CRITICAL CARE UNITS

NURSING ASSESSMENT – History & Physical

Assessment

• If the patient is Conscious , introduce yourself and

explain who you are and what you intend to do.
• Try to avoid focusing intently on the monitors and
charts, thereby ignoring the patient.
• Although we have more monitoring and tests
available
to us, the focus of our attention should always be the
patient, their symptoms and clinical signs.
• Details of the past medical history and the
presentation of the primary pathology may be difficult
to obtain, but information should be sought from
relatives, the ambulance crew, referring hospitals and
general practitioners or hospital specialists caring for
the patient’s chronic medical conditions.
• During first visit / Hospitalization, it is worth sitting
down to read the current and old hospital notes in
full (including specialists letters and old
investigations), in order to form a complete picture
of the patient’s medical history.
• Some patients will only be able to answer your
questions for a short period before clinical
deterioration or sedation prevents this.
• The information that you obtain from them may be
vital,
for example : sudden onset of chest and abdominal
pain whilst vomiting in a septic patient, suggests a
perforated esophagus, a diagnosis that can easily be
missed without a suggestive history.
• If a patient’s response to treatment is not as
predicted, review the presentation and consider
whether the working diagnosis is correct.
• Decisions made regarding admission to ICU, require
some knowledge of patient’s physiological reserve,
their quality of life and their own attitude to such
treatments.
• These decisions should be made and documented
pre-emptively rather than when a catastrophic
deterioration occurs. Patients may remain in the ICU
for some weeks.
• Experienced intensivists are able to plot the next few
days of a patients ICU stay, allowing goals to be set
for certain aspects of the patient’s illness.
• In spite of this, unexpected events occur relatively
frequently and it is important have flexibility to focus
on whatever issues arise.
EXAMINATION
 Physical examination of the patient and their
observations can often occur together.
 A systematic approach must be used and a ‘head-to-toe’
system is appropriate.
 Each section focuses on history, clinical examination and
observations.
 Even though this approach is ‘labour-intensive’ it is this
type of attention to detail that may make a difference in a
patient’s progress in ICU.

For example,
identifying and removing a cannula that has been in for 5
days, is not
being used and shows erythema around it, may prevent
an episode of Staphylococcal bacteraemia.
Head/central nervous system
General considerations : If the patient’s primary
pathology is a head injury, cranial surgery or a
cerebral event then your assessment should be
adjusted accordingly.
• The patient’s Glasgow Coma Score (GCS) should be
recorded – for head-injured patients this is most
usefully done when sedation has been stopped.
• A full cranial and peripheral nerve examination
should be performed daily where indicated - for
example in those with fluctuating neurology due to a
cerebral abscess and note the pupil size and
reaction.
• Over-sedation is undesirable and performing daily
sedation breaks reduces length of stay on ICU.
• Despite the availability of adequate methods of
analgesia and appropriate monitoring, pain control
 Pain scores should be recorded and analgesia
reviewed daily, particularly in postoperative
patients. Most of the techniques that are applicable
for postoperative patients on the surgical ward can
be used in ICU and it is useful for intensivists to
learn regional techniques such as rectus sheath and
epidural insertion.
 Simple analgesics such as paracetamol should be
prescribed routinely, although non-steroidal anti-
inflammatory drugs are usually avoided in the
critically ill.
Respiratory and ventilation
General considerations:
 A past medical history of respiratory disease, including
lung function tests, and current respiratory issues should
be noted.
• The patient’s airway and respiratory system should be
examined. If an endotracheal tube is in place, note
that the length at the teeth is as documented at insertion
and check its position is correct on the most recent chest
X-ray.
• Often it is only possible to auscultate the chest
anteriorly and in the axillae.
• The ventilator settings should be inspected and the
measured tidal volume, minute volume, peak and plateau
pressures noted.
• Note whether the patient appears comfortable on these
ventilator settings, in particular whether they are ‘fighting’
(co-ordinating poorly with) the ventilator or display an
increased work of breathing.
 The patient’s saturations and, where available,
arterial blood gases should be inspected and trends
noted. Regular arterial gas measurements of PaO2
and PaCO2 :FiO2 ratio and pH are useful
 If the clinical appearance, oxygenation or blood gases
are not satisfactory, then you must address this by
altering the ventilator mode, settings or level of
sedation to improve the situation.
 Set targets for gas exchange; these should be
specific to each patient

