UNIT IX: CRITICAL CARE UNIT

SHORT ANSWERS:
1. Describe the infection control protocol in critical care unit.
Infection control measures include the general measures and specific measures for selected infection.
General measures aim at prevention of all type of HAI in the ICU.
1. Early identification of patients with signs of infection.
 Perform significant and continuous monitoring of all critical ill patients.
2. Strict adherence of standard precautions.
 Standard precaution should be followed to prevent the transmission of blood- borne pathogens.
Minimize contact with blood, body secretions and patient care areas.
 Adhere to strict hand hygiene before touching the patient, after touching the patient, before any
sterile procedure, after body fluid exposure, after touching patient surrounding.
 Wear personal protective equipment.
3. Biomedical waste disposal
 There should be strict adherence to segregation of waste.
 Laboratory specimen should Be packed in spillage free container
 Specimen taken from patients known to harbour HBV, HCV, HIV are to be labelled with biohazard
symbol and sent separately.
4. Disinfection and cleaning of instrument and linen
 Lines contaminated visibly with blood and body fluid need to be treated with 2% sodium
hypochlorite solution
5. Maintenance of ICU environment
 Floor cleaning more than once a day
 There should be provision of hand hygiene at the entrance of the critical care unit.
 There should be provision of alcohol-based hand rubs at each bed side.
 It is desirable to have automated doors with sensors fitted on the door.
6. Training and education of all healthcare workers.
 Hand hygiene and other infection control policies need to be oriented to all new employees and
periodical refresher course on infection control is essential to implement the infection control
program effectively.
7. Antibiotic stewardship. Antibiotic abuse will lead to development of antibiotic-resistant
strains.
 Follow institutional policy for effective antibiotic use
8. Institute an active infection control committee and appropriate infection control surveillance.
REFERENCE:

Sharma S, Madhavi S, Hinkle J, Cheever K. Brunner and Suddarth's textbook of Medical Surgical Nursing. South Asian ed. New
delhi: Wolters Kluwer(india) Pvt.Ltd; 2018.

Page no: 2151-2152

2. Discuss about the principles of critical care nursing.

1. Assessment and continuous monitoring:
  Nurses need to be smart in making quick but accurate assessment of patient status. 24
hours continuous monitoring helps in ruling out and preventing the patient from further
complications.
 They need to be a keen observant. If any emergency situation arises, they have to able to
take the protocol and communicate the physician immediately.
 Also, they must be able to read and interpret the readings in various monitor and act
accordingly in the emergency situations. Therefore, assessment and continuous monitoring
holds up an important principle for critical care nursing,
2. Anticipation of complication:
 Anticipation and identification of evolving complications facilitates timely intervention to
avert deterioration in patients’ conditions. For this the nurse must be keen observer and
knowledgeable. She must have knowledge and skills to anticipate any complications.
 This also means that she must be aware of the secondary complications which occur due to
the bed ridden condition. So, she must take measures to prevent these complications such
as decubitus ulcer and total care should be given to the patient to prevent the same.
3. Collaboration:
 Critical care warrants a team approach and every member of the team deserves recognition
for his or her irreplaceable contribution for the provision of high-quality critical care.
 It is Important aspect of the critical care nursing. The nurse should very well collaborate
with the other health care team to provide an overall holistic care.
 She would be aware about the various personnel responsible for the various task and also
the physician in charge. Because at the time of any emergency she would be able contact
the required personnel.
 Therefore, collaboration in the critical care unit is highly required to provide the best care
to the critically ill patients and helps in the smooth functioning of the unit.
4. Comprehensive care:
 Provide comprehensive care by applying independent and interdependent nursing
intervention including selected proven alternative care modalities.
 Nursing interventions play a major role in the day to day care of the critically ill patient. The
nurse should be aware the care required for the patient and provide in accordingly.
 She must also understand the patient’s mental status if the patient is conscious and take care
of the little things that may affect the patient.
 The nurse must also be able to rationalize about the care she is rendering in case if the
patient family members question regarding the same.
5. Communication:
 Skilful communication within the critical care team is basis of all quality care in ICU. It
facilitates smooth functioning of ICU team and prevent patient safety mishaps.
 When it comes to critical care nursing, it’s a cent percent team work. Therefore, the nurse
should maintain a good communication pattern with her colleagues and as well as the other
health team members
 This will help in providing holistic care to the patient and smooth functioning of the unit.
 The nurse also should maintain good communication with patient’s family members. Its
important to boost the confidence and provide the moral support in such critical situations.
6. Ethical and humanistic care:
 Provide humanistic care in the high-tech environment. While rendering care to the patient
she must keep in mind the culture and background of the patient.
 She must render a care to the patient keeping in mind the ethical codes of nursing. And she
must be able to uphold the right of a human or individual
 Providing a humanistic care and value-based service is important in health profession
because every individual is unique and have and deserve all the human rights he has.
  REFERENCE:
Sharma S, Madhavi S, Hinkle J, Cheever K. Brunner and Suddarth's textbook of Medical Surgical Nursing. South Asian ed. New
delhi: Wolters Kluwer(india) Pvt.Ltd; 2018.

Page no: 2144-2145

3. Explain about indications for mechanical ventilation.

 Bradypnea or apnoea with respiratory arrest
 Acute lung injury and acute respiratory distress syndrome.
 Tachypnoea (respiratory rate >30 breaths per minute)
 Vital capacity less than 15ml/kg
 Refractory hypoxemia
 Inadequate oxygenation
 Increased intracranial pressure
 Minute ventilation greater than 10l/min
 RTA
 Hematoma
 Cardiac arrest
REFERENCE:

Available at:

http://www.medscape.com

4. What are the norms for physical setup of a critical care unit.
Location of unit
 In a calm and quiet area with sufficient natural light and away from noise.
 Near to general ICU casualty service
 Size of the unit: The actual bed capacity is based on the number of patients admitted to the hospital.
Physical design of the unit
 Should permit direct observation of the patient.
 It can be square. U or rectangle with the nurse station in the centre.
 The area should be made into cubicles separated by walls or opaque glass.
 The front wall should be made of transparent glasses for nurses’ observation.
 Curtains provided to ensure privacy.
 The doors of the cubicles should be wide to permit bed to pass.
 Individual cubicles should be large enough to accommodate equipment and for the staff to do the
resuscitative procedures.
 The minimum floor area is 10×15
 Provision made for the visitors to see the client without disturbance
 Each room provided with windows
 Each room should be adequately air conditioned and supplied with oxygen and suction
 Each room provided with clock and calendar
 Provision for calling system for each unit
 visual signals are preferred to sound signals
 The monitoring system should e placed behind the patients head so that the nurse can see the screen
 Centrally placed monitoring system
  The ancillary areas include:
 Nurses station, utility room, admission room
 Room for specialized equipment’s and procedure
REFERENCE:

Sharma S, Madhavi S, Hinkle J, Cheever K. Brunner and Suddarth's textbook of Medical Surgical Nursing. South Asian ed. New
delhi: Wolters Kluwer(india) Pvt.Ltd; 2018.

