Critical Care Unit 1
Apply knowledge of the critical care setting:
Ch1: Caring for a critically ill Pt
Nurses have unique role since they are there constantly with pt whereas Dr/PT/OT/RT aren’t
nurses give whole picture—trend of hospitals to do team rounds to eliminate
miscommunication.
- Eyes, ears, feet of pt, bedside 24/7, whereas others are there for minutes—nurses give
whole picture
Specialty ICU: Cardiac, Neuro, medical, Peds, OB, NICU,
Step-down = progressive care unit (not terrible but not ready for medsurg 1:3)
Goal is always to start planning for d/c: beginning on day 1, and preparing pt for change
(physically/emotionally etc)
Many variations of RNs: insurance, case manager, educators, woundcare, cardiac rehab and
specialties within NP: peds, ob,
Discuss the benefits of belonging to a professional organization:
Society of critical care medicine (SCCM) anyone who works in icu (physician, rn, ems)
AACN: American academy critical care Nurses: certifications, national org, awards
Affordable care act: beneficial d/t detecting diseases earlier since $, preventative screening
, pt satisfaction ratings makeup how staff are compensated
AACN- sets practice alerts, ie see trend in a specific disease process and educate on “___”
Technology: equipment always improving, goal is always to be less intrusive
Pro: pt taking advantage of preventative care
Con: enforcement on reimbursement— based on pt satisfaction ratings
Everyone on medicaid or medicare dollars should be on EHR-electronic health record.
Tele ICU: ie computer distance nursing/physician via computer. Usually used in rural setting
where intensive care specialty is unavailable but advanced hospitals are implementing as well
as a safeguard. Also in rural areas physician can monitor/doctor from afar.
Business responsibility in RN: need to be financially responsible
Interprofessional Collab: guidelines instituted.
Key role of nurses is collaborative effort
Research- looking at variables to make improvements, constant assessment to improve.
Ch 3: Pt and family response to the Critical care experience
Utilize nursing process in assessing the pt and family in critical care environment
and plan appropriate invention
-Family doesn’t equate blood- family is whoever pt says is family. Ie domestic live in partner,
spouse, polygamist,
-Realize that not everybody shares same worldview as self,
-Pt will start to bond with you in ICU and may ask you for advice (ie. Neurosurgeon walks out
family asks “what would you, nurse, do?”)
-Over the phone pt info is not allowed unless have passcode
Critical care environment: stress, anxiety, loss of privacy, don’t presume pt cant hear while in
coma,
,Address emotional and physical pain of pt- even comatose pts, assess pain every time in room,
and address pain. Pt shouldn’t be in unbearable pain.
Reduce accessory sound in ICU, don’t want to disturb pt sleep and distress. Know what pt likes
and don’t like, bring in picture/music
Pts recall about cc: difficult communication (trach/etc), pain not addressed (perhaps
communication impaired), thirst, difficulty swallowing, anxiety, loss of control
(embarrassment by lack of control), feelings of depression, optimize pt perhaps wheel them
around unit
Biggest stressor: pain, inability to sleep, financial concerns—financial counselor, social
services to address how to pay for.
Psychosocial support: reorientation is important, tell where pt is, who you are, what day it is,
plans for today
Quality of life after CC: discharge can be difficult for pt/families may feel abandoned, new
routines, less time with nurse if going to pcu/medsurg, prepare pts from day 1 of plan of care
to be d/c rehab etc
Discuss the effects of the aging process on the individuals response to the critical
care environment
Geriatric concerns: ability to adapt/cope w/ stressors of critical illness, prolonged length of
stay, at r/f negative outcomes ( mortality, functional decline, health related quality of life)
Ch 11: End of life:
It is not bad to die—support pt with spiritual care, pain mgt,
End of life care: ‘allowing natural death’ or ‘ withholding of nonbeneficial treatment’ but still
addressing pain and emotional needs
Palliative care: increase in palliative care dt babyboomers, RNs are good at end of life care,
does not only mean when pt is in end of life, if it is going to be an uphill battle to survive may
involve palliative care.
End of life:
Study found that:- aggressive tx (death is not always negative may be putting pt through more
rigamaroll), inadequate pain control, poor communication
Advanced directives: states what pt does or does not want done if unable to state for self.
