and dangerous drug
cupboards are centrally located.
8. Clean linen storage
9. Pantry for storage and food preparation
10. Conference room
11. Duty doctors room
12. Laboratory
13. Emergency equipment storage

21. PLANNING A CCU- ELECTRICAL SYSTEM
 Safe electrical system is needed to prevent shock hazards
 Special precautions if the patient needs any electrical operated devices.
 Portable fire extinguisher should be fitted at convenient places and staff
should be instructed its use.
 Electrical system should be connected to a generator
 Switches and power points for the same should be situates within the units.
 Generator connections are mandatory for CCUs in order to sustain life
saving devices during power failure.
 Walls and floors are ideally made with glazed tiles or other materials which
can be easily washed and disinfected . All wood items should be covered
with washable material.

22. EQUIPMENT IN ICU
MONITORING
RESUCITATIVE
SUPPORTIVE

23. MONITORING EQUIPMENT IN ICU
 12 lead ECG device to take an ECG when necessary.
 ECG monitor that displays the vital signs has to be connected
 Other parameters measured are CVP, Oxygen monitoring, end tidal
co2, pulmonary wedge monitoring
 Computerized monitoring with a facility of print out may beplaced.
 Special equipment like ABG machine, HB, elctrolytes has to be placed.
 Bedside monitoring of blood sugars , insulin infusions, TPN infusions.
 Access to spirometer to assess TV and VC.

24. RESUSCITATIVE EQUIPMENT IN ICU
 To manage clients with life threatening conditions like arrythmias, shock, RF
and oxygen failure.
 Crash trolley with emergency drugs fluids and equipment. This is wheeled to
patients bedside during resuscitation and ensure that needed supplies are
available.
 Venturi masks, ET tubes, laryngoscopes, and ambu bags form part of crash
trolley
 Other equipment involve suction and oxygen cylinders.
 Pacemaker , defibrillator are recommended for each unit.
 Ventilators and emergency equipment should be readily available for
management of respiratory problems

25. SUPPORTIVE EQUIPMENT IN ICU
 Special ICU beds with flat washable surfaces, detachable head
end, holes for IV drip stands at convenient places , easy moving
siderails, adjustable head and foot end, adjustable height .
 Alternating pressure mattress to prevent pressure ulcer
 All infection control protocols are strictly carried out
 Laminar airflow systems for needed clients
 Clocks, calendars and lights of varying intensity for day and night

26. CROSS INFECTION
 Cross infection is a problem and should be considered in spacing of beds.
 Single rooms, barrier nursing facilities should be considered for units with infection or immune
compromised patients.
 All surfaces should be able to withstand germicide.
 Each patient in barrier nursing area should be cared by a nurse specially assigned.
 Contaminated equipment, instruments, linen should be treated in separate utility room.
 Adequate handwashing facility.
 Casual visiting should be discouraged .
 Periodic check by bacteriology department is necessary

27. FACTORS AFFECTING PATIENT WELL BEING
 Large windows through which patient can have access to outside view is advisable.
 Color of unit should be aesthetically pleasing as possible and conducive to recovery with
minimum sensory deprivation.
 Use of clocks with night and day in different colors, large calendars and light with varying
intensity during the night will help patient to get oriented.
 Most units allow 5-10 min every 2 hours.
 Comfortable waiting room

28. ADMISSION CRITERIA
 Large windows through which patient can have access to outside view is advisable.
 Color of unit should be aesthetically pleasing as possible and conducive to recovery with
minimum sensory deprivation.
 Use of clocks with night and day in different colors, large calendars and light with varying
intensity during the night will help patient to get oriented.
 Most units allow 5-10 min every 2 hours.
 Comfortable waiting room

29. CRITICALLY ILL CLIENT-NEWS/MEWS SCORE
PARAMETERS 3 2 1 0 1 2 3
Respiration ≤8 9-11 12-20 21-24 ≥25
Oxygen saturation ≤91 92-93 94-95 ≥96
Supplemen.Oxygen Yes No
Temperature ≤35.0 35.1-36.0 36.1-38.0 36.1-
39.0
≥39.1
Systolic BP ≤90 91-100 101-110 111-219 ≥220
Heart rate ≤40 41-50 51-90 91-110 111-130 ≥131
LOC A V,P or U

30. CRITICALLY ILL CLIENT-MEWS SCORE
SCORE INTERPRETATION
LOW SCORE :1-4 Should be monitored every 12 hours
MEDIUM SCORE- 5 OR MORE Should be evaluated every 4 hours
HIGH SCORE -7 OR MORE Should be evaluated hourly

31. CASE STUDY
 Mr.R is an old man , found lying on the street
by police . On assessment his BP is
100/75mmHg, pulse is 110 beats per minute
and respiration is 9 breaths/min temperature
is 102F and spo2 is 98%. Classify the patient
 Respiration-1
 Saturation-0
 Supplemental oxygen-0
 Temperature – 1
 Systolic BP -1
 Heart rate -1
 Level of consciousness-3
TOTAL -7 RED