1.1. critical care concepts

CRITICAL CARE NURSING:
Concepts
1Prof. Dr. Ram Sharan Mehta, MSND, CON, BPKIHS

CRITICAL
 Crucial
 Crisis
 Emergency
 Serious
 Requiring immediate action
 Thorough and constant observation
 Total dependent
(Oxford Dictionary)
2Prof. Dr. R S Mehta, BPKIHS

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.

 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.

 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.

9
Critical Care Technology
 ECG monitoring
 Arterial Lines
 Oxygen Saturation
 Ventilation
 Intracranial Pressure
Monitoring
 Temperature
 Pulmonary Artery
Catheter
 IABP
 Extensive use of
pharmaceuticals
 & May more….
Prof. Dr. R S Mehta, BPKIHS

Prof. Dr. R S Mehta, BPKIHS 10
Historical Background

World War II
 Shock wards
established for
resuscitation
 Transfusion practices
in early stages
 After World war-II,
nursing shortage
forced grouping of
postoperative patients
in recovery areas
11WW-II: 1939-1945

Polio epidemic
 1950’s: use of
mechanical ventilation
(“iron lung”) for treatment
of polio
 Development of
respiratory intensive care
units
 At the same time, general
ICU’s developed for sick
and postoperative
patients

14
History Continued
 Collaboration between nurses and
physicians
 1950’s & 1960’s – CV Disease most
common diagnosis
 1960’s – 30-40% mortality rate for MI
 1965 – 1st specialized ICU – The
Coronary Care Unit
 Emergence of Specialized ICU’s
Prof. Dr. R S Mehta, BPKIHS

ICU’s also treat the dying
 Isaac Asimov:
“Life is pleasant.
Death is peaceful.
It is the transition
that is difficult”
Isaac Asimov: Professor of Biochemistry Boston 16

An Ideal ICU

Multidisciplinary & Collaborative
approach to ICU care
 Medical & nursing directors :
co-responsibility for ICU management
• a team approach :
doctors, nurses, R/T, pharmacist
• use of standard, protocol, guideline
consistent approach to all issues
• dedication to coordination and communication
for all aspects of ICU management
• emphasis on research, education, ethical
issues, patient advocacy

CLASSIFICATION OF
CRITICAL CARE PATIENTS
 Level O : normal ward care
 Level 1: at risk of deteriorating , support
from critical care team
 Level 2 : more observation or
intervention, single failing organ or post
operative care
 Level 3; advanced respiratory support or
basic respiratory support ,multiorgan
failure 23Prof. Dr. R S Mehta, BPKIHS

Types of ICU
 General
 Medical Intensive Care Unit(MICU)
 Surgical Intensive Care Unit
 Medical Surgical Intensive Care Unit(MSICU)
 Specialized
 Neonatal Intensive Care Unit(NICU)
 Special Care Nursery(SCN)
 Paediatric Intensive Care Unit(PICU)
 Coronary Care Unit(CCU)
 Cardiac Surgery Intensive Care Unit(CSICU)
 Neuro Surgery Intensive Care Unit(NSICU)
 Burn Intensive Care Unit(BICU)
 Trauma Intensive Care Unit

ICU & CCU Service of
BPKIHS
Nursing Care and Protocols

Critical Care
Considerations
 F=Feeding/fluid
 A=Analgesics
 S=Sedation
 T=Thrombolytic agents
 H=Head elevation
 U=Ulcer – bed sore
 G=Glucose monitoring

Feeding and Fluids
 It includes
 Enteral feeding
o Oro - gastric and Naso - gastric feeding
o Churn diet
o Dairy and poultry products (Milk, egg,
youghort)
o High protein liquid diet
o Medications

 Oral feeding
o Hospital diet
o Bland diet
o Normal diet
o Liquid intake

 Transparenteral diet
o Oliclinomel
Includes:-
• Amino acid solution with electrolyte (5.5%) volume
800 ml
• Amino acid 44 gram
• Na acetate
• Na glycerophosphate
• KCl

 MgCl2
 Sodium
 Magnesium
 PO4
 Acetate
 Chloride
 Glucose 20% solution with CaCl2

