Essentials of Critical Care Nursing Jaya Kuruvilla
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General Aspects of CareCHAPTER ONE

  • Evolution of Critical Care, Historical Perspectives
  • Concepts of Critical Care Nursing
  • Principles of Critical Care Nursing
  • Scope of Nursing Practice in Critical Care Units
  • Legal Aspects
  • Role of a Nurse in Critical Care Units
  • Planning a Critical Care Unit
  • Nosocomial Infections and Control in Critical Care Units
  • Psychosocial Components of Critical Care Units
  • Nursing Process in the Critically Ill2
Forty years of development in critical care and critical care nursing and its rise as a recognized specialty in nursing practice is examined from historical perspectives.
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:
  1. The expansion of American Hospital System and Hospital Insurance.
  2. Architectural, hospital changes toward private and semiprivate accommodations.
  3. Reallocations of direct patient care responsibility and creation of new forms of care.
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 defined as the unit in which comprehensive care of a critically ill patient who is deemed recoverable is carried out.3
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.
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.
Primary role of the cardiovascular and the respiratory system is to provide oxygen to the 4microcirculatory bed cells. Critical illness is a state of threatened generalized cellular hypoxia as a result of cardiorespiratory dysfunction.
Cardiorespiratory dysfunction can be either primary or secondary.
Primary: occurs as result of diseases in cardiac or respiratory systems.
Secondary: occurs as in sepsis, trauma where Hypermetabolic State occurs in response to stress. There is increased oxygen demand and initially compensatory changes occur in the cardiorespiratory system to meet this demand. The situation is not unlike severe exercising which goes on and on and if the precipitating factors are not controlled there ensues failure of these mechanisms.
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.
Reversible Stage of Critical Illness
Oxygen transport to the tissue is increased. There is tachypnea, tachycardia, increased cardiac output and a low blood pressure. Peripheries are warm and flushed. This is an early reversible stage-warm shock. The next stage of cold shock is characterized by a failing cardiac output, cold and clammy peripheries, poor capillary filling and cyanosis.
Irreversible Stage of Critical Illness
When oxygen demand exceeds oxygen supply anaerobic metabolism takes place. This lead to metabolic acidosis and if unchecked a state in which even if oxygen supply is restored, the cells are unable to utilize it. This is the point of irreversible damage, which precedes cellular death. The microcirculation fails and cells become hypoxic, cellular damage occurs.
Pathophysiological Changes in this Stage
In the Lungs
The most dramatic changes are seen in the lungs. This clinical condition is referred to as Adult Respiratory Distress Syndrome. This is a syndrome with multiplicity of predisposing factors. It is the final common pathway of respiratory failure in critical illness. Hypoxic pulmonary capillary damage leads to an increase in capillary permeability and fluid leaks out into the pulmonary interstitial. Alveolar cell damage occurs and loss of alveolar volume as well as edema leads to a defective gas exchange. The ensuing hypoxia is severe and refractory to ventilatory support.
Multiple Organ Failure
Other organs like liver also suffer from hypoxia and hepatic failure. This may be reflected in increased serum bilirubin, alkaline phosphatase, and serum albumin. There is decreased production of coagulation factor, increased platelet activity, and increased micro aggregates and Disseminated Intravascular Coagulation (DIC).
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.
Factors Predisposing to Critical Illness
  1. Severe cardiorespiratory disease. Acute myocardial infarction, chronic obstructive pulmonary disease, congestive cardiac failure.
  2. Severe multiple trauma, massive blood loss, shock, septicemia.
  3. Acute abdominal catastrophe such as pancreatitis, gangrenous bowel, peritonitis, gastrointestinal bleeding.
  4. Acute Hepatic failure.
  5. Extensive surgery
  6. Central nervous system failure
  7. Extensive burns
The first principle in critical care is anticipation. One has to recognize the high risk patients and anticipate the requirements, complications and be prepared to meet any emergency. Unit properly organized which all necessary equipment and supplies are mandatory for smooth running of the unit.
The prognosis of the patient depends on the early detection of variation, prompt and appropriate action to prevent or combat complications. Monitoring of cardio-respiratory function is of prime importance in assessment.
Critical care, which has originated as technical subspecialized body of knowledge, has evolved into a comprehensive discipline requiring a very specialized body of knowledge for the physicians and nurses working in the unit. Collaborative practice between the physicians and the nurses working in the critical care unit fosters a partnership for decision making and ensures quality and compassionate patient care. Collaborative practice is more and more warranted for critical care more than in any other field.
Intra-professional, interdepartmental and interpersonal communication has a significant importance in the smooth running of unit. Collaborative practice of communication model unlike the traditional practice model enhances better outcome as far as patient, nurse, physician and hospital are concerned. This model centers around the patient, fosters individual clinical decision-making, uses integrated medical records and joint review of care.6
Nosocomial infection cost a lot in the health care services. Critically ill patients requiring intensive care are at a greater risk than other patients due to the already immuno compromised state with the antibiotic usage and stress, invasive lines, mechanical ventilators, prolonged stay and severity of illness and environment of the critical care unit itself. The sources of infections are wounds, indwelling catheters, invasive lines, ventilator, hematogenic, and urinary route. The most common organisms are E. coli, Pseudomonas species, Staphylococcus aureus and occasionally Clostridium tetani. Quality nursing care combined with a vigilant surveillance program can minimize the incidence of nosocomial infection. The ways of minimizing nosocomial infections is, effective hand washing, routine cleaning of the unit, concurrent and terminal disinfection procedures and regular culture examination from the potential ports at different places in the critical care unit. Strict practice of barrier nursing and reverse isolation procedures wherever indicated would also minimize the nosocomial infections.
Partnerships are formulated during crisis. Bonds between nurses, patients and families are stronger during hospitalization. As patient advocates, nurses assist the patient to express fear and identify their grieving pattern and provide avenues for positive coping. Listening is a skill to be developed by every critical care nurse, to handle the extreme complex feeling of patients who are in crisis situation. Empathy is the attitude to be developed by the critical care nurse to make herself a good counsellor to the patients.
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 nursing practice in critical care unit is highly challenging and complex. Critical care nursing is fast evolving as specialty to meet 7all these challenges. The scope of critical care nursing is varied in different areas.
