An introduction to critical care Nursing and a historical perspective of ICU in Kenya

1. VALERIE SUGE-MICHIEKA

2. Devotional Meditation
Mark 9:23
‘Everything is possible for one who believes.’

3.  Define critical care nursing
 History of critical care nursing
 Define critical care nurse
 Define critical care patient
 Roles of a critical care nurse
 Standards of practice in critical care
3
Review

4. Outline continued
 Major skills of critical care nurse
 Changing role of the critical care nurse
 Issues related critical care

7. 7
Critical Care Now

8. INTRODUCTION
The intensive care unit is not
merely a room or series of room
filled with patients attached to
interventional technology; it is
the home of an organization:
the intensive care team.

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

10. THE AIM OF THE CRITICAL CARE:-
is to see that one provides a care
such that patient improves and
survives the acute illness or tides
over the acute exacerbation of the
chronic illness.

11. CRITICAL CARE NURSING
❖Critical care nursing provides care for patients who are
seriously ill
❖Coping and adaptation mechanisms failed
❖Reliant on life support equipment and external
control for their recovery.
❖Critical care nursing covers a variety of settings
including coronary care, emergency and high
dependency nursing areas.
❖The critical care nurse working in intensive care
provides care for the patient and family.

12. ➢It is a service for patients with potentially recoverable
conditions
➢Who may benefit from more detailed observation and
invasive treatment
➢It is usually reserved for patients with potential or
established organ failure.
➢ Early referral and treatment is particularly important.

13. 13
History of Critical Care & ICU’s
 1930’s – Introduction of Recovery Rooms
 WWII & Korean War – Concepts of triage and
specialty nursing
 Late 1950’s – beginning of Critical Care Units
 Early Technology

14. 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

15. Historical background
 The concept of critical care started with Florence
Nightingale.
 Nightingale developed the concept of clustering the
most acutely ill patients as far back as the 1800s.
 During the poliomyelitis and tuberculosis pandemics
in the middle of the twentieth century, special units
were established, equipped with technical equipment
to manage the airway and ventilate the patient, and
staffed by specialized care providers.

16. HISTORICAL PRESPECTIVES
 Florence nightingale recognized the need
to consider the severity of illness in bed
allocation of patients and placed the
seriously ill patients near the nurses’
station.
 1923, John Hopkins University Hospital
developed a special care unit for
neurosurgical patients .
 Modern medicines boomed to its higher
ladder after world war 2

17. HISTORICAL PRESPECTIVES
 As surgical techniques advanced it became
necessary that post operative patient
required careful monitoring and this came
about the recovery room.
 In 1950, the epidemic of poliomyelitis
necessitated thousands of patients requiring
respiratory assist devices and intensive
nursing care.
 At the same time came about newer horizons
in cardiothoracic surgery, with refinements in
intraoperative membrane oxygen techniques.

18. Bennett, D. et al. BMJ 1999;318:1468-1470

19. HISTORICAL PRESPECTIVES
In 1953, Manchester Memorial
Hospital opened a four bedded
unit at Philadelphia was
started.
 By 1957, there were 20 units
in USA and
In 1958,the number increased
to 150.

20. Bennett, D. et al. BMJ 1999;318:1468-1470

21. Cont…
 In the 1960s, recovery rooms were established for the
care of patients who had undergone surgery, and
coronary care units were instituted for the care of
individuals with cardiac problems.
 Improved outcomes were noted for patients cared for
in intensive care units.
 Critical care nursing evolved as a specialty in the 1970s
with the development of general intensive care units.
 Since that time, critical care nursing has become
increasingly specialized.

22. Bennett, D. et al. BMJ 1999;318:1468-1470

23. CRITICAL CARE UNIT
 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.

24. 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.
24

25. •Forty years of development in
critical care and critical care nursing
has given rise to a recognized
speciality in nursing practice .
•Critical care units have evolved over
the last four decades in response to
medical advances .

26.  The birth of critical care in Kenya was in the 1950s
 Kenya, faced the third polio outbreak in its history and
reached epidemic proportions
 A British anesthetist at the Respiratory Unit of the then
King George Hospital dedicated two ward beds to the
provision of a rudimentary form of respiratory support,
and critical care in Kenya was born.
 In subsequent years, the Respiratory Unit, later renamed
the Infectious Diseases Hospital (IDH), increasingly
provided invasive ventilation to a growing number of polio
victims, with varying degrees of success.