Page no: 2145 -2146

5. Explain about defibrillation.

 Defibrillation is an emergency resuscitative procedure in which therapeutic doses of high energy
electrical shocks are given to patients to restore heart beat in cardiac arrest or pulseless ventricular
tachycardia.
 It can be administered at any time in the cardiac cycle.
 It is performed during the emergency situation and it is non synchronized.
 During defibrillation high energy shock is delivered. 120-200 joules are delivered in biphasic
defibrillators and approximately 350 J are delivered in monophasic defibrillators.
INDICATIONS:
 Pulseless ventricular tachycardia
 Ventricular fibrillation
 Cardiac arrest due to or resulting in Ventricular Fibrillation

TYPES OF DEFIBRILLATORS:

1. Automated external defibrillators (AEDs):

 These are useful, as their use does not require special medical training.
 They are found in public places – eg: offices, airports, train stations, shopping centres.
 They analyse the heart rhythm and then charge and deliver a shock if appropriate.
 However, they cannot be overridden manually and can take 10-20 seconds to determine
arrhythmias
 Unsurprisingly ease of use and speed of use are important factors for success.
2. Semi-automated AEDs:
 These are similar to AEDs but can be overridden and usually have an ECG display.
 They tend to be used by paramedics.
 They also have the ability to pace.
3. Standard defibrillators with monitor - may be monophasic or biphasic.
4. Transvenous or implanted defibrillators.

PROCEDURE:
 As soon as defibrillator is available, monitor electrodes are applied to the patient’s chest and the
heart rhythm is analysed.
 When an automated defibrillator (AED) is used, the device turns on, the pads are applied to the
patient’s chest and the rhythm is analysed by the defibrillator to determine whether a shock is
indicated.
 When the ECG shows ventricular fibrillation or pulseless ventricular tachycardia, immediate
defibrillation is the treatment choice.
 The survival time decreases for every minute that defibrillation is delayed. Following defibrillation,
high quality CPR is resumed immediately.
  Survival after cardiac arrest has been improved by extensive education of healthcare providers and
by the use of AED.
 Defibrillation is a technique used in emergency medicine to terminate ventricular fibrillation or
pulseless ventricular tachycardia.
 It uses an electrical shock to reset the electrical state of the heart so that it may eat to a rhythm-
controlled by its own natural pacemaker cells.
REFERENCE:

Sharma S, Madhavi S, Hinkle J, Cheever K. Brunner and Suddarth's textbook of Medical Surgical Nursing. South Asian ed. New
delhi: Wolters Kluwer(india) Pvt.Ltd; 2018.

Page no:2163

6. Explain the usefulness of cardiac monitoring in critical care unit?

 In the emergency department, cardiac monitoring is a part of the monitoring of vital
signs in emergency medicine, and generally includes electrocardiography.
 Electrocardiographic (ECG) monitoring is routinely used in hospitals for patients with a wide range
of cardiac and non-cardiac diagnoses.
 Besides simple monitoring of heart rate and detection of life-threatening arrhythmias.
 The goals of ECG monitoring include detection of myocardial Ischemia, diagnosis of complex
arrhythmia, and identification of a prolonged QT interval.
 The ECG remains a cornerstone in diagnosis and management of patients with coronary ischemia.
 ECG monitoring in these patients can serve both a protective and diagnostic purpose.
 They detect life-threatening arrhythmias and double up as in-patient Holter monitors.
 Cardiac Monitor is a device that shows the electrical and pressure waveforms of the
cardiovascular system for measurement and treatment.
 Continuous cardiovascular and pulmonary monitoring allows for prompt identification and
initiation of the treatment.
REFERENCE:

Available at: https://oxfordmedicine.com

7. Describe in detail about cardiac monitoring.

Cardiac monitoring allows continuous observation of the heart’s electrical activity, cardiac
monitoring is used in patients with conduction disturbances or in those at risk for life-threatening
arrhythmias.
Like other forms of electrocardiography, cardiac monitoring uses electrodes placed on the patient’s
chest to transmit electrical signals that are converted into a tracing of cardiac rhythm on an
oscilloscope.
Two types of monitoring may be performed: hardwire or telemetry. With hardwire monitoring, the
patient is connected to a monitor at bedside.
The rhythm display appears at bedside, but it may also be transmitted to a console at a remote
location.
Telemetry uses a small transmitter connected to the patient to send electrical signals to another
location, where they’re displayed on a monitor screen.
Battery powered and portable, telemetry frees the patient from cumbersome wires and cables and
lets him be comfortably mobile.
 Telemetry is especially useful for monitoring arrhythmias that occur during sleep, rest, exercise, or
stressful situations.
Regardless of the type, cardiac monitors can display the patient’s heart rate and rhythm, produce a
printed record of cardiac rhythm, and sound an alarm if the patient’s heart rate rises above or falls
below specified limits.
Monitors also recognize and count abnormal heartbeats as well as changes.
Equipment
Cardiac monitor, lead wires, patient cable disposable precelled electrodes (number of electrodes
varies from three to five, depending on patient’s needs), washcloth, soap, and water, or alcohol
pads, 4’’×4’’ gauze pads, gloves, Optional: clippers.
For telemetry
Transmitter, transmitter pouch, telemetry battery pack, leads, and electrodes, gloves.

Preparation of equipment
 Plug the cardiac monitor into an electrical outlet and turn it on to warm up the unit while you
prepare the equipment and the patient.
 Insert the cable into the appropriate socket in the monitor.
 Connect the lead wires to the cable. In some systems, the lead wires are permanently secured to the
cable.
 Each lead wire should indicate the location for attachment to the patient: right arm (RA), left arm
(LA), right leg (RL), left leg (LL), and chest (C). Lead wires may also be color-coded for
placement: white (RA), black (LA), green (RL), red (LL), and brown (chest).
 This designation should appear on the lead wire, if it’s permanently connected, or at the connection
of the lead wires and cable to the patient.
 Then connect an electrode to each of the lead wires, carefully checking that each lead wire is in its
correct outlet.
 For telemetry monitoring, insert a new battery into the transmitter. Be sure to match the poles on
the battery with the polar markings on the transmitter case.
 Test the battery’s charge and test the unit by pressing the button at the top of the unit; this ensures
that the battery is operational.
 If the lead wires aren’t permanently affixed to the telemetry unit, attach them securely. If they must
be attached individually, connect each one to the correct outlet.
Implementation
 Perform hand hygiene and put on gloves.
 Confirm the patient’s identity using at least two patient identifiers according to your facility’s
policy.
 Provide privacy and explain the procedure to the patient.
 Ask the patient to expose his chest.
 Determine electrode positions on the patient’s chest based on the system and lead you’re using.
 If necessary, clip the hair in an area about (10 cm) in diameter around each electrode site to ensure
good skin contact with the electrodes.
 Clean the electrode area with a cleaning wipe or soap and water and dry it completely to provide for
adequate transmission of electrical impulses.
 Clean the intended sites with an alcohol pad to remove oils from skin and improve impulse
transmission.
  Gently abrade the skin at the intended sites to remove dead skin cells and to promote better contact
with living cells.
 Remove the backing from the precelled electrode. Check the gel for moistness. If the gel is dry,
discard it and replace it with a fresh electrode to ensure optimal function.
 Apply the electrode to the appropriate site by pressing one side of the electrode against the patient’s
skin, pulling gently, and then pressing the other side against the skin. Press your fingers in a circular
motion around the electrode to fix the gel and stabilize the electrode. Avoid pressing directly on the
gel pad to prevent spreading of the gel and loss of adhesion and transmission. Repeat this procedure
for each electrode.