Clinical Practice
The critically ill patient is a complex person in a complex environment. The nursing care of critically ill patient is challenging, identifying the individual patients response to illness as well as to treatment. The nurse who monitors the patient continuously needs to have sound knowledge, skill and careful judgment. She follows systematic approach in assessing, planning, implementing and evaluating the care provided to the patient.
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.
Policy is a course of action for dealing with a particular matter or situation by a political party, government or an organization.
Procedure is a set of actions necessary for doing something.
The ceremonial system of fixed rules and accepted behaviors especially used by companies, institutions and organizations.
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.
Critical Care Nurse—A Changing Role
As the practice becomes more sophisticated the nurses are demanded to rise unto the occasion. She needs to be qualified to practice. The former clinical experience when hired is an asset to the nurse. The average critical care nurse practices in the field for about five years and then transfers to other units or leaves the country or the profession which results in rapid turnover.
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.
Having ensured the basic and post basic qualification, a systematic program of orientation and continuing education program need to be implemented which would ensure quality and sustain the interest of the nursing professional practicing in critical care units.8
Role Development
Apart from the traditional roles new roles are being developed.
The CNS is considered as the clinician, researcher consultant and manager. The clinical nurse specialists, roles are:
  1. Monitor and evaluate quality of care.
  2. Provide formal and informal education.
  3. Promote, collaborate with and facilitate conduct of research and research utilization.
  4. Provide expert care by direct care or consultation.
  5. Serve as a role model for clinical staff.
The roles of a case manager are:
  1. Facilitating early discharge.
  2. Promoting appropriate utilization of resources.
  3. Achieving desired outcomes.
  4. Promoting and formalizing collaborative practice.
  5. Fostering satisfaction of nurse, physician and patient.
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.
As critical care nursing emerges more and more as a clinical specialty that cuts across age groups, encompasses many disease conditions and interfaces with other variety of health care disciplines it is necessary to explore the knowledge development by carrying out research. The greater the extent of nursing practice being based on research, the higher will be the quality of practice and patient outcomes. Nurses need to value and use nursing research if nursing has to have strong research based practice rather than a weak, ritual based practice.
In spite of the highly charged atmosphere of critical care unit many nurses continue to work in those units. There is evidence to show that critical care nurses found the work in those units as challenging and they expressed satisfaction over observing the recovery of the patient and the opportunity they have to learn and save the life of patients (Kuruvilla J, 1990).
To understand nursing ethics in critical care nursing one must understand both critical cares nursing and nursing in general. Ethics does set standards but those standards are 9more than minimum expectation. Ethics also identifies ideals. The specific concerns of ethics in nursing fall under normative ethics.
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.
It means active support of an important cause. The role of the advocate is to assert the patient's choices or desires. There are three models of advocacy, which can be applied in nursing practice.
Right Protection Model
The nurse is viewed as the defender of patient's rights against an impersonal and mechanical health care system, which violates patient's rights.
Value Based Decision Model
Advocacy can be viewed as value based decision model. This allows the nurse to play a role of helping the patient to discuss his needs and make choices that are most consistent with the patient's values. The nurse provides information to the patient. In this model the nurse doesn't impose any value on the patient, but helps to explore all possibilities and then make a decision.
Respect for Persons Model
The patient is viewed as an individual with dignity in this model and the nurse keeps the basic human values of the patient in mind and acts to protect his human dignity, privacy and self-determined choices. This highly applicable in critical care unit where there is tendency for any one to become mechanically and technologically oriented.
Autonomy is the term that is derived from Greek word “autos” meaning self and “nomos” meaning law or rule. The central idea autonomy is self-rule.
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.
Common Ethical Issues in Acute Care
Two major issues in acute care are advance directives and treatment withdrawal.
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:
Living wills: Generally take effect only when the patient is terminally ill and is unable to voice is or her wishes. Under these two conditions the living will directs that no life sustaining treatment is to be administered. Some living will forms include more specific directions regarding the individual wishes for with holding food and fluid or other specific treatment modalities. The presence of living wills can be quite helpful to care givers who are faced with treatment decision for patients who can no longer speak for themselves.
Durable power of attorney for health care: A second type of advance directives is more broad and flexible than a living will. It goes into effect only when the individual has lost decision-making capacity. It is helpful in seeking any life supporting treatment but also questions related to blood transfusions, antibiotic therapy and surgical procedures.
Refers to being answerable to what is being done. It is value related to the social responsibilities of nursing and to the moral and legal requirements of nursing practice. The value of accountability is seen, as superior moral standard in nursing that provides foundation for the relationship required in critical care nursing and the basis for high quality care.
Futile Therapy—Ethical Controversies
As technology has developed to sustain life, critical care professionals have struggled to determine the proper circumstances under which life-sustaining treatment should be 11limited. Despite general agreements that competent patients can refuse life sustaining treatment and the health care professional are not obligated to provide futile care, and the critical care professionals are now questioning whether patients or their significant other must authorize the provision or withdrawal of useless or futile medical therapy.
Futility means useless interventions. The situations where questions of futility arise in the critical care setting are:
  1. Burdens of treatment outweighing the benefits.
  2. Undesirable quality of life.
  3. Death is imminent.
  4. Patient or significant other refuses or demand life saving treatment.
  5. Effectiveness of treatment is questioned.
  6. Resources are limited by way of finance or personnel.
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.
Withholding and Withdrawing Treatment
Decisions to forge life-sustaining treatment have major consequences on the patient, family and health care providers. In order to protect the interest of patients and their families, critical care nurses should be aware of the appropriate decision making process. The most difficult term to define in this connection is “Death”. It can be defined in terms of cardiopulmonary death and brain death in situations like chronic persistent vegetative state and anencephalic newborns. When the person has suffered brain death he is legally dead. The difficult issue arises with patients who are terminally ill with irreversible conditions. Who makes the decision to withdraw life-sustaining technology? In case of patients with decision making capacity informing and communicating would help him to make decision of withdrawing life-sustaining treatment himself. In case of patients without decision making capacity informing and communicating would help him to make decision of withdrawing life-sustaining treatment himself. In case of patients without decision making capacity, the “Will” of the patient or advance directives given by the patient or the decision of the next of kin” can be taken into consideration for the best interest of all individuals concerned.
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.