27. Kenyan History
 Recognizing the need for a coordinated critical care service, the Kenya
Government in collaboration with the Japanese International
Cooperation Agency (JICA), established a dedicated 6-bed Intensive
Care Unit (ICU) at the King George Hospital in 1971.
 Later renamed the Kenyatta National Hospital (KNH), this institution
is our largest public, tertiary institution, and home to our first medical
school, the University of Nairobi College of Health Sciences
 The arrival of the Japanese raised the bar for critical care in Kenya, with
better equipment, improved monitoring standards, and the ability to
perform blood gas analysis for the very first time.
 The introduction of a formal critical care service at that point in our
history was timely, as there then followed an outbreak of
laryngotracheobronchitis, many of whom were successfully managed
in this unit.

28. The dawn of critical care nursing in
Kenya cont…
 Lack of local capacity to sustain a formal critical care
service when it was first launched led to Japanese
anaesthetists, surgeons and critical care nurses having to
provide the bulk of the skilled labour in the ICU, as
capacity building began in earnest.
 Critical care nursing in Kenya therefore has its genesis in
the on-the-job trainings that our nurses received from the
Japanese in the 1970s. Initially lasting only three-months,
 In house Trainings were extended to six months, and later
to nine.
 Critical care training programmes for Kenyan nurses were
later established in Japan and Madras, India.[10]

29. Cont…
 In 1975, the Kenya Medical Training College (KMTC) in Nairobi
launched a one-year critical care nursing diploma programme,
advertising for its first class of 12.
 Unfortunately, this course was not well understood outside of KNH,
and only six nurses applied. With time however, demand increased and
the programme grew, expanding its intake over the years.
 Meanwhile, at the privately-owned Nairobi Hospital, the Cecily
McDonnell School of Nursing began to offer nine-month long
trainings in 1996. In spite of this however, these programmes could not
meet the needs of a rapidly expanding critical care service at KNH, and,
in 1997, KNH began its own training programme, selectively admitting
its own nurses.
 Over time, as an increasing number of applications were received from
other facilities in the country, and from as far as Rwanda and
Zimbabwe, KNH opened its doors to nurses from outside the
institution. Other centres then emerged that offered critical care
nursing at diploma level, including the Cecily McDonnell School of
Nursing in 2009, the Moi Teaching and Referral Hospital in 2012 and
most recently, the Machakos Medical Training College (MTC) in 2018,
and then Nakuru and JOORT for Nephrology Nursing.

30. Evolution in Kenya
 A 2015 survey found there to be a total of 414 nurses in
the 21 ICUs in Kenya, 204 (49%) of whom have formal
critical care training.
 Later on with the Devolution following the 2010
constitution, all County Referral Hospitals have ICUS,
and Renal Units.
 With the COVID pandemic ICU has increasingly
expanded and is currently on very high demand……
 READ MORE!!!!

31.  In the 1960s, Infectious Disease Hospital (IDH)
currently KNH became home to the only
haemodialysis machine in East and Central Africa, a
donation from the family of a South African expatriate
who had succumbed to the complications of renal
failure while living in Kenya.
 The first patient to benefit from it was flown in from
Uganda specifically for this service and is still alive
today.

32. 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
32

33. 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.”
33

34. Cont….
 Critically ill patients are cared for in emergency
departments, post anesthesia units, High dependency
units, and interventional radiology and cardiology
units.
 Acutely ill individuals with high-technology
requirements and/or complex problems, such as those
who are ventilator dependent, may be cared for in
long-term acute care hospitals, or at home.

35. 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 .