REFERENCE:

Lippincott’s Nursing Procedures; 6th edition

8. Enumerate the common drugs used in critical care unit and state their action.
Drugs used in critical care and their actions
 Adenosine – slows down the cardiac impulse conduction in AV node, interrupts re-entry
pathway
 Atropine- Anticholinergic, para sympatholytic, antiarrhythmic
 Aminophylline- Relaxes bronchial smooth muscle, bronchodilation
 Amiodarone- Antiarrhythmic agent prolongs PR and QT interval, decreases sinus rate and
peripheral vascular resistance
 Dopamine- Inotropic agent, increases myocardial contractility, and there by increases cardiac
output. Activates the α and β1 receptors, and also dopaminergic receptors present in the renal
and mesenteric blood vessels. It produces varied dose related responses
 Dobutamine- Increases myocardial contractility and cardiac output, β agonist
 Furosemide- potent loop diuretic, enhances excretion of sodium and water
 Isoprenaline- A synthetic sympathomimetic amine that is structurally related to epinephrine but
acts almost exclusively on beta receptors
 Levetiracetam- It binds to the synaptic protein namely SV2A and thereby delays the neural
conduction across the synapses
 Potassium Chloride- replenishes potassium ion in case of hypokalemia
 Sodium bicarbonate- hypertonic bicarbonate solution intended to replenish bicarbonate ion in
serum
 Lidocaine CV- Antiarrhythmic agent combines with sodium channel and reduces myocardial
excitability and conductivity
 Morphine- potent narcotic analgesic
 Magnesium sulfate- can reverse refractory VF caused by hypomagnesemia and help to
replenish intracellular potassium
 Nitroglycerine- selective coronary vasodilator
 Noradrenaline- α-Adrenergic agonist, increases vasoconstriction and thereby increases BP
 Vasopressin- synthetic antidiuretic hormone that increases sodium and water reabsorption in the
kidney
REFERENCE:

Sharma S, Madhavi S, Hinkle J, Cheever K. Brunner and Suddarth's textbook of Medical Surgical Nursing. South Asian ed. New
delhi: Wolters Kluwer(india) Pvt.Ltd; 2018.
9. Explain the role of autonomy in critical care unit.
 Autonomy in health care is the freedom to make decisions about one’s own body without coercion
or interference of others.
 Autonomy is freedom of choice or self-determination, a basic human right. It can be experienced in
all human life events.
 The critical care nurse is often ‘caught in the middle’ in ethical situations. Promoting autonomous
decision making is one of those situations.
 As the nurse works closely with patients and their families to promote autonomous decision
making, another crucial element becomes clear: patients and their families must have information
about a given situation to make the decision that is right for them.
 For example, in the case of a kidney transplant, they must know the chances of rejection, the effects
of immunosuppressive drugs, cost of these drugs, the meaning of brain death, details of organ
donations and so on.
 This is where the nurse is an important patient advocate providing more information, clarifying
points, reinforce information and providing support.
 Hence patient autonomy becomes central to health care.
REFERENCE:

Available at: https://ijme.in

10. What ethical issues the nurse may face while working in critical care unit.
Common ethical issues are:
 DNR order:
 Allowing the person to die without initiating active resuscitation presents a lot of stress
and dilemma of critical care team members.
 If the patient has expressed in a written document his or her healthcare choice in the event
of a critical illness, which is called advance directive, or verbally passed on a message to
his or her surrogate, then the DNR is accepted. In the Indian context, it is still not a legally
valid practice.
 Withdrawal of life support:
 It is the cessation and removal of an ongoing medical therapy such as withdrawal of
dialysis for a patient with renal failure or ventilator support to a patient with acute
respiratory failure with an intent of allowing the patient to embrace natural death due to
underlying illness.
 Euthanasia:
 It is an intentional killing of a person whose life is perceived to be not worth living by an
act of commission or omission, that is, an intentional killing of a patient by the direct
intervention of a doctor, ostensibly for the good of the patient or others.
 The active euthanasia is an act of commission when termination of life is done at the
patients request.
 It is otherwise known as physician- assisted suicide.
 In most of the western countries, it is legally permitted based on advance directive or living
will or a consensus decision taken by the patient’s surrogate empowered to take health care
decisions on behalf of the patient and the treating team.
REFERENCE:

Lippincott Manual of Nursing Practice; 10th edition

11. What are Ethical and legal aspects in critical care nursing?
 Critical care unit is the most expensive unit in the hospital. Technological advancements help
clinicians to deal with challenging situations effectively but along with that brings a lot of ethical
and legal issues.
 Nurses, being the most inevitable member of the critical care team, play an important role in
resolving ethical dilemma.
 They need to play their role prudently to avoid the legal hinges.
Fundamental Ethical Principles are:
 Beneficence:
Nurses have an obligation to render the most appropriate interventions that will facilitate
recovery for the patient.
 Nonmaleficence:
Refraining from anything that may injure or cause harm/unfavourable situations for the patients.
 Autonomy:
Respecting the patients right to determine the course of treatment and care at ICU.

