Scope of Critical Care Nursing - Philadelphia



Scope of Critical Care Nursing

- Critical care nursing is subspecialties of medical surgical nursing. The

reason of being of “Nursing” in any setting is the provision of holistic

nursing care.

- The adjective “Critical” is characterized by actual or potential crises for the

recipients of nursing care –

- Critical – is defined as pertaining to a crisis, involving danger or risk.

- Critical care practice areas began to develop in the late 1960’s in response

to:-

a- Developments in medical science and technology

b- Related changes in community values and attitudes.

Definition:

- The American Nurses’ Association defined Nursing as:

- “The diagnosis and treatment of human response to actual or potential

health problem.

- In 1984, the American Association of Critical Care Nurses’ (AACN)

defined Critical Care Nursing:

- “Critical care Nursing is that specialty within nursing that deals specifically with human responses to life- threatening problems”

- Analysis of these definitions reveals several important concepts.

- The basis of the definition rests with the words human responses.

- Critical care nurses deal with

a- The total human being

b- His or her response to actual and potential health problems.

- This suggests that the critical care nurse is involved with prevention as well

as cure.

- Additionally, human response can take the form of :-

a- a physiological phenomenon.

b - a psychological phenomenon.

- Ex: a critical care nurse can teach patient methods to lower blood

cholesterol levels, which may prevent a life-threatening problem.

- Scope of critical care nursing practice

- A scope of practice statement provides a framework within which an

individual can provide a particular service.

- The AACN’s Scope of Critical Care Nursing Practice statement provides a

definition and description of the practice of critical care nursing.

- The scope of critical care nursing practice is described as a dynamic

process with three components:

1- The critically ill patients and their significant social relationship.

2- The critical care nurse.

3- The environment where critical care nursing is practiced.

- Central to the scope are nurse-patient interactions.

- The goal of critical care nursing is :-

- To ensure effective interaction of these three requisite elements to affect

competent nursing practice and optimal patient outcomes

1- Critically ill patient:-

- Critical care patients share one or more of a number of defining

characteristics:

a- A significant health breakdown problem which is life threatening.

b- Biophysiological health breakdown problems of such acuity and / or

chronicity that they may lead to extraordinary dependence on health care

providers, and possibly technology for health maintenance or life support.

- The American Association of Critical Care Nurses (AACN) described the

critically ill patient as follows:

- “The critically ill patient is characterized by the presence of actual and / or

potential (being at risk for developing) life- threatening health problems.”

- The needs of these patients require continuous assessment (observation)

and intervention to restore health and prevent complications.

- As man is biopsychosocial being the concept of the critically ill patient

includes the family and / or significant others.

- The needs of the critically ill are considerable. These needs may be

categorized as physical or non-physical

1- Physical needs:-

- are equated with basic physiological or biological needs for ex, for air,

nutrition, and elimination.

2- Non-physical needs:-

- may include social, spiritual, and psychological needs. Social integrity

(self-esteem), information, and communications are also included.

- The comfort and support provided by social relationships can enhance

effective coping. Therefore the concept of the critically ill patient includes

the interaction and impact of the patients’ family and / or significant

others.

- The nature of critical care is such that physical needs are considered a

priority and are almost always met. However, the critical care environment

can actually obstruct the fulfillment of non-physical needs contributing to

the stressful nature of critical illness.

- “Identity and social integrity can be very difficult to maintain when a

person is in a strange situation without their usual clothes, hair style, and

when work and conversation or discussion goes on around and over them

without including them as a person.”

- The obstructed need for identity and social integrity may lead to the

development of a range of negative emotional or psychological status for

ex. Loss of self-esteem & confidence.

- Obstruction of these non-physical needs increases the stress experienced by

fragile, critically ill patients.

- Obviously the needs of the patient’s family and significant others must also

be considered and met as far as possible.

- If all the needs of the critically ill are to be met, both physical and non-

physical needs should be considered in planning holistic nursing care.

2-Critical Care Nurse:-

- The critical care nurse is a licensed professional, who is responsible for

ensuring that all critically ill patients receive optimal care.

- Nurses practicing in critical care areas have to make clinical judgments to

prevent clinical deterioration in their patients.

- Anticipation and early prevention of patient problems are central

requirements of critical care nursing practice, and these requirements

mandate highly developed skills of :-

1- Assessment.

2- Clinical judgment.

- The very essence of critical care nursing is anticipation and early

intervention in problems besetting the critically ill.

- Prediction of patient problems must be based on:-

1- A sound understanding of anatomy and physiology

2- Astute assessment skills.

