General Aspects of CareCHAPTER ONE

Critical care units have evolved over the last four decades in response to medical advances. Florence nightingale recognized the need to consider the severity of illness in bed allocation of patients and placed the seriously ill patients near the nurse's station. In 1923 John Hopkins University Hospital developed a special care unit for neurosurgical patients.

Modern medicine boomed to its higher ladder after World War II. As surgical techniques advanced it became necessary that postoperative patients required careful monitoring and thus came about the recovery room, where maximum use of medical, nursing and auxiliary personnel was made available with all devices for life saving measures.

In 1950 the epidemic of poliomyelitis necessitated thousands of patients requiring respiratory assist devices and intensive nursing care. At the same time came about newer horizons in cardiothoracic surgery, with refinements in intraoperative membrane oxygen technique. Thus the need for critical care units became more obvious. In 1953 Manchester Memorial Hospital opened a four-bedded progressive care unit. Later on an eight-bedded unit at Philadelphia was started. By 1957 there were 20 units in USA and about 1958 the number increased to 150.

The central contextual forces that led to the development of intensive care units in the 1950's and 1960's are:

During 1970's the term critical care unit came into existence which covered all types special care units.

The American Association of Critical care nurses was a response to demands placed on nurses for safe knowledgeable patient care and it played an important role as vehicle for sharing knowledge about critically ill among nurses and physicians, in supporting education and standard formation.

As the medical technology advanced more and more subspecialities such as cardiothoracic, renal, coronary, respiratory and neuro surgical units were established. Thereafter critical care units underwent reformation in their design, facilities, and nurse patient relationship and nurse physician relationship.

No hospital is complete without a critical care unit. They are being incorporated more and more into the hospital structure. As the facility expands they get diversified into more specialized critical care units.

The challenge for critical care nurse today is not the monetary investment but the need to examine long-standing conflicts, character traits and social factor of patients and families.

Critical care unit is a specially designed and equipped facility staffed by skilled personnel to provide effective and safe care for dependent patients with life threatening or potentially life threatening problems. The practical problem of defining the critically ill patient arises then. It doesn't mean that all patients in danger of dying are admitted to the unit, just for the reason that a compromise between ideal and limited facility has to be arrived at. Salvagability is one of the conditions that could be used as the basis for determining the prerequisite to admission to the unit. Salvagability can be defined by eliminating those cases that are in no way able to make up due to the pathological process.

The concept of intensive care nursing took its root from Florence Nightingale who is the founder of modern nursing. She placed the seriously ill patients near the nurse's station for closer and better observation and care.

Intensive care units came about as the outgrowth of recovery room. When the surgical techniques advanced postoperative patients required careful monitoring, and thus came the concept of recovery room where maximum use of medical, nursing and auxiliary personnel is available along with life saving devices.

Advances in respiratory assist devices and cardiothoracic surgery brought about the evolving of Respiratory Intensive care units. Coronary care units could be the first of its kind available in a very small hospital where patients with coronary heart disease and arrhythmia” are treated. With renal transplantation taking a full stride in many hospitals, the renal units came into existence. Then came subspeciality unit for renal dialysis. There are medical intensive care units, surgical intensive care units, Burn” unit and Neurosurgical units in many hospitals apart from the ones mentioned before. With all these the concept of Intensive care nursing with specially trained nurses and physician, became well established. Thus biomedical knowledge, new technology and rising public expectation created new pressures and revolutionized the practice of nursing.

During 1970's the term critical care unit came into practice which covered all types of special care units. Pediatric intensive care units and special care units for babies also have come about as it was necessary to have separate units with special equipment and devices for the care of the newborn and children.

Critical care nursing in any type of unit demands providing best care possible, which requires more than being knowledgeable, highly trained and experienced. One cannot give best care by oneself. Excellent care is possible which the help of others. Successful partnership can bring about wonders in critical care units. The essence of team spirit is the pathway to success in management of most difficult situation in any critical care units.

Cardiorespiratory dysfunction can be either primary or secondary.

There are two stages of critical illness, the reversible and the irreversible. Critical care medicine is based on principles that recognize cellular dysfunction at the reversible stage and ensure adequate supportive treatment before irreversible changes occur.

Renal failure with falling urine output is an almost invariable accompaniment to failing circulation. Cellular failure may also be reflected in central nervous dysfunction as well as in compromised endocrine response to stress. All these constitute the elements of a 5vicious sycle which negate the possibility of spontaneous recovery.

The basic function of a critical care unit is to initiate cardiorespiratory and systemic support during the reversible stage of critical illness.

The prognosis of critically ill patients depends on early detection and prompt treatment. Monitoring of cardiorespiratory function is of prime importance in the assessment of adequacy of treatment.

Sudden illness or trauma can throw the family of the critically ill patient into a state of crisis. As a result it is common for the family to require significant support from the critical care nurses to survive the crisis. Family in crisis usually presents with high anxiety, denial, anger, remorse, grief and the need for reconciliation. Proper assessment determines the strengths and weaknesses and deficit on family perception, situational support and coping. Critical care nurses form a link between patients and families.

Critical care nurses themselves undergo job stress due to many factors. They need to be supported personally, professionally and spiritually which would be part of management strategies in every critical care unit.