Weaning
It is the process of decreasing the degree of ventilator
support and allowing the patient to assume a greater
proportion of their own ventilation
(eg, spontaneous breathing trials or a gradual reduction
in ventilator support).
Circulation
 A comprehensive examination of the cardiovascular
system should be performed daily.
 This should include auscultation of the heart sounds
and lung bases.
 Peripheral perfusion, pulses and the presence of
peripheral edema should be noted.
 Spontaneous clearance of edema, with an
accompanying diuresis, is usually a sign that an
acute episode of sepsis is resolving.
 It is useful to chart observations of heart rate, blood
pressure, capillary refill and interventions, such as
fluid and ionotrope administration, in order to
identify trends.
 Baseline and serial ECGs are important in patients
with ischemic heart disease, to assess for ischemic
changes associated with acute deterioration of the
patient.
 Where available, trans-thoracic (TTE) or trans-
oesophageal (TOE) echocardiography are useful in
evaluation of the structure and function of the right
and left ventricles and heart valves.
ABDOMEN AND NUTRITION
 The abdomen should be fully examined at least daily,
as it is a concealed source of infection and
subsequent driver of inflammation in critical illness.
 The presence of any surgical drains should be
noted and the trends of collection volumes noted to
see if further surgery is required, or whether the drain
can be removed.
 Nasogastric (NG) tube placement should be confirmed
on a daily basis by chest X-ray.
 The patient’s daily weights should be recorded as a
basic nutritional assessment.
Renal, fluids and electrolytes
o The urine output should be charted every hour
where appropriate.
o Most urinary catheters are colonised with bacteria,
but these are usually not clinically significant.
However, catheters should be removed if not
required.
o The trends in renal function and electrolytes should
be examined frequently and correlated with the
patient’s progress as a whole.
o The patient’s fluid administration should be
reviewed and the daily and cumulative fluid
balances noted.
o Dialysis or renal replacement therapy (RRT) may be
required in hyperkalaemia, fluid overload, uremia,
acidosis, or poisoning due to a filterable toxin.
BLOOD TESTS
 ICU patients require daily measurement of renal
function, electrolytes and haematological studies.
Magnesium and calcium levels, clotting function and
blood grouping for transfusion are frequently
required.
 Low levels of magnesium (<0.7mmol.L-1) and
phosphate should be treated by intravenous
supplementation.

VASCULAR ACCESS
 Routinely check any vascular access catheters for
each patient.
 unit should have robust system for documenting the
insertion date of each of these.
DOCUMENTATION
o Document all of your findings in a systematic way.
o Always clearly record the assessment of the patient
with date and time.
o Make a clear problem list, followed by a plan for the day
that relates to the problem list.
o It is useful to tick off the items on the plan as they are
completed.

FAMILY / NEXT OF KIN

o Ask who is the immediate family are and whether they
have had any discussion with members of the nursing or
medical staff.
o Should someone speak to them today to keep them up-
to-date with changes in the patient’s condition?
o Document any discussions that you do have.
OTHER POINTS
• Discuss the resuscitation status of the patient and
check that any decisions about the levels of care
offered in the case of clinical deterioration have
been documented.
• Ask any other members of the team whether they
have anything else to add.
• Explain your main findings and plans to the
patient, in as much detail as appropriate.
CLASSIFICATION
“Intensive care, also known as critical care, is a
multidisciplinary and interprofessional specialty dedicated
to the comprehensive management of patients having, or
at risk of developing, acute, life-threatening organ
dysfunction".