 Justice:
Fair allocation of scarce resources.
Common ethical & legal challenges include:
 DNR order: Allowing the person to die without initiating active resuscitation presents a lot of
stress and dilemma to critical care team members. In the Indian context, it is still not a legally
valid practice.
 Withdrawal of life support: It is the cessation and removal of an ongoing medical therapy such
as withdrawal of dialysis for a patient with renal failure or ventilator support to a patient with
acute respiratory failure with an intent of allowing the patient to embrace natural death due to
underlying illness.
 Euthanasia: It is an intentional killing of a person whose life is perceived to be not worth living
by an act of commission or emission, that is an intentional killing of a patient by the direct
intervention of a doctor, for the good of the patient or others. The active euthanasia is an act of
commission when termination of life is done at the patients request.
Nurses Role in Resolving Ethical Dilemma:
 The Critical care nurse may take initiative for the clear communication of the possible course
of illness, the prognosis etc. with the family members.
 He or she arranges for a consultation with the treating physician who is legally empowered to
divulge the information such as the poor prognosis of the underlying condition.
 Nurse assists families to weigh the burdens and benefits of medical interventions and
provides them with a frame work of the patient’s preference and interest.
 Nurses provides comfort care and symptomatic relief to those patients whose surrogates or
the patient himself or herself makes decisions for the withdrawal of life support.
 They arrange for psychologist consultation to cope up with a situation.
 They provide moral and empathetic emotional support to the family members.

Commonly encountered legal issues:

  Negligence:
It is an unintentional act of commission or omission of a nurse that is falling short of the
expected standard that has resulted in injury or fatal outcome in the patient It can be a medication
error, failure to recognize a serious complication, failure to intervene promptly to avoid
complications.
 Malpractice or felony:
A serious intentional act of crime is considered as malpractice such as knowingly administering
a harmful drug.
 Deformation:
Revealing highly sensitive personal information such as details of diagnosis and clinical
condition without the concurrence of the patient to others that may be claimed to damage the
public image or reputation of the individual.
Responsibilities of Nurse in Avoiding Legal Issues:
 Critical care nurses need to continuously update their knowledge and competency to match the
rapidly expanding medical knowledge base.
 Accurately monitoring and documenting the parameters as well as the care provided will save
the nurses from litigation.
 Informing all relevant people about the patient’s condition not only paves way for quality care
but also provides legal protection.
 Maintain prescribed standards of care to the patients.
 Develop trusting and healthy relationship at the workplace.
 System approach to prevent errors has been effective and enhances accountability and
direction for each member of the healthcare team in the ICU.

REFERENCE:

Sharma S, Madhavi S, Hinkle J, Cheever K. Brunner and Suddarth's textbook of Medical Surgical Nursing. South Asian ed. New
delhi: Wolters Kluwer(india) Pvt.Ltd; 2018.

PG NO: 2160- 22162.

12. Explain the factors to be taken in to account while communicating with critically ill patient & their
family members?
Critically ill patients describe impairment in communication as a terrifying experience. Communicating
effectively is a significant factor in the assessment of pain and other symptoms and in patient’s
participation in decision making about treatment in the ICU.
Barriers in Communicating with critically ill patients:
 Impaired cognition
 Patients in delirium
 Sedation
 Altered level of consciousness
 Language barriers
 Educational and cultural variation
  Presence of tracheostomy or ET tube following head and neck cancer surgery or a stroke or to
facilitate mechanical ventilation
 Poor skills of nurses in interpreting nonverbal communication
 Lack of time for nurses to understand nonverbal communication

The American College of Critical Care recommends PCC for improved outcomes in critical care.
Based on PCC model, five domains for effective patient-centred communication were shown to
improve the patient and family outcomes. They are: -
 Biopsychosocial perspective: There should be information exchange and effective
and accurate risk communication.
 Patient Provider as person: Listen to the patient’s worries and concerns, and
encourage questions.
 Shared decision making: patients or their surrogates and the clinician have shared
responsibility for improved patient outcome.
 Therapeutic alliance: Clinician knows the patient’s desires and the patient
understands care plan
 Know limitations of knowledge and appropriate involvement of other clinicians.
The patient centred communication is the central component that connects all the five domains
identified that ultimately lead to improved patient satisfaction and family satisfaction with care,
decreased anxiety and depression, and improved decision making.
Methods of communication by patients with problems in verbal communication:
 Head nods, gestures, and mouthing words
 Paper and pencil writing
 Pictorial communication boards
 Electronic voice output communication aids or a pre-recorded human voice aid
 Digitalized computer-generated voice message.

REFERENCE:

Sharma S, Madhavi S, Hinkle J, Cheever K. Brunner and Suddarth's textbook of Medical Surgical Nursing. South Asian ed. New
delhi: Wolters Kluwer(india) Pvt.Ltd; 2018.

PAGE NO:2158-2159.

13. Explain the importance of protocols in critical care unit?

 Critical care is becoming increasingly complex and challenging.
 The multitude of patient safety problems and unexpected outcomes that arise while applying the
advanced technology and the intricate nature of the critical ailments necessitate development of a
standard way of managing the patients.
 Clinical protocols, guidelines and care bundles are developed to achieve quality patient care in
ICUs.
 Protocol is a set of written rules of precisely delineated steps usually developed and tested by well-
controlled clinical research for desired clinical outcome.
 Stress ulcer prevention protocol, deep vein thrombosis prevention protocol, sedation interruption
protocol, weaning protocol, oral hygiene protocol, basic life support protocol, and advanced cardiac
life support protocol are some of the successfully implemented protocols in the ICUs.
  Checklists facilitate consistent application of protocol. By applying protocol, the similar types of
patients are treated in the same way to achieve the same outcome by avoiding omission or
commission errors.
 Protocols also facilitate clinical reasoning and appropriate decision making.
 Major disadvantages of protocols are that they are too rigid and do not allow patient cantered care.
 Critical care bundles are another type of tools for implementing standard care.
 Care bundles are a group of evidence-based interventions directed to achieve the desired goals such
as ventilator associated pneumonia prevention bundle, Catheter associated urinary tract infection
prevention bundle, and delirium prevention bundle.
 Guidelines are written policy statements. They help in smooth functioning of the unit and avoid
confusions in delivery of care.
 In level III critical care units’ various policies are followed, which include the following;
 Admission policy
 Discharge policy
 Organ donation policy
 Treatment policy
 End of -life care policy
REFERENCE:

Sharma S, Madhavi S, Hinkle J, Cheever K. Brunner and Suddarth's textbook of Medical Surgical Nursing. South Asian ed. New
delhi: Wolters Kluwer(india) Pvt.Ltd; 2018.

PAGE NO: 2147.

14, Explain the nursing care of patients on ventilator?

The main nursing care of patients on ventilator are: -
 Keep head end of the bed elevated at 30° to 45° to prevent aspiration of gastric content and
gastric reflux.
 Provide oral care with chlorhexidine solution of strength 0.12% twice or thrice as per unit
protocol.
 The oral cavity colonization can be reduced with the usage of chlorhexidine and regular oral
cavity assessment.
 Reduce the duration of intubation through early weaning protocol using daily sedation vacation
and spontaneous breathing trial.
 Reduce unplanned extubation and reintubation.

 Institute gastric ulcer prophylaxis.