Ongoing educational opportunities would enhance the staff morale. Research is to be developed to improve the standard of nursing intervention in critical care unit.

Critical care nurse needs to understand the pathophysiology of critical illness and apply the principles of critical care nursing to make the nursing practice unique and comprehensive for the patients who are admitted to the unit with varying degree of severity of illness who may also have bleak future as far as outcome is concerned.

The nurse requires to have broad knowledge of sciences, pathophysiology and interpersonal relations.

To make the clinical practice more effective in the unit it is necessary to have policies, procedures, protocols of care and quality assurance programs in corporate.

The critical care unit should have policies, procedures and protocols of care to guide the provision of care, to maintain uniformity and ensure quality. There should be clear cut policies for admission, discharge, transfer, emergency, safety procedures and infection control.

Four factors to be considered in hiring critical care nurses are, inter and inter personal factors, technical qualifications, educational background and clinical experience. It is found those persons with “hardiness” a personal constellation of challenge and commitment and courage is able to suit better to the situation in a critical care unit. Assertiveness and ability to function independently must be inherent or learned.

Additional post basic qualification in critical care nursing need to become mandatory as a prerequisite to appointment, so also qualifying examinations for licence and registration would ensure quality. Unfortunately it is in a very primitive stage in many countries around the world.

There is some overlapping of the role of clinical nurse specialist and case manager. Today's health care environment demands innovation and leadership from nursing professional. Case management models provide framework for incorporating advanced practice as an integral component of care delivery system. Clinical Nurse specialist provide leadership. She can also function as case manager by being accountable for resulting patient outcomes. Under this model CNS's clinical expertise and consultation skills can be utilized to support the development of an effective coordination among critical care nurses.

In critical care nursing the complex and technical nature of nursing function requires knowledge of values important to the practice of nursing. The values of autonomy, advocacy and accountability are traditional values in nursing profession, which are quite apt for critical care nursing.

Autonomy referred to ethics means the autonomic choices and autonomous actions of an individual. Even normal rational adults at times lose the capacity for autonomy because of an injury, period of emotional disturbance or under the influence of substances.

It is better to concentrate on discussion on autonomous actions rather than decisions and autonomous persons.

An autonomous decision is one that is based on the decision makers, values, utilizes adequate information and understanding and is free from coercion or restraint and is based on reason and deliberation.

Autonomous actions are those that stem from autonomous decision rather than from the person being forced to act or restrained from acting in a certain way. When one makes decision the person is under the influence of many factors. One should make sure that the individual is aware of the right to make a choice was physically or mentally able to make some evaluation of the options and had the necessary information to do so. The broad principle of autonomy yields to many specific rules for health care providers. The best known of this is the rule of informed consent which specifies that we must obtain 10permission from the patient before doing any procedure on him/her. Although we generally are most conscious of obtaining consent in the form of written document before invasive or risky procedure. When patients refuse treatment, medication, or diagnostic tests we are morally obligated to respect the decision and to refrain from forcing the patient to take the medication or accept the test or treatment.

Autonomy can also serve as the basis for duties of truth telling. One way in which we can interfere with the person's right to make free choices is by withholding important information or by deceiving the person in some way. If we withhold some of the information we are interfering in the patients ability to make a rational decision that is in line with his or her values and preferences and we are thus violating the principle of autonomy. But it is certainly unreasonable to expect that absolutely every fact that is known about a proposed intervention be provided to the patient. This is not only a practical impossibility but also ineffective that it is likely to confuse most people who don't have the background information. The ideal might be to try to provide exactly as much information as the individual patient needs in particular instance to understand the proposed treatment.

Advance directives: Refers to any document that is enacted by an individual before becoming ill, specifying one's wishes regarding treatment, should one be unable to express them later on. The two forms of advance directives are:

Futility means useless interventions. The situations where questions of futility arise in the critical care setting are:

Futility can be defined in each situation by a competent patient, authorized significant others, health care professionals. While providing futility care the nurses and other health care professionals suffer a sense of hopelessness, which can even lead to depression. While addressing the issues of futility care it is better to facilitate an open dialogue and an environment that fosters communication and collaboration among professionals, patients and families. It is the responsibility of the health care professionals to educate patients and their significant others regarding the obligations and responsibilities in decision making. Every critical care unit should have policies and procedural safeguards for implementation of the strategies with regard to futility care.

When an advanced decision is made regarding withholding life sustaining treatment a medical order as to this effect “No Code” may be written in the patients records. The critical care nurses must be knowledgeable about the issues, controversies and strategies in conflicting situations as these. They also need to do the documentation thoroughly in patient's records.12

To summarize the role of the critical care nurse in withholding and withdrawing treatment decisions are to be made in admitting these patients to critical care units, assisting the patient or the significant others in clarifying the values, providing the information and clarifications of issues, maintaining truthfulness in disclosure of information, encouraging a collaborative decision making, documenting the decision, caring for the patient who is dying and involving the family and others.

Standard of Care: A high standard of a care is expected from all categories of staff working in the unit. The nurse is responsible for all treatment and care procedures carried out. As part of housekeeping responsibility it is her duty to ensure adequate supplies and optimal functioning of all equipment and devices required for carrying out care. Negligence is the failure to exercise that degree of care, which a responsible person would exercise under the same circumstances. Negligence on the part of the nurse in any aspect of care can result in a high liability risk for herself and the hospital. She should adhere to policies and protocols of the unit with regard to admission, transfer and discharge of patients, administration of medications and standing orders.