36. 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.
36

37. Roles and responsibilities of the
critical care nurse
 Providing advanced life support measures within a
team environment
 Continuous monitoring and verifying data on patient
condition
 Monitoring life support equipment
 Responding to and managing changes in the patient's
condition
 Administering medications and monitoring effects
 Performing basic nursing care functions: provides
total nursing care
 Evaluating and documenting the patients progress

38. Cont…
 Patient and family teaching
 Teaching students and colleagues
 Identifying clinical problems needing research and
conducting research
 Counseling
 Participates in planning and implementation of
continuing profession education and development

39. Critical care Nurses Roles and
Responsibiliteis
 The key roles and responsibilities include care
provision and being a patient advocate .
 All other Nurses roles and responsibilities apply in the
ICU
 Review the general Nurses roles and responsibilities

40. Role of Critical Care Nurse as Patient Advocate
 Support the right of the patient or surrogate to informed
decision making.
 Intervene when the best interest of the patient is in
question.
 Help the patient obtain necessary care.
 Respect the patient’s values, beliefs, and rights.
 Provide education and support to help the patient or
surrogate make decisions.
 Represent the patient in accordance with the patient’s
choices.
 Support the decisions of the patient or surrogate.
 Intercede for patients who cannot speak for themselves.
 Monitor and safeguard the quality of care.
 Act as liaison between the patient, family, and health care
professionals.

41. Specific Responsibilities
➢Responsible for total patient care including
medication administration
➢Monitoring hemodynamic and physical status of
patients under his/her care.
➢Able to perform the techniques of
cardiopulmonary resuscitation accurately and
effectively.
➢Keeps abreast with changing techniques in critical
care nursing and maintains a high level of
expertise
➢Evaluates the nursing care provided
➢As a team leader, directs and develops the abilities

42. Specific Responsibilities Ctd…….
➢Documents correctly and maintains the patient’s
clinical records
➢Performs patient care within the principles of
Team Nursing and reports pertinent
observations
➢Participates in peer evaluation of work
performance.
➢Administers medications according to hospital
policy.
➢Practices economical use of equipment and
supplies
➢Attends and supports In-service Education
Programs.
➢Serves on Nursing Committee when requested.

43. HOLISTIC CRITICAL CARE NURSING
ROLES
1. CARING
 High technology driven CCU environment is fast
paced and directed toward monitoring and treating
life threatening changes in patients conditions
 Great emphasis is placed on technical skills and
proffesional competence and responsiveness to critical
emergencies

44. Care continued
 Caring aspect between nurses and patients is most
fundamental to the relationship and to the health care
experience.
 Physical and emotional absence, inhumane and
belittling interactions and lack of recognition of the
patients uniqueness indicate non caring.
 Holistic care focuses on human integrity and stresses
that the body, and mindand the spirit are
interdependent and inseparable.
 All aspects need to be considered in planning and
delivering care.

45. 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
45

46.  The practice in ICU depends on the nurses clinical
judgement and their interventions/actions

47. SEVEN Cs OF CRITICAL CARE
 Compassion
 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).

48. Special Skills of Critical Care Nurses
 Critical thinking skills
– Using nursing process as guide for problem solving
 affective components: confidence, contextual, perspective,
creativity, flexibility, inquisitiveness, intellectual ability,
intuition, open-mindedness, perseverance, and reflection.
 cognitive skills: analyzing, applying standards,
discriminating, information seeking, logical reasoning,
predicting, & transforming knowledge
 Collaborative skills
 Delegation skills
 – Clinical model: use Synergy Model
 Computer skills

49. THE INTENSIVE CARE TEAM.
This team –
 Doctor
 Nurses
 Therapists
 Nutritionists
 Chaplains and other support
staff, builds an environment
for healing or dying.

51. Scope of nursing practice of the
critically ill patient.
 Nursing practice in critical care is highly challenging
and complex.
 The critically ill patient is a complex person in a
complex environment.
 The nursing care and, identification of the individual
patient’s response to illness as well as to treatment is a
big challenge.

52. Scope of practice
 The nurse who monitors these patients continuously
needs to have sound knowledge, skill and careful
judgement.
 The nurse should follow a systematic approach in
assessing, planning, implementing and evaluating the
care provided to the patient.

53.  According to the Nursing Council of Kenya’s scope of
practice (2007), the nurse’s focus during management
of a critically ill patient is in giving specialized care to
these patients.
 The acutely ill patient needs support for vital
physiological functions in an atmosphere where
dignity and respect is maintained.
 The nurse should at all times utilize the nursing
process in provision of nursing care.