 Monitor ET tube cuff pressure and maintain it > 20 but<30mmHg to avoid entry of bacterial
pathogen into the lower respiratory tract without causing tracheal necrosis
 Avoid pooling of secretion above the cuff by periodic suctioning through the subglottic port.
 Assess the mode and ventilator parameters, the ventilator connections and circuits
 Place the patient in low fowler's position.
 Monitor the positive end expiratory pressure.
 Monitor the ABG, SPO2 and bilateral air entry.
 Set the alarms at the appropriate level.
 Administer nebulizer as per prescription.

REFERENCE:
Sharma S, Madhavi S, Hinkle J, Cheever K. Brunner and Suddarth's textbook of Medical Surgical Nursing. South Asian ed. New
delhi: Wolters Kluwer(india) Pvt.Ltd; 2018.

PAGE NO: 2148,2157.

15. Describe the nursing management of a critically ill patient?

 Critically ill patients often present with impairment in ventilation, oxygenation and circulation
irrespective of the pathophysiological sequence.
 They may have single organ or multiorgan dysfunction that needs to be managed simultaneously.
 Whatever may be the system involvement, they may require intubation and mechanical ventilator
support.
 They may also face circulatory collapse. Because of primary brain pathology or secondary to
circulatory or respiratory failure, the patient may have loss of consciousness.
 For the purpose of continuous BP monitoring and to draw samples for ABG analysis, an arterial
line may be inserted.
 Peripheral and central venous access may be established to administer medications and to monitor
circulatory status.
 Urinary catheterization is done to monitor the urine output.
 The patient may be connected to a continuous ECG monitor.

Nursing diagnosis:
 Ineffective airway clearance related to diminished gag reflex and/ or excessive secretion as
evidenced by visible or audible secretion, increased RR, increased airway pressure alarm in
ventilated patients and restlessness.
 Impaired gas exchange related to ventilation-perfusion mismatch as evidenced by cyanosis
in the oral mucosa, lips, spo2<93%, hypoxemia, hypercapnia, restlessness and abnormal RR
and rhythm.
 Decreased cardiac output related to Decreased fluid volume or poor contractility of heart
and or dysrthymia as evidenced by hypotension, increased or decreased heart rate, feeble
peripheral pulse and cool extremities.
 Impaired cerebral tissue perfusion related to increased intracranial pressure or CNS
depression/CNS infection as evidenced by changes in the level of consciousness,
Bradycardia, changes in rate and pattern of respiration.
 Self-care deficit related to critical illness and loss of consciousness.

Airway Management:
To maintain patient airways, the following nursing interventions have to be followed;
 Place an oropharyngeal airway to prevent tongue falling back to prevent biting the ET tube.
 Elevate the head end of the bed 30°- 40° to prevent aspiration of gastric content and gastric reflux.
 If oral secretions are more, apply suctioning using a Yank Auer suction tip.
 If the patient is intubated and on ventilator, perform gentle ET suctioning.
 If secretion is thick, provide nebulization therapy.

Gas exchange and ventilator management:

 Assess the mode and ventilator parameters, the ventilator connections and circuits.
  Place the patient in low fowler’s position.
 Monitor the positive end expiratory pressure.
 Monitor ABG, SPO2 and bilateral air entry.
 Set the alarms at the appropriate level.
 Administer nebulizer as per prescription

Maintaining adequate cardiac output/fluid management:

 Monitor the blood pressure continuously using invasive or non-invasive technique.
 Establish venous access either central or peripheral, and administer normal saline at the prescribed
rate.
 Replace electrolytes lost through infusion of IV fluids.
 If there is blood loss arrange and transfuse compatible blood.

Maintenance of cerebral tissue perfusion:

 Elevate the head end of the patient at 30°to improve venous return from the head.
 Maintain the head, neck, and body in normal alignment to facilitate venous return.
 Monitor neurological status, vital signs, spo2, pupillary signs and reflexes
 Maintain patent airway by oropharyngeal or ET suctioning

Pain management:
 Prompt assessment, timely intervention, and documentation of the intervention are the keys for
successful pain management.

Nutritional management:
 Enteral nutrition is preferred over parenteral nutrition and should be initiated as early as 24 to 72
hrs following admission or onset of a major critical illness.
 Among patients with hemodynamic instability, after completing the resuscitation, enteral nutrition
should be started.

Monitoring tolerance and adequacy of fluid intake:

 On an ongoing basis, nurses need to monitor the adequacy of enteral feeds.
 Monitor the blood glucose level.
REFERENCE:

Sharma S, Madhavi S, Hinkle J, Cheever K. Brunner and Suddarth's textbook of Medical Surgical Nursing. South Asian ed. New
delhi: Wolters Kluwer(india) Pvt.Ltd; 2018.

PAGE NO:2156-2158.

16. Write a short note on CVP monitoring.

 Central venous Pressure is a right ventricular preload and reflects the fluid volume problems. It is
most often measured with a central venous catheter placed in the internal jugular or subclavian
vein.
  It can be measured with Pulmonary artery (PA) catheter using the proximal lumen located in the
right atrium
 CVP is measured as the mean pressure at the end of the expiration.
 CVP monitoring helps to assess cardiac function, evaluate venous return to the heart, and
indirectly gauge how well the heart is pumping. The central venous (CV) catheter also provides
access to a large vessel for rapid, high-volume fluid administration and allows frequent blood
withdrawal for laboratory samples.
 CVP monitoring can be done intermittently or continuously. The catheter is inserted
percutaneously or using a cutdown method. Typically, a single lumen CVP line is used for
intermittent pressure readings with the use of a water manometer or a transducer and stopcock. A
pulmonary artery (PA) catheter has a proximal lumen appropriate for continuous CVP
monitoring.
 Normal CVP ranges from 5 to 10 cm H2O or 2 to 6 mm Hg. Changes in preload status are
reflected in CVP readings. Any condition that alters venous return, circulating blood volume, or
cardiac performance may affect CVP.
 If circulating volume increases (such as with enhanced venous return to the heart from fluid
overload, heart failure, and positive-pressure breathing), CVP rises.
 If circulating volume decreases (such as with reduced venous return from hypovolemia secondary
to dehydration, interstitial fluid shift or haemorrhage, and negative pressure breathing), CVP
drops.
 An elevated CVP indicates right ventricular failure or volume over load. A low CVP indicates
hypovolemia.
Measuring CVP with a Water Manometer:
 Prime the IV tubing and manometer setup. Attach the water manometer to an IV pole or place it
next to the patient’s chest.
 Connect the IV tubing to the CV catheter. Trace the tubing from the patient to its point of origin
to make sure that it’s attached to the proper port.
 Align the base of the manometer with the zero-reference point by using a levelling device and
secure the manometer in place. Because CVP reflects right atrial pressure, you must align the
right atrium (the zero-reference point) with the zero mark on the manometer. (See Measuring
CVP with a water manometer.)
 Typically, markings on the manometer range from −2 to 38 cm H2O However, manufacturer’s
markings may differ, so be sure to read the directions before setting up the manometer and
obtaining readings.
 Turn the stopcock off to the patient and slowly fill the manometer with IV solution until the fluid
level is 10 to 20 cm H2O higher than the patient’s expected CVP value. Don’t overfill the tube
because fluid that spills over the top can become a source of contamination
Intermittent CVP Readings using a Water Manometer
 Turn the stopcock off to the IV solution and open to the patient. The fluid level in the
manometer will drop. When the fluid level comes to rest, it will fluctuate slightly with
respirations. Expect it to drop during inspiration and to rise during expiration.
 Record CVP at the end of expiration, when intrathoracic pressure has a negligible effect and
the fluctuation is at its highest point.
 Depending on the type of water manometer used, note the value either at the bottom of the
meniscus or at the midline of the small floating ball.
 After you’ve obtained the CVP value, turn the stopcock to resume the IV infusion. Adjust
the IV drip rate, as required.
  Place the patient in a comfortable position.
 Remove and discard your personal protective equipment and perform hand hygiene.
 Document the procedure
Continuous CVP Readings using a Water Manometer
 Make sure the stopcock is turned so that the IV solution port, CVP column port, and patient
port are open. Be aware that with this stopcock position, infusion of the IV solution
increases CVP. Therefore, expect higher readings than those taken with the stopcock turned
off to the IV solution.
 If the IV solution infuses at a constant rate, CVP will change as the patient’s condition
changes, although the initial reading will be higher. Assess the patient closely for changes.
 Record CVP values at appropriate intervals.
 Remove and discard your personal protective equipment and perform hand hygiene.