Many units are faced with understaffing and lack of experienced nurses due to rapid turn over of staff nurses. Nurse manager has the responsibility to plan staffing in such a way as to cover all shifts with the available experienced staff along with the inexperienced staff thereby standard of care need not be compromised.14

While working in critical care unit the nurse has to be aware of the legal implications. Communications should be maintained between patient, family, physician and supervisor. Documentation is the most important aspect of nursing which can protect the nurse and the hospital during many conflicting situations. Documentation should be factual, descriptive, accurate, concise, timely, relevant, definite and specific and it is important to mention the patient's response.

There are times when a nurse is asked to be the witness for making the “Will” by the patient, while he is in the critical care unit.

A nurse working in the critical care unit should be aware of the legal implication, elements of negligence, process of handling medicolegal cases and witnessing. She should document in clear, concise, legible, accurate manner all relevant information. Her best 15defense against negligence is to follow the standard of care.

The critically ill patient has life threatening or potentially life threatening health problems that requires continuous monitoring and intervention to prevent complications and to restore health. Thus continuous patient surveillance and interventions to tackle and prevent complications along with participating in the treatment and care becomes the major role of the nurse in the critical care units. The nursing philosophy is accomplished by combining critically ill patient in an environment with specially trained nurses appropriate equipment, adequate supplies and ancillary health personnel. Within this environment the patient's need for close observation and immediate treatment can be met.

Critical care units have grown and developed. Critical care nursing has been recognized as a professional specialty within the field of nursing. Critical care medicine specialty has evolved which has increased nursing requirements for in-depth knowledge in the area of specialty.

Critical care nursing is defined by American Association of Critical Care Nurses as the utilization of nursing process in the intervention and prevention of life threatening situations. A highly skilled collaborative and multidisciplinary team supports the patient and family towards realistic goals.

Establishing a sense of team spirit is highly rewarding. Responsibility of physician in relation to practice of policies and protocol make it easy for the nurse to run the unit smoothly. What type of patients should be admitted to the unit and how long a patient 16should stay should be decided on the basis of policies and client's condition. If these rules are not strictly adhered to, the critical care unit is likely to end up as a VIP unit or a chronic care unit.

The nurse manager in the unit is responsible for managerial functions of planning, organizing, staffing, leading and controlling. She functions as a clinical expert as well. The participatory leadership style has been found to be effective in attracting and retaining nurses in the critical care unit. The unit should have a medical director who is responsible for the treatment of patients, utilization of unit beds and standards of care. Together with the director, the nurse manager contributes toward the smooth functioning of the unit. In times of crisis she may be expected to employ authoritarian style of leadership.

Thus the nurse in the critical care unit has multifaceted role to play.

Whatever may be the type of unit it has to incorporate many features to provide continuous observation and quick intervention.

If the plan is to have one critical care unit in the whole hospital it should be centrally located and should be easily accessible to all the departments in the hospital.

Additional beds. The number of additional ICU beds needed in an institution is calculated basing on the average daily census of patients needing CCU care and desired bed availability. Average daily census is equal to the number of admissions to CCU × length of stay in CCU/365.

Applying the formula developed by the planning agencies a hospital with 500 intensive care admissions with average 7–8 days stay per year result in an estimate 9–11 beds. Another way to determine is to quote the figure of 1 bed for 100 general patients. However the figure to be decided by the usage of keeping the statistics over a period of time and depending on whether the hospital is a referral hospital and caring to various 18specialties such as coronary, neurology, cardio-thoracic and renal. Ideally the number of beds in one unit should not exceed 10–12 and the minimum should be 4 catering to both the sexes.

The nurse's station, which is the nerve center of the unit, should be close enough to the patients to permit observation of the patient. The proximity of the nurse's station to the patient saves the energy for nurses and influences patients’ confidence. An emergency call system for nurses both from bed to nurse's section and from nurses section nearby unit is desirable.

Walls and floors are ideally made with glazed tiles or other material, which can be easily washed and disinfected. All wood item should be covered with washable material.

Electrocardiogram monitoring equipment is an essential component of the critical care unit. ECG monitoring is accomplished by attaching electrodes to the patients skin and connecting these electrodes to an ECG oscilloscope monitors at both locations while small units have one or the other. The monitors are usually equipped with a meter or digital read out that displays the heart rate and rhythm and alarm systems activated when the heart rate exceeds preset upper or lower limits. An ECG machine should be available so that a complete 12 lead diagnostic ECG can also be taken when necessary. Other parameters monitored are blood pressure, central venous pressure, oxygen saturation, end tidal carbon dioxide, respiratory rate and temperature. Cardiac output and pulmonary wedge pressure monitoring are indicated in specific cases. Monitors may have several channels to accommodate the display of these various parameters. Computerized monitoring system with facilities for a print out may be situated as peripheral and centrally placed modules.