- From the perspective of the Australian Society of Critical Care Nurses

(ASCCN),

- Critical care nursing practice is based on the following:

1- Individual professional accountability.

2- A thorough knowledge of biophysical and social sciences.

The application of this knowledge requires :-

a- Skills in clinical assessment

b- Appropriate nursing and technological intervention.

3- Recognition and appreciation of the holistic basis for nursing practice.

This includes recognizing:-

a- The individual’s uniqueness, wholeness,

b- Significant social and environmental relationships.

- Acknowledgment of the interaction and collaborative roles of all members

of the health team

(Coordination of the care delivered by various health care providers).

- Since the clinical requirements of the critically ill are such that the team

caring for any single patient may consist of :-

- Various medical officers,

- A nurse,

- A pharmacist,

- A dietician,

- A physiotherapist,

- A radiographer,

- A social worker.

- The knowledge base, which underlines critical care nursing practice, is

highly specialized and it is constantly subject to revision and development

as a consequence of:-

a- Research activity

b-Technological innovation.

- Preparations for practice in critical care must emphasize the importance of

a holistic approach to nursing care. Such an approach is most likely to meet

the needs of the critically ill person.

3- Critical Care Environment:-

- Critical care nursing takes place in a specialized environments that are

designed and organized to give the best possible patient care in an area

where significant change in patient morbidity can occur rapidly, and often

does.

- The safety of both patients and staff in the CCU is a primary consideration

in designing the milieu in which critical care nursing is carried out.

- The critical care environment is viewed from three prospective:

1-The conditions and circumstances surrounding the direct interaction

between the critical care nurse and the critically ill patient.

- The environment must contain resources that constantly support this

interaction. E.g. emergency equipment and supplies.

2-The setting within which critically ill patient receive care. Here critical

care management and administrative structure ensure effective care

delivery through provision of:-

- Adequate human and financial resources,

- Quality control systems, and maintenance of standard of nursing care.

-Factors that influence the provision of care to the critically ill:-

- Legal,

- Regulatory,

- Social,

- Economic,

- Political factors.

- The presence and application of technology as a common component of

patient management is another key feature of critical care nursing practice.

- Critical care nurses are required to be competent in the use of a wide range

of technological devices, many of which are necessary for life support.

Stress

- Is defined as non-specific response of the body to any demands made upon

it.

Stressor:

- It is stress inducing demands (factor that disturbs the body’s equilibrium).

- The stressor could be physical or emotional, pleasant or unpleasant, leading

to a series of physiological responses, which then require the individual to

adapt. (G. A. S).

- General Adaptation Syndrome (G. A. S.) (Selye’s theory) Comprises 3

stages:

1- Stage of alarm reaction:-

- Initial reaction, the defenses of the whole body mobilized and prepared to

action.

2- Stage of resistance:-

- Body’s adaptation takes place\ body attempts to cope.

3- Stage of exhaustion:-

- If exposure to the same stressor is prolonged, the adaptation energy is lost.

Coping:

- “an attempt to gain mastery over conditions of threat”

or

- “efforts to manage environmental and internal demands and conflicts

which tax or exceed a person’s resources”.

Physiologic adaptation:

- There are a large number of physiologic responses of the human body to

stressors.

- The common adaptive mechanisms

1- The endocrine adaptive response.

2- The neurologic adaptive response.

3- The inflammatory adaptive response.

4- The immunologic adaptive response

Stress response indicators

- (Lab investigations, diagnostic procedures and the other indices of stress)

include:

- Blood and urine analysis to demonstrate change in hormonal levels and

hormonal breakdown products.

- Blood levels of catecholamines, corticoids, and adenocorticotrophic

(ACTH).

- Drop in eosinophils.

- Blood creatinine / creatinine ratio, and elevation of cholesterol and free

fatty acids.

- Immunoglobulin assays.

- Electro-encephalogram may be used to measure brain activity.

- Galvanic skin resistance which measures the electrical conductivity of the

skin. (To measure of sweat excretion, which rises in stress)

- Blood pressure and heart rate and other indices of stress that may be

observed by others or by the person himself. (both physical and behavioral

changes)

- (Increase respiratory rate, excessive sweating and thirst, sleep disturbance,

and anxiety).

Physiological stress responses of the critically ill patient:

- Blood volume is enlarged,

- Respiration become faster and deeper,

- Cardiac output becomes larger,

- Protein, fat, glycogen are converted to glucose for energy.