REFERENCE:

1. Lewis, Heitkemper, Dirkson, O’Brien, Bucher. Lewis ‘s Medical Surgical Nursing Assessment and Management of
Clinical problem s. Second South Asian edition. Elsevier. PAGE NO: 1670
2. Also available at: https://nursekey.com/central-venous-pressure-monitoring/

17. Differentiate between cardioversion and Defibrillation

Cardioversion:
 This is a medical intervention used to normalize an abnormal heart rate that occurs in atrial flutter,
atrial fibrillation or ventricular tachycardia. In these conditions the heart rate exceeds 100 bpm and
is irregular.
 The condition can be episodic and indicates an underlying heart condition such as hypertension,
cardiomyopathy etc.
 It is a planned procedure and It is synchronized at the R wave.
 Here lower energy shock is delivered. Approximately 50-100J is delivered and is increased if
needed.
INDICATIONS:
 Supraventricular tachycardia
 Atrial Fibrillation
 Atrial flutter
 Ventricular tachycardia with pulse
TYPES:
 Electrical cardioversion is performed in a hospital. If you decide on treatment with electrical
cardioversion, your care team will sedate you so that you sleep through the procedure. While you
 are asleep, a mild electric shock will be administered to your heart. The shock will “reset” your
heartbeat, putting it back into normal sinus rhythm
 Pharmacologic cardioversion is a process of taking specific medications to restore your heartbeat
to its normal sinus rhythm. If your doctor recommends pharmacologic cardioversion, he or she will
prescribe a combination of medications that maintain the rate and/or rhythm of your heart. For
many patients, this may be performed in the hospital.

Defibrillation:
 This is an emergency resuscitative procedure in which therapeutic doses of high energy electrical
shocks are given to patients to restore heart beat in cardiac arrest or pulseless ventricular
tachycardia.
 They can be administered at any time in the cardiac cycle.
 It is performed during the emergency situation and it is non synchronized.
 Here high energy shock is delivered. 120-200 joules are delivered in biphasic defibrillators and
approximately 350 J are delivered in monophasic defibrillators.
INDICATIONS:
 Pulseless ventricular tachycardia
 Ventricular fibrillation
 Cardiac arrest due to or resulting in Ventricular Fibrillation

TYPES OF DEFIBRILLATORS:

5. Automated external defibrillators (AEDs):

 These are useful, as their use does not require special medical training.
 They are found in public places – eg: offices, airports, train stations, shopping centres.
 They analyse the heart rhythm and then charge and deliver a shock if appropriate.
 However, they cannot be overridden manually and can take 10-20 seconds to determine
arrhythmias
 Unsurprisingly ease of use and speed of use are important factors for success.
6. Semi-automated AEDs:
 These are similar to AEDs but can be overridden and usually have an ECG display.
 They tend to be used by paramedics.
 They also have the ability to pace.
7. Standard defibrillators with monitor - may be monophasic or biphasic.
8. Transvenous or implanted defibrillators.

REFERENCE:
Available at: https://patient.info/doctor/defibrillation-and-cardioversion

18. Explain the modes of mechanical Ventilator

Mechanical ventilation is the process by which the FIO2 is moved in and out of the lungs by a mechanical
ventilator. The two Major types of mechanical ventilation are
A. Negative pressure ventilation
B. Positive pressure ventilation
Negative Pressure Ventilation:
 It involves the use of the chambers that encase the chest or body and surround it with intermittent
sub atmospheric or negative pressure.
  Intermittent negative pressure around the chest wall causes the chest to be pulled outward reducing
the intra thoracic pressure.
 Air rushes via upper airway, which is outside the sealed chamber. The machine cycles off, allowing
the retraction. This type of pressure reduces intra thoracic pressure produce inspiration and
expiration is passive.
Positive Pressure Ventilation (PPV):
 It is the primary method used with acutely ill patients. During inspiration the ventilator pushes air
into the lungs under positive pressure. Unlike spontaneous ventilation, intra thoracic pressure is
raised during lung inflation rather than lowered. Expiration occurs passively.
 Modes of PPV are categorized into two categories:
o Volume Ventilation
o Pressure Ventilation
VOLUME MODES:
1. Assist control mode (AC) OR Assisted Mandatory Ventilation (AMV):
 Requires respiratory rate, Tidal volume, inspiratory time and PEEP be set for the patient.
 The ventilator sensitivity is also set and when the patient initiates a spontaneous breath, a full
volume breath is delivered.
2. Intermittent Mandatory Ventilation (IMV) and Synchronized Intermittent mandatory
ventilator (SIMV):
 Requires respiratory rate, tidal volume (VT), inspiratory time and PEEP be set for the patient.
 In between mandatory breaths patients spontaneously breath at their own rates and VT. With
SIMV the ventilator synchronizes the mandatory breaths with the patient’s own inspirations.
PRESSURE MODES:
1. Pressure Support Ventilation (PSV):
 Provides an augmented inspiration to a spontaneously breathing patient.
 The clinician selects an inspiratory pressure level, PEEP and sensitivity
 When the patient initiates a breath a high flow of gas is delivered to the preselected pressure
level and pressure is maintained throughout the inspiration
 The patient determines the parameters of VT, respiratory rate and inspiratory time.
2. Pressure control inverse ratio ventilation (PC-IRV):
 Combines pressure limited ventilation with an inverse ratio of inspiration to expiration.
 The clinician selects the pressure level, rate. Inspiratory time and the PEEP level.
 With prolonged inspiratory time auto PEEP may result. Conventional inspiratory times are used
and rate, pressure level and PEEP are selected.
3. Airway Pressure release Ventilation (APRV):
 Provides two levels of continuous positive airway pressure. (CPAP) with timed releases and
permits spontaneous breathing throughout the respiratory cycle.
 The clinician sets both high and low pressure along with time high and time low.
 Tidal volume is not a set variable and depends upon the CPAP level, the patient’s compliance
and resistance and continuous breathing effort.
POSITIVE END EXPIRATORY PRESSURE (PEEP):
 Creates positive pressure at end exhalation and restores functional residual capacity.
 The term PEEP is used when the end expiratory pressure is provided during ventilator positive
pressure breaths.
CONTINOUS POSITIVE AIRWAY PRESSURE(CPAP):
 Similar to PEEP, CPAP restores the functional residual capacity
 This pressure is continuous during spontaneous breathing
 No positive pressure breaths are present.
REFERENCE:
Lewis, Heitkemper, Dirkson, O’Brien, Bucher. Lewis ‘s Medical Surgical Nursing Assessment and Management of Clinical
problem s. Second South Asian edition. Elsevier. Page no: 1681-1683