Non Malificence
Refers to doing harm with a purpose of achieving good, for example amputation done in a patient with gangrene. Many treatment procedures carried out in the patient are harmful to the patient. In most of the situations it is the responsibility of the nurse who may be partly doing harm while not necessarily making decision. Taking responsibility for the action may be viewed as following orders. That doesn't protect the nurse legally and ethically. It is important for each nurse to examine and evaluate a situation to determine if harm is being done or if the risk of harm is too great. The nurse must not stop analyzing. She must actively decide and act on the basis of evaluation. Whenever possible she should use the mechanisms and processes available within the institution as a vehicle for minimizing harm to the patient.
Standing Orders
Standing orders are the policies made by the hospital management in relation to administration of medication/treatment procedures without the already written medical orders at the time of emergency and otherwise. Every critical care unit should have it made and available for nurses thereby the nurses are protected and patients are ensured safe care.
Medicolegal Case
All patients admitted after accidents, suicide attempts burns and assaults are medicolegal cases, which should be notified to police through proper channel. If such a patient die body is handed over only after police clearance is obtained. This is also applicable in case of discharge of a medicolegal case.
Valuables in Critical Care Unit
Patients who are admitted to the unit with gold, jewellery, cash and other expensive and valuable items are at a risk of losing them. If the responsible relative is available it can be handed over to that person immediately. Otherwise a list of articles in duplicate is made, signed by the person receiving and a witness. Thereafter the articles with the list are kept in safe custody until it is handed over to the next of kin of the patient or patient himself when he becomes well.
Informed Consent
An informed consent or an operative permit form is signed by the patient and witnessed. Granting permission to have an operation/treatment, performed as described by the patients physician. This is a medicolegal requirement.13
  1. To ensure that the patient understands the nature of treatment including the potential complications.
  2. To indicate that the patients decision was made without pressure.
  3. To protect the patient against unauthorized procedures.
  4. To protect the hospital staff and the hospital against legal action by a patient who claims that an unauthorized procedure was performed. Prior to signing an informed consent the patient should be told in clear and simple terms about what is going to be done, the risks and possible complications, disfigurement and removal of parts. Client should have general idea of what to expect in the early and the late postoperative period and have opportunity to ask any questions.
Circumstances Requiring A Permit
Any surgical procedure where scalpel suture, hemostasis or electrocoagulation, entrance into body cavity, general anesthesia, local infiltration and regional block are used a written permit is required. Admission to critical care unit requires many of these procedures being done and it is not practical to obtain consent at each occasion. Therefore it is advisable to get the consent signed at the time of admission itself.
Consent Issues
Nurse needs to ensure that the patient/competent and responsible adult relative of the patient signs the consent form of the hospital.
Liability Risk Issues in Critical Care Nursing
Effective health care and maintenance requires a partnership of trust between the nurse and the patient. However the critical care nurse has more and more accountability for professional practice. Further critical care nursing has evolved into a highly technical specialized field, increasing the risk of liability. The critical care nurse has to be prepared to identify the liability risk issues and the measures to reduce them in actual practice. Following are the liability risk issues in a critical care unit.
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
Administration of Medication, Standing Orders
The nurse needs to practice all rules of administration of medication in critical care unit. Standing orders should be formulated in consultation with management, medical director and nurse manager, which should be made available to the staff and followed strictly. Strict caution as far as verbal, telephonic and inappropriate orders to be followed by nursing staff.
No code, With-holding Withdrawing Life Support orders
Medical orders for not resuscitating with-holding or withdrawing life support should be written down in the patient's records by an authorized physician working in the unit.
Incident Report
At any occasion if there is violation of normal rules an incident report to be made confidentially, the main purpose of which is to make the individual aware of the mistake/negligence so that such acts could be avoided in the future.
As the legal implications of practice increases nurses are wanted as witnesses in the court of law and otherwise. Witnessing can be for medicolegal case. When a nurse is asked to be the witness following guidelines can be followed:
  • Inform nursing administration
  • Be prepared to answer any questions to describe the standard and to define nursing and the nurse's role
  • Have belief in yourself and explain the reason for your action
  • Limit the answer to yes, no or I don't know or I don't recall
  • Maintain good posture, dress professionally and be relaxed and take time to think and answer
  • Testify only to your expertise
  • Avoid Vague and Blanket Statement.
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.
Common Causes of Liability
Common causes of liability are fall of patients, use of restraints, equipment malfunction, errors in administration of medication and treatment, failure to observe and report changes in patient's condition, application of heat and subsequent burns, accidental disconnection from life saving machines.
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.
Critical care units began as an outgrowth of post anesthesia room. It is equipped with sophisticated monitoring and emergency equipment which is readily available and staffed by personnel qualified and experienced and with access to all support departments.
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 nurse is one member of the team involved in the care of critically ill patient. The nurse provides round the clock care and continuity while other health professional visit the patient. By virtue of this she becomes the coordinator of patient care activities. She delivers care with a holistic approach.
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.
Nurse Physician Collaboration
There is no other area where a collaborative effort by the nurses and physicians is required than in critical care unit and the primary focus remains the patient. The need for open communication should not be underestimated. A physician's attitude of openly valuing nursing boosts nursing staff morale, which indirectly improves the quality of patient care. Nurses appreciate and value a physician for:
  1. Staying near when a patient's condition deteriorates.
  2. Keeping the family informed of patient's condition.
  3. Listening to nurses concern related to patient's condition.
  4. Teaching nurses about new therapy and intervention.
  5. Recognizing the nurses maximum efforts and assisting her in emergency situation.
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.
Nurse as a Manager
The importance of leadership in the role of the nurse manager is critical to effective health care delivery. The essential leadership skills required of a nurse manager in the unit are creation of a vision, the building of trust and maintenance of motivation, facilitating of change and creation of work environment which is conducive to patients welfare and staff's learning.
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.
Nurse as Caregiver
Critical care nurse is a qualified nurse by virtue of experience or specialized training responsible to provide direct patient care to all patients admitted to the critical care unit. She uses sound scientific knowledge in using nursing process while delivering nursing care to patients. She needs to ensure adequate supplies, equipment in optimal working condition and be available to meet all emergencies that may occur in the unit. She is also responsible to maintain the records and reports, which are used in the unit. She forms a liaison between the patient, family and other members of the team.
Thus the nurse in the critical care unit has multifaceted role to play.