- So the alarm stage should be limited, if it sustained it leads to death.

- The body moves into stage of resistance, in which it attempts

to cope with the stressor.

- Secretion of adrenal cortical and medullary hormones returns to normal.

- If the body not returned to the normal state exhaustion will occur.

- Potassium depletion may be a major factor in exhaustion.

The symptoms of this stage include:-

1- Irregular pulse,

2- Hypotension,

3- Weakness,

4- ECG chances.

- The catecholamine release will cause ( hypermetabolism and (

- ( Blood pressure and (pulse rate and (RR and alertness (

- This can pose special problems for the persons who has pulmonary and

cardiovascular problems because he will be unable to meet the ( O2 needs,

or to handle the circulatory demands.

- Also the selective vasoconstriction of the vessels that serve vital body

parts. E.g. Kidney cause (

- ( releasing of rennin to ( its supply and this will lead to (

- Peripheral vasoconstriction.

- If stress reaction is very severe or prolonged ( permanent damage to

Kidney or lactic acidosis can result.

- Gluconeogenesis, from Protein and fat will cause ( Blood sugar, this is

very dangerous for diabetics.

- Also catecholamine stimulate the release of clotting factors, although these

effects are basically protective, they can cause ( blood viscosity and

predispose to stasis.

- Fluids must be given with great care to the severely stressed person.

(because of the increased intravascular volume) that cause ( (Fluid

overload, and ( urinary output).

Psychological stress responses of the critically ill patient:

A- Delirium.

B- Catastrophic reaction.

C- Euphoric response.

A- Delirium.

- Is abnormal mental condition

(clinical picture includes:

1- Reduced ability to focus, shift, and maintain attention

2- Disorganization of thinking or speech,

3- Illusions and hallucinations,

4- Disturbed sleep wake cycles,

5- Altered psychomotor activity

6- Disorientation

7- Memory impairment).

B- Catastrophic reaction.

- It is a passive response to severe anxiety.

1- Patient exhibits flat affect,

2- Hyperalterness,

3- Immobility,

4- Lack of spontaneity, with monosyllabic response to questioning

5- Passive cooperation with treatment.

C- Euphoric response.

1- The patient try to deny the seriousness of their illness

2- Patients are noted to be extremely active and his activities are contrary to

the therapeutic limitations).

Sources of stress in the critical care unit:

- In addition to the trauma, disease, surgery,the following factors are

considered to be stressful factors for the critically ill patient.

- Pain.

- Fear of death.

- Presence of tubes.

- Monitors.

- Ventilators.

- Lack of sleep.

- Immobility.

- Isolation.

- Admission to the I. C. U.

- Too much light (sensory overload).

- Extreme of temp.

- Noise.

- Separation from family and friends.

- Presence of very ill patient in the CCU.

- Nurses and doctors.

Coping patterns:

A- Problem-focused coping patterns,

B- Emotion-focused coping patterns,

A- Problem-focused coping patterns,

- Which directed to manage the problem by dealing with demands.

1- Try to maintain some control over the situation.

2- Try to change the situation.

3- Talk the problem over with some one who has been in the same type of

situation.

4- Draw on the past experience to help handle the situation.

B- Emotion-focused coping patterns,

- Which directed at lessening the emotional distress

1- Pray.

2- Work off tension with physical activity.

3- Go to sleep.

4- Seek comfort or help from family or friends.

1- Explanation and clarification:

- Explain his illness to him.

- Correct any misconceptions about disease and its consequences

- Provide orientation to the place, personnel, time,

- Explain every procedure before its performance.

2- Fostering optimism:

- Allow the patient to continue to use deny their emotional feelings as a

means of coping with stress at least to a certain point.

- Treat the patient with the conviction that recovery is fully anticipated.

- Emphasize survival and recovery rather than risks and dangers.

3- Reassurance:

- Provide reassurance by talking to the patient in the most encouraging

fashion possible.

- Act in a calm, positive, efficient manner.

- Inform the patient with any evidence of progress toward recovery.

- Avoid broad promises such as, “Don’t worry, everything will be all

right”

4- Listening:

- Listen attentively and demonstrate genuine to assist the patient to ventilate

his feelings which decrease fears ,to recognize the sources of the problem,

and be able to deal with them.

5- Manipulating environment:

- Maintain a peaceful atmosphere which helps the patient to relax

and regain his emotional equilibrium.

- Provide rest periods for the patient during whom visitors or the staff does

not disturb time.

- Allow radio, television, and newspapers to prevent a feeling of isolation.