19. Explain the process of weaning the patient of the ventilator.

Weaning is the process of reducing ventilator support and resuming spontaneous ventilation. The weaning
process differs for patients requiring short term ventilation (up to 3 days) versus longer term ventilation
(more than3 days).
Weaning generally consist of three phases:
 The pre-weaning Phase
 The weaning Process
 The outcome Phase
THE PREWEANING PHASE:
 also known as the assessment phase determines the patient’s ability to breathe spontaneously.
Assessment in this phase depends on the combination of respiratory and non-respiratory factors.
 Weaning assessment should include criteria to assess the muscle strength (negative inspiratory
force) and endurance i.e. Spontaneous tidal volume, minute ventilation and rapid shallow breathing
index.
 In addition, the patient’s lungs should be reasonably clear on auscultation and chest x-ray. Non
respiratory factors include patient’s neurologic status, hemodynamic, fluid, electrolyte and acid
base balance, nutrition and haemoglobin.
 It is important to have an alert, well-rested and well-informed patient relatively free from pain and
anxiety who can cooperate in the weaning plan.
 A spontaneous breathing trial (SBT):
 It is recommended for patients who demonstrate the readiness. An SBT should be at least 30
minutes and not more than 120 minutes.
 It may be done with the low levels of CPAP, low levels of PSV or a T piece trial. Tolerance
of the trial may lead to extubation.
 Failure to tolerate an SBT may prompt a search for reversible or complicating factors and a
return to the non-fatiguing ventilator modality for the patient. The SBT should be re
attempted the next day.
 The use of a weaning protocol decreases ventilator days. The parts of the protocol are not as
important as the use of the protocol to prevent delays in the weaning.
 The patient receiving SIMV can have the ventilator breaths gradually reduced as his/her
ventilatory status permits.
 CPAP or PSV can be added to SIMV. PSV is taught to provide gentle, slow respiratory
muscle conditioning. Some patients may be weaned by simply providing humidified
oxygen.
THE WEANING PHASE:
 The weaning process may be tried any time of the day, although it is usually done during the day,
with the patient ventilated at night in the rest mode.
 The rest mode should be a stable, non-fatiguing, and comfortable form of support forte patient.
Regardless of the weaning mode selected, all healthcare team members should be familiar with the
weaning plan.
 Additionally, it is important to permit the patients respiratory muscles to rest between weaning
trials once the respiratory muscle become fatigue, they may require 12-24 hours to recover.
  The patient being weaned and the caregiver need ongoing emotional support. Explain the weaning
process to them and keep them informed of the progress.
 Place the patient in the comfortable sitting or semi recumbent position. Obtain baseline vital signs
and respiratory parameters.
 During the weaning trial closely monitor the patient for signs and symptoms that may signal
intolerance and the need to end the trial.
 Document the patient’s tolerance throughout the weaning process and include statements regarding
the patients and caregiver’s perception.
THE WEANING OUTCOME PHASE:
 It is the period when the patient is extubated or weaning is stopped because no further progress is
being made.
 The patient who is ready for extubation should receive hyperoxygenation and suctioning.
 Instruct the patient to take a deep breath and the peak of inspiration, deflate the cuff and remove the
tube in one motion.
 After removal encourage the patient to deep breath and cough, and suction the oropharynx as
needed.
 Administer supplemental oxygen and provide naso-oral care.
 Carefully monitor the patient’s vital signs, respiratory status, oxygenation immediately after
extubation within one hour.
 If the patient does not tolerate extubation, immediate re intubation or a trial of NIV may be
necessary.
REFERENCE:
Lewis, Heitkemper, Dirkson, O’Brien, Bucher. Lewis ‘s Medical Surgical Nursing Assessment and Management of Clinical
problem s. Second South Asian edition. Elsevier. Page no 1688-1689

19. Write a short note on Crisis Intervention

 Crisis is a dramatic emotional or circumstantial upheaval in a personal life and a stage in a sequence
of events at which the trend of all future events, especially for better or determined turning point.
 Crisis intervention refers to the methods used to offer immediate, short term help to individual who
experience an event that produces emotional, mental, physical and behavioural distress or problems.
 A crisis can refer to any situation in which individual perceives a sudden loss of his or her ability to
use effective problem solving and coping skills.
Goals of crisis Intervention:
1. To decrease emotional stress and protect the crisis victim from additional stress
2. To assist the victim in organizing and mobilizing resources or support system to meet unique needs
and reach a solution for the particular situation that precipitated the crisis
3. To assist the individual in recovery from the crisis and to prevent serious long-term problem.