54. nurse taking care of the acutely ill patients shall:
 Perform comprehensive patient examination, make
diagnosis , plan and implement care as appropriate
 Take and analyse the ECG strip and carry out
appropriate measures
 Prepare and admit a patient to the ICU
 Diagnose cardio- pulmonary arrest and carry out
resuscitation procedures as appropriate

55. Scope of practice
 Perform/ assist in special procedures e.g. intubation,
insertion of central venous pressure cannulae, measure
CVP, carry out blood analysis; interpret results and
take the necessary interventions
 Plan and implement care on patients requiring special
care e.g. underwater seal drainage, suction, open heart
surgery, renal transplant, neurosurgery, continuous
renal replacement therapy
 Assist during physiotherapy of the critically ill

56. Categories of critical care nursing
thought, action and practice
 Thought and action
 Clinical grasp and clinical inquiry: Problem
identification and clinical problem solving
 Clinical forethought: Anticipating and preventing
potential problems

57. The use of the Synergy Model
 Synergy: results when the needs and characteristics of a
patient are matched with a nurse's competencies
 Patient Characteristics :
 – Resiliency
 – Vulnerability
 – Stability
 – Complexity
 – Resource availability
 – Participation in care
 – Participation in decision making
 – Predictability

58. Synergy Model Continued…
 Synergy: results when the needs and characteristics of a
patient are matched with a nurse's competencies • Nurse
Competencies:
 – Clinical Judgment
 – Advocacy and Moral Agency
 – Caring Practices
 – Collaboration
 – Systems Thinking
 – Response to Diversity
 – Facilitation of Learning
 – Clinical Inquiry (Innovator/Evaluator)

59. Categories cont…
 Practice
 Diagnosing and managing life sustaining physiologic
functions in unstable patients
 Managing a crisis by using skilled know –how
 Providing comfort measures for the critically ill
 Caring for patients’s families
 Preventing hazards in a technoloic environment
 Facing death: end of life care and decision making
 Communicating and negotiating multiple perspectives
 Monitoring quality and managing breakdown
 Exhibiting the skilled know howoof clinical leadership and
the coaching and mentoring of others

60. THE NURSING PROCESS IN
CRITICAL CARE
 Method of making clinical decisions
 Review

61. Professional Organizations
 Two professional organizations support critical care
practice.
 These include the Kenya Association of Critical-Care
Nurses (KACN) and the Society of Critical Care
Medicine (SCCM).
 NCK has adopted the values of AACN which include
accountability, advocacy, integrity, collaboration,
leadership, stewardship, life-long learning, quality,
innovation, and commitment (AACN, 1999b). These
values are supported through education, research, and
collaborative practice.

62. Certification
 Critical care nurses are eligible for certification.
 Certification validates knowledge of critical care
nursing, promotes professional excellence, and helps
nurses to maintain a current knowledge base
 The Nursing Council of Kenya (NCK) oversees the
critical care certification process.

63. Standards of Practice: (What are they?)
▪ Critical care nursing standards are statements that
describe the level of performance expected of registered
nurses in critical care practice
▪ The components focus on professional competence,
practice expectations, and legislation.
▪ Standards of practice provide a guide to the knowledge,
skills, judgment and attitudes that are needed to
practice safely

64. Standards of Competence
▪ Collects relevant patient health data.
▪ Analyzes the assessment data in determining diagnoses.
▪ Identifies individualized, expected outcomes for the
patient.
▪ Develops a plan of care that prescribes interventions to
attain expected outcomes.
▪ Implements interventions identified in the plan of care.
▪ Evaluates the patient’s progress toward attaining expected
outcomes.

65. ❑ Are authoritative statements describing the level of
care or performance by which the quality of nursing
care can be judged.
❑ Are written to establish roles and responsibilities
expected of the practitioner
❑ They prescribe the competence level of nursing
practice, professional performance, roles and
behaviors expected of nursing professionals.

66. Standards of Professional Practice
❖The nurse caring for acutely and critically ill
patients systematically evaluates the quality
and effectiveness of nursing practice.
❖The practice should reflect knowledge of
current professional practice standards,
laws, and regulations.
❖The nurse acquires and maintains current
knowledge and competency in the care of
acute and critically ill patients.
❖The nurse interacts with and contributes to
the professional development of peers and
other health care providers as colleagues.