The critical care unit is a specially designed and equipped facility, staffed by skilled personnel to provide effective and safe care for patients with life threatening or potentially life threatening health problems. Critical care services require specialized facilities and equipment especially trained nursing staff and a wide range of support services. Since all these are expensive, for optimal care to be provided at the lowest possible cost, it is important to develop an integrated regional plan for intensive care services. Extensive planning is obviously required to achieve this. Critically ill patients are in a physiologically unstable condition or at high risk for deterioration and hence the need for careful monitoring. This could be as a result of injury or surgery or disease leading to a single or multiple organ failure. They include patients in hemorrhage, shock, coma, heart attack, acute respiratory problems, complications of surgery, those requiring specialized care and monitoring after major surgical procedures. Some hospital have generalized units whereas larger hospitals have specialized critical care units such as Burns unit, Neonatal unit, Coronary care unit, Post operative cardio-thoracic unit and renal units. Critical care units 17may be classified into three levels depending on the staffing and support facilities of the hospital. A three level classification consists of:
Level 1. It is a high dependency unit, which could be either separate or attached to a general ward. Patient nursed in these units are those who require special observation following an uncomplicated myocardial infarction or surgical procedures. These units undertake only immediate resuscitation, short-term ventilation and cardiac monitoring. The nurse patient ratio is 1:3 and the medical staff are not present in the unit all the time.
Level 2. This level of critical care unit is capable of providing prolonged mechanical ventilation but does not have access to comprehensive support facilities. Nurse patient ratio is 1:2 and junior medical staff is available in the unit all the time and consultant medical staff is available if needed. The unit has educational programs and may be involved with major teaching unit in research.
Level 3. It is a comprehensive critical care unit, which serves as major teaching and referral center with cardiothoracic, and neuro-surgical facilities. Medical staff is in the unit all the time and the nurse patient ratio is 1:1. These units have teaching and research obligation.
Whatever may be the type of unit it has to incorporate many features to provide continuous observation and quick intervention.
Location: It is easier to design a unit as an integral part of a new hospital. However it is often necessary to adapt existing part of a hospital which inevitably imposes a number of design limitations, particularly with regard to space. The location is decided depending on the type of patient to be treated. For example if the unit is used for care of surgical patients it is best cited near the operating/recovery room. Other specialized units prefer to have them as part of their own department where the patient care is based on the concept of progressive care. That is from intensive care to intermediate care and then to general patient care area.
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.
Number of beds: Estimation of bed need. The first step in planning is estimating the number of intensive care beds needed in any unit. Considering the number of patients seeking CCU care, average length of stay in the unit and occupancy rate and applying the formula developed by planning agencies, one lakh population needs 14–15 CCU beds.
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.
Determining the optimal critical care unit size: The beds can be organized into general beds or specialized beds. Six to eight beds is the ideal size to be served from one nursing station, even though a maximum of ten to twelve beds can be accommodated. The minimum beds in any unit should be at least for to utilize the facilities effectively.
Features of a Critical Care Unit
As a general rule at least as much floor area is required for non-patient use (storage, cleaning, maintenance, and visiting) as required for patient care area. The British medical Association recommendation is 200–300 sq.feet. This includes 3 ft between head of bed and the wall. This is necessary for carrying out procedures like endotracheal intubation. Space between bed is essential not only to accommodate bulky equipment but also to allow access to patients. The total floor space required for a critical care unit depends on the number of beds, the unit design, the number and size of utility spaces such as store room, equipment room, linen room, clean and dirty utility room, pantry and changing room. Each unit should have separate isolation rooms, conference room, adjacent visitors waiting room. Ideally there can be two sections, clean and dirty, so that patients who have potential source of infection can be segregated. The provision of single room and barrier nursing facility to be considered for the units dealing with infective or immunosuppressed patients. When there are clean and dirty sections in the same unit there are a need to duplicate the facilities and the nursing staff required. There is a practical problem of restricting the traffic between the two sections. A compromise could be the use of partial cubicle. Beds are separated by glass partitions where the patient can be observed from the central nursing station while allowing the infection to contain within itself.
There are many designs which can be selected for the given place to plan the critical care unit. The critical care unit can be X shaped U shaped or semicircle so as to have good observation. Individual rooms are recommended to minimize cross infection, reduce noise level and provide privacy for conscious patients. This would require more staff for the unit. A compromise may be to have separate cubicles over the glass area may be drawn when privacy is required (Fig. 1.1).
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.
zoom view
Figure 1.1: An incubed in Ibri hospital
Critical care implies continuous observation. The unit must be well lit. Background illumination from ceiling should be color corrected so that minor degrees of cyanosis or jaundice cannot be masked. Lighting should be as natural as possible. In addition portable spotlight should be available. Each bed should be provided with a night lamp so that during night bright light can put off so those patients get oriented to diurnal variations.
Temperature and Humidity
The unit should be air conditioned for the sake of patients, equipment and staff, temperature adjusted around 68–72 degree F. The temperature extremes can add burden to the ill patient. Adequate air exchange should be possible, twenty times per hour is recommended. If air conditioning units manipulate temperature and movement of air, but not humidity, excessive drying of skin and mucous membranes may occur. Therefore air conditioners should have humidity control to provide comfort. Isolation rooms should incorporate nonrecirculating air control that maintains slightly positive pressure for reserve isolation or slightly negative pressure for conventional isolation. Wall thermometers should be ideally placed to check the efficiency of air conditioning systems.
  1. Nurses station: Nurses station should be planned permitting direct visual observation of patients with facilities for charting, telephone, placement of patients record and central cardiac monitoring systems.
  2. Hand washing facilities convenient to nurses station, drug distribution area, pantry, clean and dirty utility area and individual rooms especially in the isolation rooms. The taps should be elbow operating or peddle operating.
  3. Staff toilet room.
  4. Changing room. It should be separate for men and women with shoe rack and individual cupboards for storing personal effects of nursing and other personnel.
  5. Workroom: Clean workroom appropriates with working and storing for clean and sterile supplies. This shall include the workcounter and hand washing facilities and a window with a collapsible doors through which supplies can be received thereby limiting the entry of supply man into the unit.