ICU may be classified according to the availability of qualifies

staff, the complexity of the care delivered and speciality i.e.,

1. MICU (medical ICU)

2. SICU (Surgical ICU)
3. CCU (Critical care Unit)
4. RICU (Respiratory ICU)
5. Septic ICU
6. Cardiac / Coronary ICU
7. Neonatal ICU
8. Paediatric ICU
9. Burns ICU
BASIC PRINCIPLES OF INTENSIVE CARE NURSING
1. Airway Safety
2. Breathing
3. Circulation
4. Disability / Level of Consciousness
5. Exposure

Airway Safety & Breathing Pattern:

There are two different types of invasive airways the
patient may have in place.
* An Endotracheal tube or a Tracheostomy:
Endotracheal tube (ETT) and a Tracheostomy (Trache) are
closed system airways used to deliver ventilation to the
patient.
Patients who require an ETT are usually in respiratory
failure and unable to adequately breath for themselves or
are unable to protect their airway due to other
• A Tracheostomy may be formed when patients are
likely to have a prolonged period of mechanical
ventilation.(This will be a planned procedure)
• Both airways sit in the trachea delivering air/02
directly to the lungs.
• Sputum management
SPECIAL EQUIPMENTS
Types of Devices
I.Patient monitoring devices
II.Life support & emergency resuscitation devices
III.Diagnostic devices

Patient monitoring devices

•Arterial line
•Bedside monitor
•Blood pressure device(sphygmomanometer)
•ECG machine
•EEG machine
•Intracranial pressure monitor
•Pulse Oxymetry
•Glucometer
Life support & emergency resuscitation devices
1. Cardiac Monitors (to watch signs of complications)
2. Mechanical ventilators
3. Oxygen(wall mounted & Portable) and Ambubag
4. Defibrillators
5. Pulse Oxymetry
6. Airways
7. Suctioning Machine (wall mounted & Portable ie., Suction
Catheter)
8. ECG Machine
9. Syringe pumps
10. Infusion Pumps(used to deliver fluids & medications in
Controlled manner i.e., chemotherapy drugs, Insulin)
11. Feeding Tubes (NG tubes)
12. Endotracheal Tubes
13. Crash Cart or Resuscitation cart (for Advanced Life Support &
CPR)
14. Blood Warmer
15. Laryngoscope
Other special Equipments are
1. Urinary catheter
2. Urinary drainage collector
3. Intravenous line or catheter
4. Central or arterial lines

Diagnostic Equipments
5. Mobile x-ray units
6. Portable clinical laboratory devices
7. Bronchoscope
8. Colonoscopy
9. Endoscope
10.Gastroscope
Infection Control Protocols
Infection control addresses factors related to the
spread of infections within the health-care setting,
including prevention, monitoring/investigation of
demonstrated or suspected spread of infection within a
particular health- care setting, and management
(interruption of outbreaks).

STANDARD PRECAUTION STEPS –

1. Hand washing
2. PPE
3. Decontamination
4. Waste disposal

HAND HYGIENE is the single most effective measure

in infection control(about 80% of the diseases are
spread through hands).
PERSONAL PROTECTIVE EQUIPMENT
• Gloves • Gown • Mask • Protective eye wear • Face
shield • Apron
SAFE HANDLING OF SHARPS
• Never pass sharps from one person to another.
• Always dispose your own sharps.
• DO NOT RECAP needles.
• Dispose sharps in
puncture proof container.
.
DISINFECTION
Reduce the number of microorganisms on an object
or surface but not the complete destruction of all
microorganisms or spores via various methods

WASTE TRANSPORTATION
Points to be remembered:
Before taking the bags it should be tied & labeled.
 Waste handlers should not touch any other articles.
 A covered cart with biohazard symbol to carry the
waste to the central area of collection
Transitional care
“It refers to the co-ordination &continuity of health care during
a movement from one health care setting to either another or
a to home”.

 Older adults who suffer from a variety of health conditions

often need health care services in different settings to meet
their many needs.