Purpose of the Intervention:

1. To reduce the intensity of an individual’s emotional, mental, physical and behavioural reaction to a
crisis.
2. To help the individual return to their level of functioning before the crisis
Requisites for the effective crisis intervention:
a) In addition to being non-judgemental, flexible, objective, empowering, supportive, following are
considered to be essential requisites for service providers to enable and individual to a journey from
a vulnerable crisis
b) Ability to create trust via confidentially and honestly
 c) Ability to listen in an attentive manner
d) Provide the individual with the opportunity to communicate by talking less
e) Being attentive to verbal and non-verbal cues.
f) Pleasant, interested, intonation of voice.
g) Maintaining good eye contact, posture and appropriate social distance if in a face to face situation.
h) Remaining undistracted, open honest, sincere
i) Asking open ended questions
j) Asking permission, never acting on assumptions
k) Checking out sensitive cross-cultural factors.
 The length of time for crisis intervention may range from one session to several weeks, with the average
being four weeks.
 Crisis intervention is not sufficient for individuals with the long-standing problems and it may range
from 20 minutes to 2 or more than 2 hours.
 It can take place in a range of setting such as hospital emergency room, counselling centres, mental
health clinicals school and social service agencies and crisis centres.
Key elements of the Management:
 Management will depend on the severity and causes of the crisis as well as the individual
circumstances of the patient
 Many relatively minor crises can be managed by providing friendly support in primary care without
referral.
 However more severe crisis will require referral to counsellors or the local mental health team
 Crisis therapy includes short term behaviour/ cognitive therapy and counselling
 Involvement of family and another key social network is very important
 Therapy should be relatively intense over a a short period and discontinued before dependence on
the therapist develops
 The risk of suicide and self-harm must be assessed at presentation and each review.
Techniques of crisis intervention:
 Catharsis: the release of feelings that takes place as the patient talks about emotionally charged
areas.
 Clarification: encouraging the patient to express more clearly the relationship between certain
events
 Suggestion: influencing a person to accept an idea or belief, particularly the belief that the nurse
can help and that person will in time feel better
 Reinforcement of behaviour: giving the patient positive response to adaptive behaviour
 Support of defences: encouraging the use of healthy, adaptive defences and discouraging those
that are unhealthy or maladaptive
 Rising self-esteem: helping the patient regain feelings of self-worth
 Exploration of solution: examining alternative ways of solving the immediate problem.
PHASES OF CRISIS INTERVENTION:
Immediate crisis intervention:
 it involves establishing rapport with the victim, gather information for short term assessment and
service delivery and averting a potential state of crisis
 Immediate crisis intervention also includes caring for the medical, physical, mental health and
personal need of the victim and providing information to the victim about local resources or
services.
Second phase:
 the second phase of crisis intervention involves an assessment of needs to determine the service and
resources required by the victim in order to provide emotional support to the victim
  The purpose of the second phase is to determine how the crisis affects the victim’s life, so that a
plan for recovery can be developed, allowing the victims to begin towards the future
Third phase:
 recovery intervention helps victims re-stabilize their lives and becomes healthy again
 It also involves helping the victim prevent further victimization from the criminal justice system or
other agencies, the victim may come into contact with in aftermath of victimization
STEPS IN CRISIS INTERVENTION:
1. Assessment
2. Planning therapeutic intervention
3. Implementing techniques of intervention
4. Resolution of the crisis and anticipatory planning.

Assessment: the assessment process attempts to answer questions such as –

what has happened?
Who is involved?
What is the cause?
How serious is the problem?
 The crisis worker determines the following during the assessment process
 Onset of the crisis
 Precipitating factors (including the 5 W’s of the situation)
Planning therapeutic intervention:
 the person should be involved in the choice of alternative coping methods. The needs and reactions
of significant other must be considered.
 Therapeutic intervention: it depends on pre listing skills, the creativity and the flexibility of the
crisis worker and rapidity of the persons response.
 The crisis worker helps the person to establish an intellectual understanding of the crisis by noting
the relationship between the precipitating factors and the crisis
Resolution and anticipatory planning:
 During the evaluation phase or step of crisis intervention, re assessment must occur to as certain
that the intervention is reducing tension and anxiety.
 Assistance is given to formulate realistic plans for the future, and the person is given the
opportunity to discuss how present experiences may help in coping with future crisis.
REFERENCE:
Available at: https://www.louisianahealthconnect.com/content/dam/centene/louisiana-health-connect/pdfs/
medicaid-provider/Crisis-Intervention.

20. Explain the role of nurse in critical care nursing.

 The American association of critical-care nurses (AACN) defines critical care nursing as that
speciality dealing with human responses to life threatening problems.
 A critical care nurse has in depth knowledge of anatomy, physiology, pathophysiology,
pharmacology and advanced assessment skills. As well as the ability to use the advanced
technologies.
  As a critical care nurse, she performs frequent assessments to monitor trends in the patient’s
physiologic parameters. This allows the nurse to rapidly recognise and manage complications while
aiding, healing and recovery.
Specific critical care nurse duties and responsibilities can include:
 Monitor exact, detailed reports and records of the critically ill patients
 Monitor and record symptoms and changes in the patient’s conditions and inform the physician
 Order, interpret and evaluate diagnostic tests to identify and asses the patient’s condition
 Carefully observe and document patient’s medical information and vital signs
 Document patients’ medical histories and assessment findings
 Document patient’s treatment plans, interventions, outcomes or plan for the revisions
 Consult and coordinate with health care team members about whole patient care plans
 Modify patient treatment plans as indicated by patient’s response and condition
 Monitor the critical patients for changes in status and indications of conditions such as sepsis or
shock and institute appropriate interventions
 Administrating intravenous fluids and medications as per doctor’s order
 Monitor patient’s fluid intake and output to detect emerging problems such as fluid and electrolyte
imbalances
 Monitor all aspects of patients care, including the diet and physical activity
 Identify patients who are at risk of complications due to nutritional status
 Direct and supervise less skilled nursing/health care personnel, or supervise a particular unit on one
shift to patient’s response and conditions
 Treating wounds and providing advanced life support
 Assist physicians with procedures such as bronchoscopy, endoscopy, ET intubation and elective
Cardioversion
 Ensuring that ventilator, monitors and other types of medical equipment’s are function properly
 Ensure the equipment’s are properly stored after use
 Identify malfunctioning equipment’s or devices
 Collaborating with fellow members of the critical care team.
 Responding to life saving situations, using nursing standards and protocols for treatments
 Critical care nurses may also care for pre- and post-operative patients when those patients require
ICU care
 In addition, some act as manager and policy makers, while others perform administrative duties
 Asses patients pain levels and sedation requirements
 Prioritize nursing care for assigned critically ill patients based on assessment data and identify
needs
 Assess family adaptation levels and coping skills to determine whether intervention is needed
 Acting as a patient advocate
 Providing education and support to patient families
 Critical care nurse must be able to draw ABG blood and interpret the reports correctly
 She should have enough knowledge about GCS scale and also evaluation capacity of patient’s
condition.
REFERENCE:
1. Lewis, Heitkemper, Dirkson, O’Brien, Bucher. Lewis ‘s Medical Surgical Nursing Assessment and Management of
Clinical problem s. Second South Asian edition. Elsevier. Page no 1660-1661
2. Available at: http://nursingexercise.com/icu-nurse-duties-responsibilities/