  6. Sluice room where there are facilities for flushing the bedpans and automatic bedpan washers are situated.
  7. Drug distribution station where medicine trolley and dangerous drug cupboard are centrally located.
  8. Clean linen storage.
  9. Pantry for storage and preparation of food.
  10. Emergency equipment storage.
  11. Conference room.
  12. Duty doctors room.
  13. Laboratory.
Electrical System
A safe electrical system is essential to prevent shock hazards. Special precautions must be taken when care of patient requires any type of electrically operated devices. Portable fire 20extinguisher should be fitted at convenient places and the staff instructed on the use of that equipment. The electrical system should be connected to the generator for the use at the time of power failure. The switches and power points for the same to be situated within the units. A study conducted by the author to identify stress among critical care nurses, brought out that frequent power failure resulting in non functioning of life saving devices was one of the factors which was most stressful. The generator connections are mandatory for critical care units in order to sustain life saving devices during power failure.
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.
Mechanically operated beds, which can be adjusted to various positions, and levels are recommended. The base and the mattress should be firm enough to enable to carry out resuscitative procedures. A detachable rail at the head end of the bed allows for easy access to endotracheal intubation. Bed with side railing and easily movable one for transfer with a locking system is desirable for CCU.
A great deal of expensive sophisticated equipment is required and the choice will depend on the type of unit. The recommended equipment for critical care units can be classified into monitoring, resuscitative, and supportive.
Monitoring Equipment
Electronically monitored parameters of cardiac, respiratory, and perfusion status provide essential information for routine and acute management of each patient. ECG, invasive and non-invasive Blood pressure, Central venous pressure, End tidal CO2, Pulse oximetry and skin and/or core temperatures are routinely monitored. Monitoring of Cardiac output, chamber pressures, systemic and pulmonary pressures and resistance, and oxygen consumption may be required in specific instances.
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.
Resuscitative Equipment
Resuscitative equipment is essential in the management of patients with life threatening conditions such as arrhythmias, respiratory failure, and shock and oxygen failure. Each unit should be equipped with a crash trolley containing emergency drugs, fluids and equipment. This is wheeled to the patient's bedside during resuscitation and ensures that needed supplies are available.
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.
Supportive Equipment
Special ICU beds are available with flat washable surface, detachable head end to facilitate resuscitation, holes for intravenous drip stands at convenient places, easy moving side rails, adjustable head and foot end and adjustable height. Alternating pressure air mattresses are used to prevent pressure sores, for those who are prone to develop them. All infection control protocols are carried out to prevent infection in these patients who are prone to them. To provide additional protection for patients, who are highly susceptible to infection, laminar air flow systems are used. LAF produces a constant flow of filtered air over the patient and reduces exposure to bacteria.
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.
Cross Infection
The prevention of cross infection is a problem in the unit and should be considered in planning and in spacing of beds. Provision of single rooms, barrier-nursing facilities should be considered for units with infection or immunocompromised patients. All surfaces should be able to withstand germicide. Each of the patients in the barrier nursing area should be cared for by a nurse specially assigned. Contaminated instruments, linen, equipment should be treated in separate utility room. Adequate facility for hand washing should be available.
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.
Factors affecting patients well-being: The critical care environment produce adverse effects on the patient. It is discussed elsewhere. However designing the unit with large windows through which patient can have access to outside view is advisable.22
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.
Admission criteria: Criteria are formulated as per the type of services offered by the unit and the policy of the institution. Some units have a list of those who are not suitable for admission to critical care unit, such as terminally ill patient who require more that standard nursing care.
Nursing charts: The nursing chart or a flow sheet is a monitoring aid that record data chronologically to allow rapid review in a form, which is easily interpretable. The chart should include recording of:
  1. Vital Signs: These include temperature, pulse and respiratory rate. If the patient is mechanically ventilated the mode, peak air way pressure, expired tidal volume, air way temperature, inspired oxygen percentage, pulse oximetry measurements, sputum amount and colour.
  2. Cardiovascular parameters. These include blood pressure, central venous pressure and swan ganz pressure measurement.
  3. Central nervous system parameters: These include an assessment of patients state of consciousness, pupillary changes, reflexes and motor responses which could be recorded in a Glasgow coma scale incorporated into the routine flow sheet.
  4. Fluid balance parameters: These include intravenous and gastro intestinal fluid input and gastro intestinal and urinary output recording along with measurement of any drainage present.
Flow sheet should have provision for recording of the laboratory investigation such as blood count, ABG, Renal function tests and liver function tests.
Staffing: Paradoxically so many doctors have an interest in some aspects of the treatment and it is difficult to decide who is overall in charge of patient. Many have tried with different category. A specialist in critical care medicine is the most ideal if one can find such a person. Otherwise the most specified areas are anesthesiologist and surgeons. The need to train physicians in critical care medicine is also beginning to be recognized. The level of physician coverage that is required for the unit should be addressed. This aspect depends on hospital size. One full time physician available throughout is necessary. Most guidelines provide for a availability of specialist intensivist within 20 minutes in the larger hospitals. Some agencies believe that a committee can do overall direction.
Ancillary personnel recommended are given below:
  • Safety officer
  • Biomedical engineer
  • Secretary
  • Administrative coordinator
  • Clerk/Typist
  • Dietitian
  • Respiratory Therapist23
  • Social Worker
  • Physical Therapist
  • Laboratory Technician
  • Clergy Man
  • Receptionist
  • Cleaning Staff.
Nursing staff: The importance of the nursing staff is very significant. The recommendations deal with ratio of nurses to patients and the need for adequate training. The ideal ratio is considered to be one nurse per patient. However it is recognized that manpower limitations prevent this from not being realized in most setting. Most guidelines set a ratio of one nurse for three patients as maximum. Allowing for sickness and holiday it requires 4.25 nurse per bed plus one sister in charge in each shift. It is ideal to have a senior nursing officer as overall in charge. Guidelines also stress that the need for training of nursing personnel. Training should include orientation program reinforced by continuing education programs.
Management policy: Management policies and procedure are essential to the effective and efficient operation of the critical care unit. It should include the following aspects:
  • The patients to be served by the critical care unit
  • The type of CCU services provided
  • Relationship of CCU to other units and departments
  • Management of the unit
  • Admission and discharge criteria
  • A system of informing the physician about the changes in the condition of the patient
  • Use of standing orders
  • Location and storage of medication supplies and special equipment
  • Method of care delivery
  • Method of procurement of drugs, equipment and other supplies
  • Responsibility for maintaining the emergency drug system
  • Regulation regarding visitors to the unit.