- Allow the patient to sit in a bedside chair (if the condition permits) is

usually a source of encouragement.

6- Anticipating emotional reactions:

- Explain that emotions experienced by patient are normal, common reaction

and anticipated response during this period.

7- Drug therapy:

- Administer tranquilizers during the first few days of hospitalization.

- Adjust the dosage so that the patient is not constantly drowsy or sleepy.

Delirium

Definition:-

- It is a reversible global impairment of cognitive process, usually of sudden

onset, .

Clinical manifestation:-

1- Disorientation,

2- Impaired short-term memory,

3- Altered sensory perceptions (hallucinations),

4- Abnormal thought processes,

5- Inappropriate behavior.

Incidence of delirium:-

- Delirium is probably more prevalent than generally recognized and is

difficult to diagnose in the critically ill patient.

- The incidence ranges from 30% to 70% in medical-surgical critical care

patients.

Causes of delirium:-

1- Metabolic

2- Intracranial

3- Endocrine

4- Organ failure

5- Respiratory

6- Alcohol withdrawal

7- Heavy metal poisoning.

8- Drug related

9- Additional causes

1- Metabolic

- Acid-base disturbance,

- Electrolyte imbalance,

- Hypoglycemia.

2- Intracranial

- Epidural hematoma,

- Subdural hematoma,

- Intracranial hemorrhage,

- Meningitis,

- Encephalitis,

- Cerebral abscess,

- Tumor.

3- Endocrine

- Hyperthyroidism

- Hypothyroidism,

- Addison's disease,

- Hyperparathyroidism,

- Cushing's syndrome

4- Organ failure

- Liver encephalopathy,

- Uremic encephalopathy,

- Septic shock.

5- Respiratory

- Hypoxemia

- Hypercarbia.

6- Alcohol withdrawal,

7- Heavy metal poisoning.

8- Drug

- Digitalis,

- Antibiotics,

- Steroids,

- Beta adrenergic blockers,

- Respiratory stimulant.

9- Additional causes

- Sleep deprivation,

- Sensory deprivation

- Sensory overload,

- Immobilization,

- Age over 60 years old.

The major categories to assess delirium :-

1- Acute onset of mental status changes or fluctuating course.

2- In-attention.

3- Disorganized thinking.

4- Altered level of consciousness, which include any level of consciousness

other than "alert" (vigilant, lethargic, stupor, coma).

Forms of delirium:-

A- Hyperactive delirium

B- Hypoactive delirium

C- Mixed delirium

A- Hyperactive delirium

The patient may

- Become violent;

- Be extremely restless .

- Remove invasive devices (intravenous lines, catheters, machines, and

dressings

- Try to get out of bed;

- Pick at things in the air;

- Call out of persons who are not there.

Sympathetic nervous system responses are evident :-

- Tachycardia,

- Dilatation of pupils,

- Diaphoresis,

- Facial flushing

B- Hypoactive delirium

The patient may:-

- Complain of extreme fatigue,

- Be slow to respond,

- Have hypersomnolence that can progress to

loss of consciousness.

At times the patient

- is absorbed in a dreamlike state,

mumble to them,

- Experience vivid hallucinations,

- Make inappropriate gestures.

C- Mixed delirium ( sundown's syndrome )

- It is a mixture of agitation and hypoactive behaviors that may vary

throughout the day.

- Symptoms and hallucinations seem to worsen during night, with more

lucid intervals during the day.

Management:

A- Prevention

- Preventive measures through correcting the underlying cause of delirium.

B- Non- pharmacologic strategies

1- Backmassage,

2- Music therapy,

3- Noise reduction in the environment,

4- Decreasing lights at night to promote sleep,

5- Clustering nursing care to provide some uninterrupted rest periods,

6- Speaking in calm, quit, and gentle voice.

C- Pharmacologic strategies:-

1- Sedatives for short-term use are prescribed for patients with hyperactive

delirium.

- Risperidone (Risperdal) is now preferred over Haloperidol in treatment

of delirium because it produces :-

- Less sedation

- Fewer anticholinergic effects

(e.g., dry mouth, constipation, urinary retention).

2- Narcotics can be administered when delirium is considered to be

secondary to pain,

- However, the following can exacerbate the delirium.

a- The paradoxical effects of depressed respiration

b- The paradoxical effects of cardiac output

3- Neuromuscular blocking agents sometimes used for severely agitated

patients who are on mechanical ventilation

a- To decrease in oxygen consumption,

b- To promote synchrony with the ventilator,

c- To increase tissue oxygenation.

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