Specialized equipment is required for monitoring respiratory function. Blood gas 21analyzers provide information regarding acid base status, hemoglobin, and electrolytes. Bedside monitoring of blood sugar levels with electronic equipment is useful to monitor diabetic patients on insulin infusions and patients on TPN. Access to a spirometer for measuring tidal volume and vital capacity is also recommended.

Venturi masks, endotracheal tubes, laryngoscopes and ambu bags form part of a crash trolley. Other resuscitative equipment includes, suction and oxygen cylinders. A pacemaker and a defibrillator are recommended for each unit. Ventilators and emergency equipment should be readily available for management respiratory problems.

Clocks, calendars and lights with varying intensity for day and night are necessary in the critical care unit, to help patients to get oriented to the time, day and date.

All staff should change into clean gown before entering the unit and it is wise to regard the unit as an extension of operating room.

Casual visiting should be discouraged and high standard of cleanliness must be maintained. Periodic check by becteriology department is necessary to identify any potential source of infection.

The colour of the unit should be as aesthetically pleasing as possible and conducive to recovery with minimum sensory deprivation.

Use of clocks with night and day in different colors, large calendars and lights with varying intensity during the night will help the patient to get oriented.

Most units allow visits 5–10 minutes every two hours. Family members must be made comfortable in a waiting room and reassured that they will be called if there is any change in the condition of the patient. A statement as the patient needs rest usually helps the family to understand the restriction.

Flow sheet should have provision for recording of the laboratory investigation such as blood count, ABG, Renal function tests and liver function tests.

Ancillary personnel recommended are given below:

Bacteria are perhaps the most numerous and widely distributed of the microorganisms. They are classified into:

Gram stained bacteria is classified into gram positive and gram negative.

E. coli is a normal flora in the large intestine and it can cause would infections, abdominal sepsis, septicemia and urinary tract infections. salmonella and shigella cause infections of gastrointestinal tract.

Complete attire with a clean gown, cap, shoes, should be worn by all individuals working in the units. There should be changing rooms in the unit to practice this effectively.

As a routine:

All horizontal surface including bed frames, stands, chairs should be washed. All pieces of equipment and any fomites that cannot be cleaned should be sent to central sterile supply department. Use double bagging technique for contaminated articles.

All equipment used, should be washed and disinfected using appropriate germicidal solution.

Curtains should be changed when the room is terminally cleaned. Cubicle curtains in critical care areas should be laundered on a regular basis.

Regular thorough cleaning of the unit should be planned and carried out during the lean periods of occupancy.

Surveillance is the responsibility of all personnel who care for the hospitalized patient. Personnel who are engaged in routine patient care must practice routine surveillance on their patients. Certain conditions and treatment may cause some patients to be more susceptible to nosocomial infections. Patients who are immunocompromised and with lowered defense mechanism are vulnerable and meticulous care should be taken.

Patients, who are receiving intravenous therapy, hyperalimentation, indwelling Foley's catheter care, antibiotic steroids or anti neoplastic drugs should be carefully observed for sings and symptoms of infection.

Preventive surveillance and control measures pertaining to hospital environment include:

Meticulous aseptic technique should be followed while doing catherization and while on indwelling catheter is required for a long time. A closed drainage system should be maintained at all times. The distal end of catheter and proximal end of drainage tube are most common sites of entry for ascending urinary tract infection.

The nurse working in the critical care unit must be conscientious at all times about the risk of infections and practice and simple rules of aseptic technique to reduce infection.

Stress is defined as any adjustive demand that requires an adaptive response. Stress is a condition in which the human system responds to changes in its normal balanced state. A stressor is anything that causes stress. As with stress the perception and effects of the stressor are holistic and highly individualized. Stressors are neither positive nor negative but rather have positive or negative effects as the person responds to change. Illness acts as a Stressor.

Stress is manifested in different ways. The usual responses are:

It is not very easy to eliminate stress especially in a critical care unit when there is a sense of inadequacy about mere existence of life it can result in anxiety. The nurse needs to explore the usual coping patterns and how well they can be used to eliminate the present stress. Patient needs to modify the existing coping patterns so that a homeostatic equilibrium is achieved. Nursing measures that reinforce a sense of control and autonomy can be tried wherever possible. Allowing small choices and participating him into the care goes a long way to reduce anxiety and to feel self worth.

Another cause of anxiety for a patient in critical care unit is social isolation in the midst of a more socializing crowd of strangers. The sick person in a critical care unit cannot identify himself with the rest. The severity of the illness and fear of dying separate him from relatives. The efficiency and activity engulfing him increase his sense of separateness, as he lies isolated in his bed.

Thirdly the security of the patient is questioned. Many people associate CCU stay with severity of illness and death of relatives and friends. But for the nurse it is a place where there is more vigilance for safety of life.

In a study conducted by Mathew. M, identifying the emotional factors experienced by patients in a surgical intensive care unit it was found that 78% of them experienced anxiety. The anxiety level was more during first two days and increased again as the ICU stay prolonged.

Denial may serve as the period when the patient's resources are blocked by shock and can be regrouped for the battle ahead. The principle of intervention consists of not stripping away the defense of denial but in supporting the patient and acknowledging the situation. The nurse has to accepts and recognize the patients illness. She communicates the acceptance through her tone of voice, facial expression and use of touch. Nursing Diagnosis as applied in critical care unit in psychosocial components.