Overall volume of TPN = 2000 ml
 Osmolarity = 75 mOsm/L
 pH = 6
 Amino acid = 44 gram
 Total calorie = 1,215 Kcal

 Fluids
 IV fluids like NS, RL, 5% D, 10% D, DNS

Analgesics
 Fentanyl
o It works 600 times more effectively than
Morphine and reduces the pain and
increases the pain threshold
o Used in moderate and severe pain
o In ICU 50 – 100 µg per Kg
o Antidote Naloxone 0.05 mg/ Kg

 Morphine
o Reduces pain
o Chiefly used in MI
o 2-4 mg dissolved in 10 ml NS
o Antidote: Naloxone
o Supplied by hospital.

 Acetaminophen and NSAIDs
o Often more effective than opioids in reducing
pain from pleural or pericardial rubs, a pain that
responds poorly to opioids.
o particularly effective in reducing muscular and
skeletal pain
o Tab form: 500mg OD

Sedatives
 Benzodiazepines
1. Midazolam
oShort acting sedatives and hypnotics
oIn intubated patients
oDose 0.01- 0.05 mg/Kg for several hours

Benzodiazepines…
2. Diazepam
• Adult dose = 0.2 – 0.5 mg/ Kg
• Not given in MI patients

Dissociative Anaesthesia
 Ketamine
 Adult dose= 1 – 3 mg/kg IV

Propofol
o Arousal is rapid 10- 15 min
o Used in neuro cases and those with
increased ICP, during tracheostomy
procedure

Inotropes
 Dopamine
 Dobutamine
 Nor- adrenaline

Thrombolytic agents
 TEDS compressive stocking
 SCD (Systematic Compressive Device)
 LMWX
 Heparin flush

Head elevation
 Head is elevated to 30 degree.

Ulcer
 Two hourly position change
 Back care in each shift
 Oxygen therapy
 Each shift dressing of pressure sore
 Air mattresses

Glucose monitoring
 RBS as prescribed
 Insulin therapy
 Careful monitoring of signs of
Hypoglycemia
(trembling, clammy skin, palpitations,
anxiety, sweating, hunger, and irritability)

Infection control
 Hand washing before, during and after the procedure
 Sterility maintenance during procedures
 Use of disinfectants
 Weekly high wash
 Monthly culture test of health personnel, equipments
and infrastructures
 Regular inspection by infection control team
 Each shift CVP dressing

Specific equipments used in
ICU and CCU
 Ventilators
 Infusion pumps
 Cardiac monitors
 Defibrillator
 ABG machine
 ECG machine

Drugs used in CCU
 Aspirin
 Clopidogrel
 Nitroglycerine
 Atorvastatins
 LMWX
 Morphine

Sedation score in ICU is
done by RASS
(Richmond Agitation Sedation Scale = RASS)

RASS
(Richmond Agitation Sedation Scale)
Number Characteristics Definition Intervention
+4 Combative Violent, immediate
danger to staff
Restrain and
sedate
+3 Very agitated Aggressive, pull or
remove tubes
Restrain and
sedate
+2 Agitated Frequent non
purposeful movement,
fights ventilator
Restrain and
sedate
+1 Restless Anxious movement
but not aggressive or
vigorous
Sedate
0 Alert and calm

Number Characteristics Definition Intervention
-1 Drowsy Not fully alert but has
sustained awakening,
eye contact to voice
(>10 sec)
Verbal
stimulation
-2 Light sedation Briefly awakens, eye
contact to voice
(<10sec)
Verbal
stimulation
-3 Moderate
sedation
Moderate or eye
opening to voice but
no eye contact
Verbal
stimulation
-4 Deep sedation No response to voice
but movement or eye
opening to physical
stimuli
Physical
stimulation
-5 No response No response to voice
or physical stimuli
Physical
stimulation

“It may seem a
strange principle to
enunciate (articulate)
as the very first
requirement in a
Hospital that it should
do the sick no harm.”
[1859]

Thank you…!!!

1.1. critical care concepts

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1.1. critical care concepts