Critical care units are of different levels depending on the staffing and support services. They are either general units or specialized units depending on the type of patients catered to. Critical care services require specialized facilities and equipment especially trained nursing staff, medical staff and wide range of support services. It should be geographically closely associated with emergency department, operating theater, recovery room and other intensive care areas.
Nosocomial infections are ones that develop during hospitalization and are not present or incubating at the time of admission to the hospital. Nosocomial infections cost the health care industry a large sum every year. In 1979 Bennet et al noted that hospital acquired or nosocomial infections affect nearly two million patients each year in USA. Apart from the heavy expense incurred on them to the tune of 5 billion to 10 billion dollars each year, nearly 3% of these patients die as a result of hospital acquired infection. Critically ill patients requiring CCU care are at a greater risk for nosocomial infections in comparison 24with the other patients in the general ward for following reasons:
  1. They often have underlying conditions or diseases that compromise their host defenses.
  2. They are often exposed to invasive procedures, some of which are done as emergency. During this emergency treatment traditional infection control practices may be violated.
  3. They are often close to other highly susceptible or infected patients, a situation that allows ample opportunity for cross infections since contacts between patients and staff is frequent.
  4. CCU's often become the reservoirs of antibiotic resistant microorganisms. Most of these patients have poor nutritional status and covered by heavy antibiotic usage thereby resistance to infection is reduced.
  5. Use of mechanical ventilators makes them more prone to infections.
  6. Length of stay in CCU. As the length of stay in CCU becomes more they are more prone to infections.
The most common sources of infections are wounds; indwelling catheters, ventilators, suctions, nebulizers, respiratory, blood and urinary systems.
Microbes, which cause infection, fall into the groups of bacteria, viruses, fungi and protozoa.
Bacteria are perhaps the most numerous and widely distributed of the microorganisms. They are classified into:
  1. Gram Stained
  2. Acid fast bacilli
  3. Spirochetes.
Gram stained bacteria is classified into gram positive and gram negative.
Gram Positive Bacteria
Staphylococci: Which are seen as clusters, positive coagulase test indicates staph aureus.
Staphylococcus aureus: This is the normal flora in the nose of 10–30% normal people. Skin infections caused by this are boils, carbuncles, abscess, surgical wound infections, neonatal skin infection, sepsis, deep tissue infections, including septic arthritis and septicemia.
Staphylococcus epidermidis: Found normally in the nose of skin flora of healthy people. Diseases caused include endocarditis after heart surgery, shunt infections in infants, infections of hip joint prosthesis.
Streptococcus: There are different types. They are pneumonia, S. Viridans, B. hemolytic streptococci group A, B, C, D.
Groups A: 5% of the population has hemolytic streptococci in the throat. Diseases include sore throat, scarlet fever, otitis media, skin infections, wound infections rheumatic fever and acute glormerulonephritis.
Group B: Normal sites is perineal skin and lower vagina. Main diseases associated include neonatal septicemia and meaningitis.
Group D (S. faecalis): Normal flora in intestine. Diseases produced are sore throat, skin infections, septicemia and endocarditis.
Streptopneumonia: It is a normal flora of throat and nose. Diseases include Otitis media, 25mastoiditis, pneumonia, meningitis and septicemia.
Streptoviridans: It is normal flora in the mouth. Diseases produced include dental caries, liver abscess.
Bacillus species: This include B. anthracis, which causes anthrax in man and animal.
Cornebacterium Species
These include C. diphtheria. These are commonly isolated in skin or throat. This also causes urinary tract infections or bacterial endocarditis affecting a prosthetic heart valve.
Clostridium species: Clostridium tetani and clostridium perfinges (welchii) which are common causes of outbreaks of tetanus and gas gangrene in critical care units.
Gram Negative Bacteria
Neisseria species: These include N. gonorrhea, N. meningitides. These are oxidase positive Neisseriae meningitidis carried in the nasopharynx of 5–30% of general population and these are the ones causing bacterial meningitis.
Enterobacterial – includes E. coli, Klebsiella Proteus, Salmonella and Shigella.
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.
Pseudomonas: The common ones are Pseudomonas aeruginosa, occurs in the fecal flora of patients. Most pseudomonas species may be isolated from moist environment sites in the hospital including contaminated suction apparatus, contaminated ventilators and humidifers. Diseases produced are wound infections, chronic osteomyelitis, eye infections.
Puriobacteria: These include H. influenza and other hemophilus species frequently found in the normal throat flora and nasal flora causing diseases like H. Influenzae.
Hand Washing
  1. Personnel should adhere to strict hand washing between all patient contacts and as when otherwise indicated.
  2. Washing facility should be provided at convenient locations throughout the CCU and in each of its isolation room.
  3. Antiseptics such as hibiscrub should be made available for hand washing.
  4. Gloves should be worn for high-risk patient contacts.
Spacing Patients
  1. Sufficient space should be provided around each patient for equipment and for the passage of personnel to decrease the likely hood of infection transmission by direct contact.
  2. There should be adequate ventilation air-conditioned with adequate exhaust fans wherever needed.
Isolation in Intensive Care Unit
Appropriate isolation facilities should be available in CCU if infected patients requiring 26isolation are admitted to these units. However quality of care should not be compromised because of isolation.
Aseptic technique: There should be adequate preparation of the patients skin for emergency procedures such as insertion of intravenous and urinary catheters, cannulas, cut down, tracheostomies, swan ganz catheters central venous pressure lines, monitoring devices, not withstanding the urgency with which many of these procedures are carried out.
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.
Visiting privileges to seriously ill patients in the CCU is to be determined as a policy and limited, as the traffic in this area should be kept to a minimum. It is preferred to limit visiting to a specified length to time and to limit the total number of visitors to a level consistent with efficient operation of the CCU.
Standard operational procedure pertaining to cleaning practices should be written and strictly adhered to because of the high probability of environmental contamination in the CCU.
As a routine:
  1. All horizontal surfaces should be washied down daily and as needed with soap and water first and an approved germicidal solution.
  2. Floor should be cleaned daily and as needed using a wet vacuum and an appropriate germicidal solution.
  3. When mops are used they should be disposed and if non-disposable mops are used they should be bagged separately after use and sent to laundry. A fresh batch of germicidal solution should be used for each mopping.