Critical care nursing involves excessive physical and emotional stress due to the very nature of the environment which is that of a closed one, isolated from the rest of the hospital. In a critical care unit there is constant use of sophisticated machines and equipment amidst which a nurse is expected to work calmly and efficiently at all times. Nurses encounter stress while facing death of patients in the critical care units when they have nursed carefully which the perceive as a failure of their work. A sense of inadequacy prevails among nurse as they lack confidence in handling the patients and the equipment's.

Stress is an imbalance between demand and the ability to cope with it. Stress response results when the individual fails to cope with a stimulus. Shouk Smith defined it as the body state of tension, which result from external or internal stressors. External or internal stressors trigger a stress response. External stressor is an environmental event such as disasters or being taken seriously ill very suddenly. Internal stressors are our own responses to wide range of events and situations.

One popular way of defining stress is to link it with life events. Life events scales are available which can be used to score stress. Life event scales are based on the assumption that there is a certain capacity for coping. But every event we experience requires adaptation or change. Each event thus makes a demand on our coping resource and as the number of event increase, the resource also diminishes, until eventually the demand exceeds the supply and then we suffer from stress.

Stress is not determined by the event itself but by the way we respond to it. There are few events, which can be avoided or changed. On the other hand, one can change responses.

The common stressors are threat of physical violence, changing work place, moving house, rows with partner, paying bills, sickness, separation and death. Voges et al identified following job stressors:

Scaly studied nurses under stress (D Roger, poppy, N. 1993). It was found that nurses under stress snap and argue with others, make other members of the staff as scope goat, blame another shift nurse for the things that have gone wrong, be defensive with colleagues, adopt a busy behavior, show intolerance of others behavior or ideas, respond to others with dullness and silence.

To understand stress and to respond appropriately we need to know about attention, emotion, detachment and communication.

A number of writers have noted the relevance of the social skill approach for 35nursing practice. As members of multidisciplinary team the nurses often provide crucial link for many desperate approaches to treatment. They are also expected to develop skills which help them deal with the problems experienced by their patients and the families. Additional demands are made because of the use of provider purchaser terminology which might make it difficult for nurses to speak enthusiastically about offering a high quality service when they are often constrained by limited resources. In all these issues stress and communication are extricable. Stress causes poor communication and which in turn causes stress leading to a spiral of conflict that leaves everyone dissatisfied. Further more, communication is the medium through which stress is expressed.

Communication skills makes the emotion easier. The expression of emotion itself may be a coping mechanism. Mutual trust is the basis of good communication organizational problems always revolve around poor communication and poor communication is both the cause and result of stress. When the communication is poor the effects of low morale and dissatisfaction are evident.

‘Relate’ the essence of communication should be applied wherever necessary.

The notions ‘Striking’ and ‘Stroking’ capture the role of communication in stress. Striking is undesirable, which can increase the intensity of stress whereas stroking by way of positive criticism can ease the stress, and improves the morale of the staff.

Personal skills in coping can develop so that emotional involvement is minimized and interpersonal skills can be applied which allow communication by feedback mechanism rather than criticism, thereby reducing stress. Feedback offers comments on work and not the person by which communication can be sustained and stress is avoided (Roger D. Poppy 1993).

As morale of staff, job satisfaction and communication skill improve there is reduction of stress. Symptoms of stress are the outward signs the cause of it is a preoccupation with emotional upset and the outcome is not just the misery for ourselves but to everyone we come in contact. The body is provoked into the usual fight or flight response. With the repeated elevation of adrenaline and cortisone and other hormones exert a continuous strain on the cardiovascular and immune function. It is this mechanism that explains how the stress is transformed into physical illness.

Jo Ann Griff reported the result of a readership survey among nurses working in critical care units in USA which showed that the highest among all other reasons for leaving critical care areas was stress (33%) (Jo et al 1988) documented shift schedule system as one of the major factors of causing stress and burn out among nurses. It was also found that the longer the time nurse had been on the shift the greater the job related stress. James Goront (1980) in a comparative study found that ICU nurses were more stressed than even air traffic controllers. Huckabay and Jagler (1979) revealed that physical work load, communication problem with doctors and administrators and death of the patients ranked as factors that are most stressful. The data from stress audit (N-1800) of ICU nurses in USA (1980) indicated that inadequate staffing pattern, lack of support in dealing with death and dying, inadequate workspace and unresponsive nursing leadership as factors producing stress. G. Foster (1972) found that nurses from critical care units showed significantly more depression irritability, resentment than non-ICU nurses. N ford and Seark (1988) demonstrated that nurses working in one of the critical care units expressed very little distress and showed high levels of job satisfaction contrary to the popular belief of increased levels of stress in critical care units. Kuruvilla J (1990) in a study conducted by the author in critical care units of Christian Medical College Hospital, Vellore, India, to identify stress among critical care units, following factors were identified as most stressful:

Critical Care nursing is most demanding. CCU is a real pressure cooker with the staff constantly coping with crisis. The work in critical are unit is not to everyone's taste which requires repetitive routines, attention to tiny details sharp, quick and irreversible observation high level of concentration and effective use of highly sophisticated equipment all in a very limited amount of space with virtual obstacle of cords and wires. This highly charged atmosphere is filled with succession of emergencies, frequent failures, quick turnover of patients all conspire to make the atmosphere impersonal (Jo A G Al pach 1988).