Improving quality of transitional care

After leaving a particular care setting, older patients
may not understand how to manage their health care
conditions or
whom to call if they have a question or if their condition
gets worse.
Poorly managed transitions can lead to physical
and emotional stress for both patients and their
caregivers.
The Care Transitions Intervention
•The Care Transitions Intervention is a coaching
intervention to assist patients in resuming self-care
following a change in health status.
•It uses coaching techniques to ensure that patients
are comfortable in managing their own medications
and their own health information, understand the
signs and symptoms that should lead them to contact
a healthcare provider, and have assertion skills to ask
important questions of providers.
•Although the coaching intervention occurs for the first
30 days following the transition, this approach has
been shown to significantly reduce hospital
readmission as far out as six months.
 Ethical and legal issues
Ethical and Legal Issues in Critical Care Nursing
• Critical care nurses are often confronted with ethical
and legal dilemmas related to informed consent,
withholding or withdrawing life-sustaining
treatment, organ and tissue transplantation,
confidentiality and justice in the distribution of
healthcare resources.

Ethics: are concerned with the basis of the action

rather than whether the action is right or wrong, good
or bad.
It refers to what rules are required to
prevent harm to persons and to the collective beliefs
and values of a community or profession.
Moral Distress: Nurses face multiple
challenges on a daily basis:
 Emergency situations.
 Tension from conflict with others.
 Complex clinical cases.
 New technologies.
 Increasing regulatory requirements.
 Acquisition of new skills/knowledge.
 Staffing issues.
 Financial constraints.
 Workplace violence..
• Moral distress occurs when a person knows the
ethically appropriate action to take but cannot act
on it. It also manifests when a nurse acts in a
manner contrary to personal and professional
values.

• As a result, there can be significant emotional

and physical stress that leads to feelings of loss
of personal integrity and dissatisfaction with the
work environment.

• Relationships with co-workers and patients are

affected, and the quality of care can be
negatively affected
Ethical Principles
These principles are intended to provide respect and
dignity for all persons:

• Autonomy: Respect for the individual and the ability of

individuals to make decisions with regard to their own
health and future (the basis for the practice of informed
consent).

• Beneficence: doing good and preventing harm to

patients is the sine qua non for the nursing profession.

•Non maleficence: Actions intended not to harm or

bring harm to others.

• Veracity: The obligation to tell the truth is an important ethical

principle that underlies the nurse-patient relationship.
• Fidelity: The moral duty to be faithful to the
commitments that one makes to others.

• Confidentiality: Respect for an individual’s

autonomy and the right of individuals to
control the information relating to their own
health.
Eg : suicidal cases or MLC with family conflicts

• privacy

• Justice: In health care, justice is described

as the fair allocation or distribution of
healthcare resources.
Nursing Code of Ethics: The ANA Code of Ethics for Nurses provides

the major source of ethical guidance for the nursing profession.

The nine statements of the code are;

1. The nurse in all professional relationships, practices with compassion

and respect for the inherent dignity, worth, and uniqueness of every

individual, unrestricted by considerations of social or economic status,

personal attributes, or the nature of health problems.

2. The nurse’s primary commitment is to the patient, whether an

individual, family, group, or community.

3. The nurse promotes, advocates for, and strives to protect the health,

safety, and rights of the patient.

4. The nurse is responsible and accountable for
individual nursing practice and determines the
appropriate delegation of tasks consistent with the
nurse’s obligation to provide optimum patient
care.

5. The nurse owes the same duties to self as to

others, including the responsibility to preserve
integrity and safety, to maintain competence, and
to continue personal and professional growth.

6. The nurse participates in establishing,

maintaining, and improving health care
environments and conditions of employment
conducive to the provision of quality health care
and consistent with the values of the profession
7. The nurse participates in the advancement
of the profession through contributions to
practice, education, administration, and
knowledge development.

8. The nurse collaborates with other health

professionals and the public in promoting
community, national, and international efforts
to meet health needs.

9. The profession of nursing, as represented

by associations and other members, is
responsible for articulating nursing values, for
maintaining the integrity of the profession and
its practice, and for shaping social policy.
What Is an Ethical Dilemma?

In general, ethical cases are not always clear-cut. An

ethical dilemma exists if there are two (or more)
morally correct actions that cannot be followed. The
result is that both something right and something
wrong occur.
In these situations, there are both ethical conflict
and ethical conduct issues.
The most common ethical dilemmas encountered
in critical care for going treatment and allocating the
scarce resource of critical care, but how does the
health care worker know that a true ethical dilemma
exists?
Early Indicators For Ethical Dilemmas

• Signs of conflict among health care (HC) team members, family

members, and HC team and family
• Signs of patient suffering
• Signs of nurse distress
• Signs of ethics violation
• Signs of unrealistic expectations
• Signs of poor communication.