  4. Dry dusting and cleaning should be avoided.
  5. Use double bucket technique for wet mopping. In this technique soiled water is not wrung into the solution used for mopping but is held in separate bucket. Redistribution of soil is minimized because soiled water it not added to the floor via the mop.
  6. All spills of blood and blood products, exudates and other body fluids should be wiped up immediately using a germicidal solution.
Cleaning of Fixtures, Sinks and Closets
Hand washing facilities, service sinks bath room fixtures, bedpan flushers and dirty utility rooms should be thoroughly cleaned daily or more times. Blood clots, blood and blood products provide an excellent medium for growth of microorganisms and should not be left without cleaning.
Cleaning of Patients Rooms
Concurrent cleaning of the room should be conducted as a routine using approved technique and germicidal solution.27
Terminal Cleaning
All floors should be wet vacuumed after removing all used articles from the room. Floor should be mopped using double bucket technique using an approved germicidal solution. Walls are cleaned with a germicidal solution after being washed with soap and water.
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:
  1. The observance of correct shelf life of hospital sterilized items
  2. Routine checking for the sustained integrity of prepackaged, pre sterilized items.
  3. Decontamination, disinfection and sterilization practices.
  4. The proper management of infectious waste on all wards.
Environmental Sampling (Culturing)
Routine enviromental microbiological sampling can play an important role eqidemiologically in the following.
  1. Investigations of particular problems within the hospital such as an outbreak of infection.
  2. Microbiologic sampling of personnel is appropriate when there is evidence of exogenous source in outbreaks of infection such as staphylococcal, streptococcal and salmonella. Nosocomial spread of gram-nagative bacilli such as klebsiella, proteus or psuedomonas is also detected by personnel sampling. Nose or throat culture in personnel, when indicated. Sampling may serve as a useful tool for education, training and research.
Specific Indications for Routine Microbiologic Sampling
Routine microbiologic sampling is appropriate in specific instances as for equipment such as sterilizers which should be microbiologically monitored. Clinical surveillance may provide epidemiological evidence associating 28particular pieces of medical equipment with specific infections in patients, such equipment, should be monitored by microbiologic culturing periodically.
Procedures that May Increase the Risk of Nosocomial Infections in Critical Care Unit
Any patient who enters the hospital and requires certain procedures may be susceptible to acquiring in nosocimial infection, when these procedures are carried out with the utmost care and with infection control in mind and if the patient is not immunocompromised, the risk of infections is minimized. The procedures that may increase the risk of nosocomial infection in a critical care unit are.
  1. Intravenous therapyIntravenous therapy is an integral part of patient care especially in seriously ill. An IV system offers a ready means of direct access to patients vascular system for hemodynamic monitoring and administration of fluid and medications. IV systems also provide a potential route for microorganisms to enter the vascular system by passing normal defense mechanisms. These organisms can cause serious infection if they are allowed to enter and proliferate in the IV cannula, wound or IV fluid. Thus IV therapy is a potential source of nosocomical infection, which can even result in serious illness, or death for hospitalized patients. During IV infusion therapy strict aseptic technique should be followed during all stages of the procedures. Cannulas and IV infusion sets should be changed every 48–72 hours in long term use.
    1. Heparin Locks: Heparin locks are frequently used for prolonged regular administration of medication. The injection site should be thoroughly cleaned. Blood allowed to remain in the tubing for any length of time, can provide an ideal breeding place for microorganisms. The site should be changed every 72 hours. Faulty or inadequate care of heparin locks needles could lead to many problems.
    2. I.V Infusion Pumps are devices for automatically delivering IV fluids at a pre selected flow rate. The use of IV infusion pumps is increasing in critical care units. The number of tubing's connections that the pump requires increase the possibility of contamination and subsequent infection. Pumps must be thoroughly cleaned on all surfaces between each patient use.
  2. Total parenteral nutrition (hyper alimentation)
    Total parenteral nutrition is a therapeutic procedure whereby the total body nutritional and fluid requirements are supplied intravenously. Because of the presence of a direct route into the vascular system there are potential complication of sepsis. Practicing strict infection control measures at all stages of administration can reduce the risk of infection.
  3. Wound care—surgical dressing: The dressing serves to protect the wound against contamination. If not carried out aseptically it can itself be a source of infection.
  4. Invasive pressure monitoring: Invasive pressure monitoring devices are increasingly being used in the care of critically ill patients when direct measurement of certain physiological pressures is essential.
    Infection is the main disadvantage observed in pressure monitoring devices. 29Infection at the site of the arterial catheter placement is more common when a surgical cut down is used for placement of the monitoring catheter and the risk of developing a local infection of the catheter site is very high. The risk of septicemia from such infection has also remained high.
    Common causes of infection in invasive pressure monitoring devices
    1. Contamination of transducer.
    2. Local infection at the site of an indwelling catheter.
    3. Re sterilization of disposable transducer.
    4. Contamination of the inter space between the transducer surface and protective closure membrane.
    5. Contamination of the stopcocks and sampling ports.
  5. Tracheostomy care: The patient with tracheotomy is at a risk for acquiring an infection because the tracheostomy establishes a direct line of communication between the environment and broncho pulmonary tree. The normal upper respiratory passage is bypassed and it leaves a higher chance of respiratory infection. Inspired air is normally humidified whereas on tracheostomy it is dry and irritates the mucosa resulting in pulmonary impairment. Added to this the usual impaired immune status of the critically ill patient makes him vulnerable to infections. To prevent infection the tracheostomy site should be cleaned and the inner cannula changed using aseptic technique while using disposable portex tracheostomy. Inner cannula need not be changed but whole set to be changed every 3–4 days.
  6. Suctioning: Suctioning is one procedure done for patients on tracheostomy, mechanical ventilation or airway obstruction. The following infection control measures to be followed while doing suctioning.