Nurses are expected to treat a patient as a whole person but a critically ill person is transfigured by his condition, his true personality hidden behind the mask of his illness. The nurse in her enthusiasm to provide holistic care tries to humanize but is hindered by the invasion of high technology.

Noise induced stress, as predictor of burnout in critical care nurses has also been documented. Personnel and patients experience sensory overload in the critical care unit. The hissing of oxygen valves, beeping of the monitors and ventilators, bright lights and the unit personnel prodding and probing is producing it.

Junior medical staff works in a unit for a short period of time while nurses are permanently there and often resent doctors requesting alteration in usual treatment and procedures. At times there are communication problems, non-availability of doctors during critical intervention or lack of adequate response from them.

The critical care unit has a high mortality compared to the general wards. But the medical profession is oriented toward preserving life. This paradox leads to a situation in which death is seen as a bitter defeat or failure after the hard struggle. Continuous close contact with a distressed frightened family can also drain a nurse's emotional battery at an alarming speed. To guide and support the grieving family during this process requires emotional strength on the part of the nurse.

Loneliness creeps in while caring for a patient for 6–8 hours where the patient doesn't give any feedback. This can cause intense frustration to the nurses. Nurses working in the general section regard CCU nurses as different and they feel isolated from the rest of the nurses.

Nurses new to the critical care unit feel quietly when they discover that they have missed some vital detail or cannot operate sophisticated equipment. The depth of knowledge required for this field of nursing can be too demanding even for the experienced nurses. The jargon that is used confuses the new nurse. She has to learn a new language of Jargons.

Pressures of working continuously understaffed, physical and psychological strain of long work schedules, shift rotation, impact of job on the family life, lack of authority, dealing with poorly trained people, lack of cooperation, equipment, mechanical and electrical failure are some of the other factors resulting in stress.38

Attention control, detachment and communication skills are used in stress management challenge of a program developed at the works skill center, university of York is based on the principle of waking up and controlling attention and remembering to stop physically and mentally and then to practice being detached and rational. It is clear that the key to dealing with stress is detachment.

Stress management is not about pretending it is not there. Event is there. It hasn't changed but ones perception can be changed and the aim of stress management is to bring this point of resolution.

Our perception to the situation has to be changed. Emotion is a human response, which is so damaging if it has to go on dwelling trying to anticipate the future or rewrite the past.

Relaxation plays a prominent role in stress management program. It allows the body to switch back to the natural state. Relaxation routine will cause less fatigue, headache and more relaxed attitude. At the same time one should not exaggerate the effect of relaxation, which is short lived. Tension of the body is created by the attitude of the mind. As long as the attitude of the mind remains in place the tension also will return. Thus the effect of relaxation is palliative.

Nurses must be educated to suggest reduction of stressors and setting realistic views of tasks in relation to the self.

Social support refers to a group of people available who can be approached when one experiences stress.

In a survey done among 61-community psychiatry nurses 81% responded that peer group support is an effective way of stress management.

Counseling can get into the real issue of stress. While in depth counseling requires the services of a professional counselor there is also room for informed counseling from individuals who have learned basic counseling techniques.

Workshop can orient nurses to learn the methods and skills, which are necessary to deal with stress as relaxation techniques and yoga.

CCU nurses should talk to the patients even if they are not getting any response. This will help them to

Use of care plan provides scientific systemic basis for nursing care in all health care setting. So much more in critical care set up as the needs and problems are complex.

For suitable care plan for the use in critical care unit, one, formulated is based on combination of two models one a general model Maslow's Hierarchy of needs and a nursing theory, Roy's Adaption model.

Creativity as a guideline for solving problems and carrying out interests. To meet this need the nurse must focus on strength and possibilities rather than on problems. Nursing interventions are aimed at caring for the total person providing a sense of direction and hope and teaching aimed at maximizing.

Roy (1984) views the person's adaptive system that functions as whole through interdependence of its parts. The system consists of input, control processes output and feedback input are stimuli from the external environment and the internal self-including information from the regulatory mechanism. Output is the adaptive and ineffective behavioral responses of the person. Feedback is information regarding the behavioral responses that is conveyed as input in the system.

Stressors called stimuli affect each person. The person's ability to adapt to changing stimuli are determined by the person's adaptation level. Roy describes two basic internal processes used in adaptation, the regular subsystem and the cognator system. The regular subsystem receives and processes changing stimuli from the external environment and the internal self through neural chemical endocrine channels. It produces automatic unconscious reactions on target organs or tissues. The cognator subsystem receives varying internal and external stimuli involving psychological and social factors. Physical and physiological factors, including bodily responses from the system. The regulator and cognator subsystems produce behavioral responses in four effector modes physiological, self-concept, role function and interdependence.