Physician orders for life sustaining tx (POLST)- MD must follow a pts written requests.
Pt self determination act- pts have the right to make their own decisions. Ie if there is a life
saving treatment, it is the patients right to say no. ie Jehovah’s witness blood. Ensure that
patient knows facts and respect decision
Comfort care:
Withholding- not currently on life-support but if should need wont implement
Withdrawal- remove life sustaining tx
DNR- signed b/w pt or POA in front of physician- says no CPR/Defb
Pain mgt: nonopioids vs opioids—don’t automatically presume that pt should be on opioids,
should be more of a last resort first implement nonpharmacological interventions, other meds,
etc
When withdrawling life support involve family as to when to withdraw ie when family can all
be there. It may not be immediate, give pt realistic expectations, give private space as possible.
Turn off monitors or send them to rn station, d/c unnecessary meds ie PPI
, Sx mgt/providing care:
- Dyspnea
- N/V
- Edema
- Delirium
- Metabolic derangement
- Fever/inf
Brain death: different facilities have different protocols to declare brain death
CPR: best indication to allow family in room if they’d like, for better coping mechanism
After death: clean and tidy pt. and allow family to grieve with pt in room if corners case
cannot remove anything (IV, catheters etc. corner case= unexpected death ie. dies shortly after
medical procedure, if family requests)
Professional issues: staff may take death of pts hard, staff burden, moral distress
Stress response:
Eugenic stress: good stress (able to cope, HR RR, adrenaline, ‘pre-exam’)
Distress: bad stress
Stages:
1- Alarm: fight or flight
2- Resistance or adaptation- are able to cope and have positive compensatory
mechanism, regulating and successfully ie stress anexiety
3- Exhaustion: compensatory mechanisms start to fail, now begins to harm
body systems
Reactive: ‘how will react/respond’
Anticipatory: ‘how will react/respond
Conditional: body’s learned behavior (Pavlov)
Sympathetic: speeds things up:
SNS Stimulates: Limbic, Cerebral cortex, Hypothalamus stimulated (endocrine responses) SNS,
ACTH and corticotropin-releasing hormones
Parasympathetic: slows things down
Apply knowledge of the critical care setting:
Ch1: Caring for a critically ill Pt
Nurses have unique role since they are there constantly with pt whereas Dr/PT/OT/RT aren’t
nurses give whole picture—trend of hospitals to do team rounds to eliminate
miscommunication.
- Eyes, ears, feet of pt, bedside 24/7, whereas others are there for minutes—nurses give
whole picture
Specialty ICU: Cardiac, Neuro, medical, Peds, OB, NICU,
Step-down = progressive care unit (not terrible but not ready for medsurg 1:3)
Goal is always to start planning for d/c: beginning on day 1, and preparing pt for change
(physically/emotionally etc)
Many variations of RNs: insurance, case manager, educators, woundcare, cardiac rehab and
specialties within NP: peds, ob,
Discuss the benefits of belonging to a professional organization:
Society of critical care medicine (SCCM) anyone who works in icu (physician, rn, ems)
AACN: American academy critical care Nurses: certifications, national org, awards
Affordable care act: beneficial d/t detecting diseases earlier since $, preventative screening
, pt satisfaction ratings makeup how staff are compensated
AACN- sets practice alerts, ie see trend in a specific disease process and educate on “___”
Technology: equipment always improving, goal is always to be less intrusive
Pro: pt taking advantage of preventative care
Con: enforcement on reimbursement— based on pt satisfaction ratings
Everyone on medicaid or medicare dollars should be on EHR-electronic health record.
Tele ICU: ie computer distance nursing/physician via computer. Usually used in rural setting
where intensive care specialty is unavailable but advanced hospitals are implementing as well
as a safeguard. Also in rural areas physician can monitor/doctor from afar.
Business responsibility in RN: need to be financially responsible
Interprofessional Collab: guidelines instituted.
Key role of nurses is collaborative effort
Research- looking at variables to make improvements, constant assessment to improve.
Ch 3: Pt and family response to the Critical care experience
Utilize nursing process in assessing the pt and family in critical care environment
and plan appropriate invention
-Family doesn’t equate blood- family is whoever pt says is family. Ie domestic live in partner,
spouse, polygamist,
-Realize that not everybody shares same worldview as self,
-Pt will start to bond with you in ICU and may ask you for advice (ie. Neurosurgeon walks out
family asks “what would you, nurse, do?”)