Steps in Ethical Decision Making:

1. Identify the health problem.
2. Define the ethical issue.
3. Gather additional information.
4. Delineate the decision maker.
5. Examine ethical and moral principles.
6. Explore alternative options.
7. Implement decisions.
8. Evaluate and modify actions.
• Informed Consent: Many complex dilemmas in critical care
nursing concern informed consent. Consent problems arise
because patients are experiencing acute, life threatening
illnesses that interfere with their ability to make decisions
about treatment or participation in a clinical research study.

• Elements of Informed Consent: Three primary elements

must be present for a person’s consent or decline of medical
treatment or research participation to be considered valid:
competence, voluntariness, and disclosure of information.

• Competence (or capacity) refers to a person’s ability to

understand information regarding a proposed medical or
nursing treatment. Competence is a legal term and is
determined in court. The ability of patients to understand
relevant information is an essential prerequisite to their
participation in the decision-making process and should be
carefully evaluated as part of the informed consent process.
Patients providing informed consent should be free from
severe pain and depression.
• Consent must be given voluntarily, without coercion or fraud,
for the consent to be legally binding. This includes freedom
from pressure from family members, healthcare providers,
and payers. Persons who consent should base their decision
on sufficient knowledge.

Basic information considered necessary for decision making

includes the following:
•A diagnosis of the patient’s specific health problem and
condition
• The nature, duration, and purpose of the proposed treatment
or procedures
• The probable outcome of any medical or nursing intervention
• The benefits of medical or nursing interventions
• The potential risks that are generally considered common or
hazardous
• Alternative treatments and their feasibility
• Short-term and long-term prognoses if the proposed
treatment or treatments are not provided.
Elements of Good Ethical Practice in Medical Decisions
in ICU

• Careful assessment of the patient’s condition.

• Evaluation of the risks and benefits of therapeutic
options.
• Clear communication with the patient to inform
about options and identify plan of care.
• Identification and respect for a competent patient’s
• Plan of care based on clinical assessment and
mutually identified goals
• Toleration of uncertainty when making decisions
• Toleration of disagreement between parties
•Ongoing dialogue to resolve difficult situations.
Critical Care Nursing Practice: critical care nurses to
better understand their clinical judgment between the
two. They identified two major categories of thought
and action and nine categories of practice that
illustrate clinical judgment and the clinical knowledge
development of critical care nurses.

These major categories are delineated in

Thought and Action
• Clinical grasp and clinical inquiry: problem
identification and clinical problem solving.
• Clinical forethought: anticipating and preventing
potential problems.
Practice
• Diagnosing and managing life-sustaining
physiologic functions in unstable patients.
• Managing a crisis by using skilled know-how
• Providing comfort measures for the critically ill
• Caring for patients’ families
• Preventing hazards in a technologic environment
• Facing death: end-of-life care and decision
making
• Communicating and negotiating multiple
perspectives
• Monitoring quality and managing breakdown
• Exhibiting the skilled know-how of clinical
leadership and the coaching and mentoring of
others
 Communication with Patients:
•From an ethical standpoint, communication is an
important component of respect for patients; it is an
indispensable ingredient for learning about patients’
needs, values, and preferences.

• Many factors undermine communication with

patients and with families in the ICU:
 insufficient time for staff members and patients to
get to know one another and develop a trusting
relationship, discomfort or fear of talking about
illness and death, focus on the patient’s physiologic
function, and lack of a conducive setting for
communication. However, taking time to talk to
patients and families on a daily basis is a crucial
element of respectful care.
Specific needs of Family Members of critically ill
patient

• Information concerning patients prognosis and

treatment.
• Being sure that the patient is receiving the best
possible care and treatment.
• Opportunity to visit the patient frequently
• Good communication from the health professionals.
• Support and comfort from the health team.
• Honest and sincere information concerning the
patients progress.
Intensive Care Records
Principles of Record Writing
Uses of Records