Health is defined as a state or process of facing and becoming an integrated and whole person (Roy 1984). Through adaptation the person's energy is freed from ineffective coping attempts and can be used to promote integrity healing and enhance health of integrity. Nursing is considered as the science and practice of promoting adaptation for holistic functioning of person through application of the nursing process. Nursing aims to increase the person's adaptive responses by decreasing the energy needed to cope in a given situation so that there is more energy for other human processes. Roy's model of the nursing process has two level of assessment. In first level assessment, the nurse assesses the person's adaptive and ineffective behavior in each of the four modes. The physiological mode includes Oxygenation, nutrition, elimination, activity and rest, skin, integrity, the senses, fluids, electrolytes, neurological and endocrine function. The 42psychosocial adaptive modes, self-concept, role function and interdependence. Self-concept mode consists of the individual feelings and beliefs at a given point in time. This mode includes psychointegrity, physical self, personal self, self-consistency, self-concept and self-esteem. The third mode is role function, which includes role position, role performance, social integrity instrumental and expressive behavior. The four modes focus an ability to love respect and value others. This includes nurturing significant other and support system patient may present with problems concerning each of these modes.

After assessing the problems concerning these modes the nurse proceeds to assessment of second level which include determining the focal, contextual and residual stimuli which contribute to the ineffective or adaptive behavior. The focal stimuli are those immediately confronting the person. Contextual stimuli are other stimuli are the stimuli present within the person or the environment. Residual stimuli are beliefs, attitudes or traits that have an effect on the person's present situation.

The nursing diagnosis is derived from two assessment levels that are ineffective or require reinforcement. Nursing goals are identification of those adaptive behavioral outcomes. The nursing interventions to achieve these goals aim to manage focal, contextual or residual stimuli by removing, decreasing, increasing or altering the stimuli. Evaluation is a reassessment of attainment of the goal of adaptive behavior.

Environment includes internal and external stimuli which are focal, contextual and residual stimuli. Environmental stimuli include all conditions, circumstances, and influences surrounding and affecting the development and behavior of the person.

Roy's model views the person as an adaptive system that response to internal and external environmental stimuli in four adaptive modes, physiological, self-consept role function and interdependence. Nursing promotes person's adaptation level by manipulating the environmental stimuli to reduce ineffective responses and enhance adaptive responses. Roy's model encompasses biopsychosocial factors and as broad enough to apply any individual in all components of the nursing process. It an excellent tool for assessing and analyzing the client's health pattern and identifying nursing diagnoses. Nursing interventions are directed towards changing focal contextual and residual stimuli.

Objective data can be collected through the sense of sight, touch and healing. By using these sensor characteristics of appearance and function, content and process of interactions and environment can be observed. Maintaining accuracy in observing clients is important.

Measurements are form of observation, which is a means of obtaining objective data.

Physical examination: is carried out and it may also involve use of instruments in ascertaining the extent, dimensions, rate, rhythm, quantity and size.

The self-concept mode incorporates physical self and personal self.

Role function involves role performance and role mastery.

The need for affectional adequacy, support system and family are all parts of the interdependence mode.

Planning is the second step in the nursing process. This includes setting priorities goals and nursing interventions. As soon as the patient's problems are identified the nurse must establish priorities by determining which problems are most urgent goals acceptable by the patient are set. Specific objectives in behavioral terms are stated. The nursing actions are directed toward accomplishments of the objectives. It should be individualized realistic and measurable.

The entire planning phase of nursing process ends in the formation of patients nursing care plan by the professional nurse.

Mayers (1983) defined patient care planning as “systematic assessment and identification of problems, the setting up of objectives, and the establishment of methods and strategies for accomplishing them.” It is a systematic approach to planning patient care, which will meet individual needs of the patient. Nursing care plan is the visible and written record of the implementation of care planning. It documents the use of this approach. The components if nursing care plan are a nursing assessment of patient, the goals of nursing intervention, the nursing interventions expressed in the form of nursing orders and the evaluation in terms of expected outcome.

Care planning and nursing process is closely linked. The nursing care plan takes into account the patients background and environment, his likes and dislikes, his response to illness and his ability to cope with his illness and daily life. Because it is a written plan it is available to all those involved in the care of the patient. It also becomes the basis for reporting sessions.

The information in the nursing care plan should be written in a concise, systematic simple manner that facilitates use by all the nursing personnel. Care plan is subjected to change as patients problems change, as priorities change and as problems resolve. Additional information about patients health are added and care plan may be changed accordingly. A well developed, continuously updated nursing care plan is the patients greatest assurance that his problems are resolved and the basic needs will be met. Nursing care plan is to be kept as current and flexible to meet the patients changing needs. While planning, patients and significant others are involved in all aspects of planning. There are many formats that can be used what we plan to use is the format which is based on Maslow's hierarchy of needs and Roys Adaptation model.

Implementation is the actual giving of care to the patient. Care is personalized to be appropriate for a specific patient.

Implementation of a care plan also contributes to continuity of care and coordination of care. Without planning and adequate communication about the plan patient could experience gaps and duplications of care. Plan guides even flow of nursing care throughout the different stages of illness and coordinates scheduling of diagnosic tests and therapies from other health personnel into an adequate 45sequence of events. Completed nursing action end the implementation phase.

Evaluation: The final but continuous phase of nursing process is the evaluation or appraisal of the care given. Evaluation of the patient's progress is based on a comparison of the outcome of care given with outcome to be achieved by the nurse/patient/family as stated in the objection. Evaluation of nursing care is the feedback mechanism of judging quality and is designed to improve nursing care.