-Over the phone pt info is not allowed unless have passcode
Critical care environment: stress, anxiety, loss of privacy, don’t presume pt cant hear while in
coma,
,Address emotional and physical pain of pt- even comatose pts, assess pain every time in room,
and address pain. Pt shouldn’t be in unbearable pain.
Reduce accessory sound in ICU, don’t want to disturb pt sleep and distress. Know what pt likes
and don’t like, bring in picture/music
Pts recall about cc: difficult communication (trach/etc), pain not addressed (perhaps
communication impaired), thirst, difficulty swallowing, anxiety, loss of control
(embarrassment by lack of control), feelings of depression, optimize pt perhaps wheel them
around unit
Biggest stressor: pain, inability to sleep, financial concerns—financial counselor, social
services to address how to pay for.
Psychosocial support: reorientation is important, tell where pt is, who you are, what day it is,
plans for today
Quality of life after CC: discharge can be difficult for pt/families may feel abandoned, new
routines, less time with nurse if going to pcu/medsurg, prepare pts from day 1 of plan of care
to be d/c rehab etc
Discuss the effects of the aging process on the individuals response to the critical
care environment
Geriatric concerns: ability to adapt/cope w/ stressors of critical illness, prolonged length of
stay, at r/f negative outcomes ( mortality, functional decline, health related quality of life)
Ch 11: End of life:
It is not bad to die—support pt with spiritual care, pain mgt,
End of life care: ‘allowing natural death’ or ‘ withholding of nonbeneficial treatment’ but still
addressing pain and emotional needs
Palliative care: increase in palliative care dt babyboomers, RNs are good at end of life care,
does not only mean when pt is in end of life, if it is going to be an uphill battle to survive may
involve palliative care.
End of life:
Study found that:- aggressive tx (death is not always negative may be putting pt through more
rigamaroll), inadequate pain control, poor communication
Advanced directives: states what pt does or does not want done if unable to state for self.
Physician orders for life sustaining tx (POLST)- MD must follow a pts written requests.
Pt self determination act- pts have the right to make their own decisions. Ie if there is a life
saving treatment, it is the patients right to say no. ie Jehovah’s witness blood. Ensure that
patient knows facts and respect decision
Comfort care:
Withholding- not currently on life-support but if should need wont implement
Withdrawal- remove life sustaining tx
DNR- signed b/w pt or POA in front of physician- says no CPR/Defb
Pain mgt: nonopioids vs opioids—don’t automatically presume that pt should be on opioids,
should be more of a last resort first implement nonpharmacological interventions, other meds,
etc
When withdrawling life support involve family as to when to withdraw ie when family can all
be there. It may not be immediate, give pt realistic expectations, give private space as possible.
Turn off monitors or send them to rn station, d/c unnecessary meds ie PPI
, Sx mgt/providing care:
- Dyspnea
- N/V
- Edema
- Delirium
- Metabolic derangement
- Fever/inf
Brain death: different facilities have different protocols to declare brain death
CPR: best indication to allow family in room if they’d like, for better coping mechanism
After death: clean and tidy pt. and allow family to grieve with pt in room if corners case
cannot remove anything (IV, catheters etc. corner case= unexpected death ie. dies shortly after
medical procedure, if family requests)
Professional issues: staff may take death of pts hard, staff burden, moral distress
Stress response:
Eugenic stress: good stress (able to cope, HR RR, adrenaline, ‘pre-exam’)
Distress: bad stress
Stages:
1- Alarm: fight or flight
2- Resistance or adaptation- are able to cope and have positive compensatory
mechanism, regulating and successfully ie stress anexiety
3- Exhaustion: compensatory mechanisms start to fail, now begins to harm
body systems
Reactive: ‘how will react/respond’
Anticipatory: ‘how will react/respond
Conditional: body’s learned behavior (Pavlov)
Sympathetic: speeds things up:
SNS Stimulates: Limbic, Cerebral cortex, Hypothalamus stimulated (endocrine responses) SNS,
ACTH and corticotropin-releasing hormones
Parasympathetic: slows things down
