Lecture Ncscsacsscdvdsvdvumber One

7/25/2019 Lecture Ncscsacsscdvdsvdvumber One

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critical care nursing

lecture1

Introduction to critical care nursing


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Learning Outcome 1

Define critical care nursing

Define critical care nurse

Define critical care patient


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Critical-care nursing

is that specialty within nursing that deals

specifically with human responses to life-

threatening problems.

critical-care nurse is a licensed

professional nurse who is responsible for

ensuring that all critically ill patients and

their families recei!e optimal care


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#he first intensi!e care units emerged inthe 1$%&s as a means to pro!ide care to!ery sic' patients who needed one-to-one

care from a nurse. #he first critical care unit were CC( and

reco!ery room

It was from this en!ironment that thespecialty of critical-care nursing emerged.


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Critical-care nurses rely upon a

speciali)ed body of 'nowledge* s'ills* and

e+perience to pro!ide care to patients and

families and create en!ironments that are

healing* humane* and caring.

,oremost* the critical-care nurse is a

patient ad!ocate.


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urse as /atient d!ocate

0upport autonomous decision ma'ing anddecisions made respect !alues representpatient based on these choices

Inter!ene in patients best interests intercede forthose who cannot ad!ocate for sel!es helppatients get care

ducate patient and family members nsure safe* uality care

0er!e as liaison between patient* family* andpro!iders

5elp the patient obtain necessary care


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critically ill patients

C Definition

merican ssociation of Critical Care urses

defines critically ill patients as

7those who are at high ris' for actual or potentiallife threatening health problems. #he more

critically ill the patient is* the more li'ely he or

she is to be highly !ulnerable* unstable and

comple+* thereby reuiring intense and !igilant

nursing care.8


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Learning Outcome 3

Discuss the concerns e+pressed by

critically ill patients


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1. Concerns of critically ill patients

oise* lights* and alarms

9eing thirsty

5a!ing tubes in their mouths and nose

ot being able to communicate

9eing restricted by tubes:lines 9eing unable to sleep

ot being able to control themsel!es


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Critical Care n!ironment

oise le!els

;ight 24 hours:day


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Learning Outcome 4

Compare and contrast the use of enteral

and parenteral nutrition in the critically ill

patient.


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COMMON

PROBLEMS OF

CRITICAL CAREPATIENTS utrition=

>#he primary goal of nutritional support is topre!ent or correct nutritional deficiencies.

> #his is usually accomplished by the early

pro!ision of enteral nutrition ?i.e.* deli!ery of

calories !ia the gastrointestinal @AIB tract orparenteral nutrition ?i.e.* deli!ery of calories

intra!enously.


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1. nteral utrition

Deli!ery of nourishment by feeding tube in thegastrointestinal tract

Deli!ered through a large bore nasal or oralgastric tube ?short-term use

0mall bore feeding tubes or gastrostomies ?long-term use

/referred route for nutritional supplementation ;ower rates of infection Composed of proteins* calories* !itamins* and

minerals 0tandard formulas


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nteral ,eeding

. Common /roblems with arly nteral

,eeding

5igh gastric residual !olumes

9acterial coloni)ation of the stomach

Increased ris' of aspiration pneumonia


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/arenteral nutrition

Infusion of nutrients using a !enous catheter located in a large*usually central !ein

(sed when nutrition supplement is needed and enteral feedingscannot be initiated within 24 hours of IC( admission

,ormulated by pro!iding de+trose* lipids* protein* electrolytes* water*

and !itamin elements 0pecific components of the infusion is prescribed for each patient

should be considered only when the enteral route is unsuccessful inpro!iding adeuate nutrition or contraindicated

?e.g.* paralytic ileus* diffuse peritonitis* intestinal obstruction* pancreatitis*AI ischemia* intractable !omiting* and se!ere diarrhea.


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Common /roblems ssociated with /arenteral

utrition:urse Inter!entions

Aut mucosal atrophy

!erfeeding

5yperglycemia Increased ris' of infectious complications

Increased mortality


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;earning out come "

Identify common problems in critical care

unit and there management


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n+iety=

> #he primary sources of an+iety for patients include the percei!edor anticipated threat to physical health* actual loss of control orbody functions* and an en!ironment that is foreign.

>ssessing patients for an+iety is !ery important and clinicalindicators can include agitation* increased blood pressure*increased heart rate* patient !erbali)ation of an+iety* andrestlessness.

> #o help reduce an+iety* the nurse should encourage patients andfamilies to e+press concerns* as' uestions* and state their

needs and include the patient and family in all con!ersationsand e+plain the purpose of euipment and procedures.

> ntian+iety drugs and complementary therapies may reduce thestress response and should be considered.