The advancement in medicine and the growth in monitoring and regulating body systems in the critical care unit brought bout significant changes in the role of the critical care nurse. It has extended and expanded to incorporate technical aspects of care, thereby the nurse is forced to focus skills on physiological problems even at the expense of meeting the psychosocial needs of the patient and family. The quality of a critical care nurse depends on the extent to which she has developed whole range of skills which enables her to provide total care to her clients. The patient in critical care unit experiences physiological crisis, a threat to his survival. Uncertainty and threat to life poses a series of real, imagined or potential threats to family members whose main concern is the safety and survival of the patient. The anxiety and distress experienced under these circumstances will have an impact on the excessive demands upon their abilities to cope. (Millar, 1989).

The abnormal patterns of sensory information are received from the patient internal and external environments, the patient has to mark sense or to interpret these signals, when their cognitive abilities have been affected by the pathophysiology of the illness, the drug therapy and the inability to communicate easily, either verbally or nonverbal (Ashworth, 1980, Hudak et al 1986). The patient has to cope with and deal with his thoughts, feelings of dependency, social isolation, powerlessness, fear, anxiety, insomnia and sensory perceptual alterations characterized by disorientation, restlessness, body image alterations, paranoia and depression. These experiences reduce the motivation to survive.

Communication is fundamental to any human relationship. It involves exchange of information through verbal and nonverbal behavior. To families in critical care, the interpersonal skills of the caregiver makes significant change in their overall experience of critical illness. The patients rely on them for information, support, reassurance comfort, empathy and security. Behaviors, which express this commitment, are motivated by values, which cannot be replaced by technology (Julie. P, 1994).

The nurse is involved in the total care of the patients and their families. The dependency of the patient, complexity of critical illness and modalities of life support add to the complexity of the assessment, data gathering, observation, decision making and coordination of the activities of other members of the multidisciplinary team towards, provided high quality care. The nurse plays a key role in coordinating the care and communicating on behalf of the team and ensures continuity of care.

Effective communication and good interpersonal relational skills of the caregivers can modify the patient's sensory perceptual alteration. Effective communication has a valuable contribution towards the well being of the patient, the family and it positively affects the outcome of the illness. Thus it is a challenge for every critical care nurse to develop the effective sills of communication and to incorporate into her daily routine in 50spite of the great demands on her time to meet the physiological needs.

Competent communication includes both cognitive and behavioral abilities, the knowledge about the communication process and the skills to enact the knowledge Wiemann (1977) summarizes the process as selecting interaction choices, accomplishing interpersonal goals and recognizing the interpersonal and contextual constraints of communication situations.

In a typical critical care unit patients are admitted or transferred form other units on an emergency basis. The initial emphasis of nursing care must be to meet the patient's physical and physiological needs working along with the multidisciplinary team to achieve homeostasis. The nurses face the challenge of utilizing their skills in, accurately assessing the patients problems through the continuous cycle of assessment, planning, implementation and evaluation of the care provided. Once this is achieved her attention turns to the family who is experiencing major situational crisis caused by the unexpected and unpredictable events which have led to the admission to the critical care unit. The challenge for the nurse is to enable the patients and the family members to utilize the available resources within themselves to cope with the situation. The ability of the nurse to meet the needs for open and honest information about the patient with the family determines the outcome of the crisis. The nature of distress is complex due to the threat to life, outcome of illness and its long term effect, the alteration in the family role, degree of trust in the caregivers, comprehension of the information received and the ability to cope with physical, physiological, emotional and environmental stimuli.

The interpersonal goals for the nurses involved in critical care are to:

Develop open, trusting relationship with patients and relatives so that they feel free to ask question and doubts.

Assess the family's ability to grasp the information.

Repeat and reinforce the information.

Interpret the medical and technical language.

Prepare the family for visiting and demonstrating their care and concern to the patient through verbal and nonverbal communication.

Assess the ability of the family to deal with crisis and in assisting with plan of care.

Nurse may have to spend enormous time in getting the patent to cooperate and participate in the activities of care that are planned. Letter boards and nonverbal signs and signals and closed questions which enable the patient to node or shake the head will assist in maintaining communication with the patient who has impaired communication related to disease process or therapeutic management.

Another event in the critical care unit where communication plays an important role in getting the patient prepared for a transfer form the unit due to the dependency developed over the time. It is important to maintain continuity of care between the unit and ward areas.

The receiver decodes or converts messages into meaning and requires knowledge of the symbols and signals used and the sender and receiver must share the same encoding and decoding processes for example same language. The meaning derived may not be the accurate interpretation of what the sender intended to communicate.

There may difficulty in choosing the correct transmission channel or the same limited by inability to vocalize due to intubation or dyspnea. As a result of pathophysiology of illness, mechanical constrains of the invasive monitoring or chemical constraints of sedative drugs the patient may not be able to use appropriate nonverbal gestures.

The nurse need to use feedback techniques to check interpretations of the message through questioning, reflecting and summarizing.

Attention overload involves competition for the receiver's attention, which can occur frequently within the critical care setting. The nurse may receive a message from the patient while being disturbed by the alarm sound, telephone rings and other information from others. Patient may also experience attention overload from abnormal sensory out put such as noise from people, machines, artificial lighting and intensity of interactions with others.