67. Cont….
❖The nurse’s decisions and actions on behalf of the
patients are determined in an ethical manner.
❖The nurse collaborates with the team, which consists
of patient, family, and health care providers, in
providing patient care in a healing, humane, and
coring environment.
❖The nurse considers factors related to safety,
effectiveness, and cost in planning and delivering
patient care.

68. Standard of Care I: Assessment
THE NURSE CARING FOR CRITICALLY ILL PATIENTS
COLLECTS RELEVANT PATIENT HEALTH DATA.
➢ Data collection involves the patient, family, and other healthcare
providers as appropriate to develop a holistic picture of the patient’s
needs.
➢ The priority of data collection activities is driven by the patient’s
immediate condition and/or anticipated needs.
➢ Pertinent data are collected using appropriate assessment
techniques and instruments.
➢ Data are documented in a retrievable form.
➢ Data collection process is systematic and ongoing.

69. Standard of Care II: Diagnosis
THE NURSE CARING FOR CRITICALLY ILL PATIENTS
ANALYZES THE ASSESSMENT DATA IN DETERMINING
DIAGNOSES.
▪ Diagnoses are derived from the assessment data.
▪ Diagnoses are validated throughout the nursing
interactions with the team consisting of the
patient, family, and other healthcare providers,
when possible and appropriate.
▪ Diagnoses are prioritized and documented in a
manner that facilitates determining expected
outcomes and developing a plan of care.
▪ Diagnoses are documented in a retrievable form.

70. Standard of Care III: Outcome Identification
THE NURSE CARING FOR ACUTE AND CRITICALLY ILL PATIENTS
IDENTIFIES INDIVIDUALIZED, EXPECTED OUTCOMES FOR THE
PATIENT.
❑Outcomes are derived from actual or potential diagnoses.
❑Outcomes are mutually formulated with the patient, family,
and other health care providers when possible and
appropriate
❑Outcomes are individualized in that they are culturally
appropriate and realistic
❑Outcomes are attainable in relation to resources available
❑Outcomes are measurable and should include a time
estimate
❑Outcomes provide direction for continuity of care so that the
nurse's competencies are matched with the patient's needs.
❑Outcomes are documented in a retrievable form.

71. Standard of Care IV: Planning
❑THE NURSE DEVELOPS A PLAN OF CARE THAT
PRESCRIBES INTERVENTIONS TO ATTAIN EXPECTED
OUTCOMES.
❑The plan is individualized to reflect the patient's
characteristics and needs.
❑The plan is developed collaboratively with the team,
consisting of the patient, family, and healthcare providers
❑The plan reflects current acute and critical care nursing
practice.
❑The plan provides for continuity of care.
❑Priorities for care are established.
❑The plan is documented to promote continuity of care.

72. Standard of Care V:
Implementation
THE NURSE IMPLEMENTS INTERVENTIONS
IDENTIFIED IN THE PLAN OF CARE.
❖Interventions are delivered in a manner that minimizes
complications
❖The patient and family participate in implementing the
plan of care based upon their ability to participate in and
make decisions regarding care.
❖Interventions are documented in a retrievable manner.

73. Standard of Care VI: Evaluation
THE NURSE CARING FOR ACUTE AND CRITICALLY ILL PATIENTS
EVALUATES THE PATIENT'S PROGRESS TOWARD ATTAINING
EXPECTED OUTCOMES.
❖Evaluation is systematic, ongoing, and criterion-based.
❖The team consisting of patient, family, and healthcare providers is
involved in the evaluation process as appropriate.
❖Evaluation occurs within an appropriate time frame after
interventions are initiated.
❖Ongoing assessment data are used to revise the diagnoses,
outcomes, and plan of care as needed.
❖Revisions in diagnoses, outcomes, and plan of care are
documented.
❖The effectiveness of interventions is evaluated in relation to
outcomes.
❖The patient's responses to interventions are documented.

75. 75
Critical Care Technology
 ECG monitoring
 Arterial Lines
 Oxygen Saturation
 Ventilation
 Intracranial Pressure
Monitoring
 Temperature
 Pulmonary Artery
Catheter
 IABP
 VAD
 Extensive use of
pharmaceuticals

77. Intensive care Unit Bed

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 QUESTIONS??