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/ain=

> #he control of pain in the IC( patient is paramount asinadeuate pain control is often lin'ed with agitation andan+iety and can contribute to the stress response.

> IC( patients at high ris' for pain include patients

?1 who ha!e medical conditions that include ischemic* infectious*or inflammatory processes

?2 who are immobili)ed

?3 who ha!e in!asi!e monitoring de!ices* including endotrachealtubes

?4 and who are scheduled for any in!asi!e or nonin!asi!e

procedures.> Continuous intra!enous sedation and an analgesic agent are

a practical and effecti!e strategy for sedation and pain control.


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Impaired communication=

> Inability to communicate can be distressing for thepatient who may be unable to spea' because ofsedati!e and paraly)ing drugs or an endotrachealtube.

> #he nurse should e+plore alternati!e methods ofcommunication* including the use of de!ices such asnotepads or computer 'eyboards.

> on!erbal communication is important. Comfortingtouch with ongoing e!aluation of the patientsresponse should be pro!ided.

> ,amilies should be encouraged to touch and tal' withthe patient e!en if the patient is unresponsi!e orcomatose.


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Delirium

0udden onset of disturbances in cognition*

attention* and perception


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Delirium

> Delirium in IC( patients ranges from 1"E to 4&E. Demographic factors predisposing the patient to delirium include

1.ad!anced age*

2. pree+isting cerebral illnesses*

3.n!ironmental factors that can contribute to delirium include sleep

depri!ation* an+iety* sensory o!erload* and immobili)ation.

4./hysical conditions such as hemodynamic instability* hypo+emia*

hypercarbia* electrolyte disturbances* and se!ere infections can

precipitate delirium.

5. Certain drugs (e.g sedatives, furosemide, antimicrobials)have been associated with the development of delirium


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0leep problems=

> /atients may ha!e difficulty falling asleep or ha!e disruptedsleep because of noise* an+iety* pain* freuent monitoring* ortreatment procedures.

> 0leep disturbance is a significant stressor in the IC(*contributing to delirium and possibly affecting reco!ery and candecreases patient immunity

> #he en!ironment should be structured to promote the patientssleep-wa'e cycle by clustering acti!ities* scheduling restperiods* dimming lights at nighttime* opening curtains during thedaytime ?natural light* obtaining physiologic measurementswithout disrupting the patient* limiting noise* and pro!idingcomfort measures.

> 9en)odia)epines li'e Dia)epam ?Faliumlora)epam?ti!an and ben)odia)epine-li'e drugs ?Golpidemcan beused to induce and maintain sleep.


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Learning Outcome 6

Discuss ways to identify and meet the

needs of families of critically ill patients.


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ISSUES RELATE TO FAMILIES

,amily members play a !aluable role in the

patients reco!ery and should be considered

members of the health care team.

#hey contribute to the patients well-being by=> /ro!iding a lin' to the patients personal life

>d!ising the patient in health care decisions or

functioning as the decision ma'er when the patient

cannot> 5elping with acti!ities of daily li!ing

> /ro!iding positi!e* lo!ing* and caring support


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#o pro!ide family-centered care effecti!ely*

the nurse must be s'illed in crisis inter!ention.

> Inter!entions can include acti!e listening* reduction of

an+iety* and support of those who become upset orangry.

> ther health team members ?e.g.* * psychologists*

may be helpful in assisting the family to adHust and

should be consulted as necessary.


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#he maHor needs of families of critically ill patients ha!e beencategori)ed as

informational needs* reassurance needs* and con!enience needs.

> ;ac' of information is a maHor source of an+iety for the family.> #he family needs reassurance regarding the way in which the patients

care is managed and decisions are made and the family should bein!ited to meet the health care team members* including physicians*nurses *dietitian* respiratory therapist* social wor'er* and physicaltherapist* .

> igid !isitation policies in IC(s should be re!iewed* and a mo!e towardless restricti!e*

> esearch has demonstrated that family members of patientsundergoing in!asi!e procedures* including cardiopulmonaryresuscitation* should be gi!en the option of being present at the bedsideduring these e!ents.


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eeds of ,amilies of Critically Ill /atients

/ersonnel care about the patients

9elie!e there is hope

Jaiting room near the patient Called when changes in the patient occur

Know the prognosis

5a!e uestions answered honestly Know specific facts about patients progress

9e allowed to see the patient freuently


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eeds of ,amilies of Critically Ill /atients

/ro!ide information Discuss patient goals Jritten instructional guidelines to pro!ide

information about critical care way to contact the nurse Consistency in the nurse pen !isiting hours

ssess to telephones* bathrooms* and food Aood communication ela+ed waiting area near the patient


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!i"ua# Ma$

Critically Ill /atient 0ummary

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Lecture Ncscsacsscdvdsvdvumber One