    1. Sterile saline solution is used for tracheal lavage and clearing the tubes.
    2. Separate catheters should be used for tracheal suctioning/oral and nasal suctioning.
    3. Suction bottle should be changed every 12 hours or more frequently.
    4. Suction bottle should be washed and resterilized before reuse.
    5. Portable suction should have an exhausted filter.
    6. Washing hands and following aseptic technique is mandatory during procedure.
    7. Tracheostomy and ET tube suctioning catheters to be sterilized or discarded after each use.
    8. Sterile gloves to be worn while suctioning.
  7. Catheterization: The urinary tract is the most common site of nosocomial infection. Mostly due to urinary tract instrumentation such as catheterization. No patient should be catheterized unless it is absolutely necessary. Paying attention to certain factors that give rise to urinary tract infection can minimize the risk of infection. They are:
    • Faulty techniques in which pathogenic organisms are introduced into the bladder as the catheter are inserted.
    • Trauma to the urethral mucosa by forceful insertion of catheter or inflating of balloon when it it still in urethra or removal of catheter without deflating balloon can result in infection as well as serious injury.30
    • Prolonged use of indwelling catheter coupled with inadequate care of it can result in infection.
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.
Procedures for Collecting Specimens for Culture
Blood culture, urine culture, sputum culture, cerebrospinal fluid culture are the usual ones carried out in a critical care unit. Strict aseptic technique is mandatory in carrying out these procedures. Specimen should be sent to the laboratory without any delay.
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.
Illness is an abnormal process in which any aspect of person's functioning is altered as compared to previous level, when an individual's hemodynamics is disturbed. His coping mechanism also fail. There is considerable relationship between the emotional response to illness and adaptation.
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.
Adaptation is the series of responses made by the individual in reaction to stressors. These responses are constant as the individual strives to maintain balance in both internal and external environment. The end results of adaptation are optimal functioning in all dimensions. Stress and adaptation are major components in health and illness and strongly influence nursing care.
Stress is manifested in different ways. The usual responses are:
Anxiety is defined as an uneasy feeling of impending danger. Anxiety is more of an alarm signal than a negative type of stress. In a continuous state it can result in tension and dis equilibrium. Illness threatens ones source of wholeness, containment, security and control. The physiological and behavioral manifestations can be observed and they may vary from individual to individual and are familial and culturally learned. Lot of valuable energy is directed at it. It should be directed to eliminate the stressor. The goal of nursing care is to promote equilibrium, so that the energy could be utilized for healing and recovery.31
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.
Coping with Anxiety
  1. Positive thinking: Patients are encouraged to think positively and verbalize the internal turmoil that is going on. He can be encouraged to talk to others or to speak accurately about himself. Allowing him to participate in decision making can reduce his sense of helplessness.
  2. Relaxation and mental imagery: There are useful techniques to help to reduce their tensions. In this process patient is encouraged to imagine himself in a very pleasant experience. Technique, which induces deep muscle relaxation, can be used in decreasing the anxiety.
Anger is a strong emotional response characterized by feeling such as resentment, dislike, and feeling of vengence when this is directed to the self it is labeled as guilt. Anger is the function of loss or grief. The reltionship between loss and anger is well established. Breakdown of the denial defense mechanism is followed by a stage of anger. Anger is also a component of widely discussed coronary behavior pattern commonly referred to as type A personality. People who possess this type of personality feel angry to themselves and others. They are perfectionists and time and efficiency oriented, when they are faced with inefficiency they explode with anger.
Depression is a stage of mourning marked by low self-esteem. It is a universal finding among patients in critical care units particularly when hospitalization is prolonged. In Mathew M's study in a surgical intensive care unit, it was found that 21.7% of patients where depressed. Depression is manifested as anorexia, or over eating, constipation, loss of 32initiative, decreased energy, lack of pleasure and overall pessimism. The patient should be allowed to grieve providing empathetic support.
Fear is induced in these patients in the critical care unit due to many factors. The very nature of the environment with its complicated machinery produces fear in the patients. It can be fear of the unknown, fear of death, fear of being attached to machines, and fear of being disconnected from the machine. All these can be reduced by an understanding nurse, who takes time to talk to, explain the progress and listen to the patient.
Denial is the refusal to accept the reality of a situation cognitively or affectively. It is the initial human response to loss. The loss may be actual or perceived. Rather than accepting the loss as real they cope with their situation by denying the existence of loss. Denial can be positive coping response to a certain extent. But if the patient continues to deny it can result in fear and depression. Denial of a critically ill patient represents the flight mechanism. Engel reports that the person who responds to loss with feeling of hopelessness and despair are more prone to sudden death.
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.
Nursing Diagnosis
  1. Mobility impaired related to restraints, being hooked to monitors and ventilators.
  2. Alteration in body image related to illness.
  3. Social isolation related to therapeutic management.
  4. Sensory perceptual alteration related to therapeutic environment.
  5. Fear and anxiety related to nature and outcome of illness.
  6. Powerlessness related to loss of control and dependence on others and machines.
  7. Communication impaired.
  8. Coping ineffective-individual.
Nursing Interventions
  • Restrict use of restraints
  • Change positions
  • Employ active listening
  • Provide information
  • Help clarify options
  • Optimize identification and use of resources
  • Regulate sensory stimulation
  • Allow visiting as per CCU rules
  • Return as much control of self and environment to the person as possible
  • Employ relaxation techniques and mental imagery
  • Use touch as a therapeutic device
  • Optimize physiologic functioning
  • Establish optimal and alternate methods of communication
  • Reduce sensory over load
  • Avoid sensory deprivation33
  • Orient them to time, place, date and day
  • Encourage to experience diurnal variation
  • Provide empathetic support.
The environment of critical care unit is complex, life threatening and alien to the patient. The depersonalization of the patient and staff with the ICU dress, use of all kinds of machines and jargons makes the environment vulnerable for the patient. The psychosocial support needed in the critical care units is more demanding than the physical and mechanical. Under such circumstances the nurse needs to take up the role of a negotiator, to the needs of the patient. The most common adverse effects are:
Sensory Overload
The noise produced by the machines, alarms, clicks multiplied with indiscriminate talking and calling out for people all add sensory overload. The bright lights are on for 24 hours of the day without allowing for any diurnal variation. Physical planning can aim at soundproof unit. It is perhaps not feasible to control noise in the critical care units completely. But it is essential that nurses exert a conscious effort to reduce noise in such an environment. There can be dim and bright light and the later can be put off during occasions when it is not necessary to carry out any treatment and procedures especially during night.
Sensory Deprivation
It is variety of symptoms following a reduction in the quantity or the degree or structure or quality of sensory input. Behavioral changes are noted following exposure to sensory deprivation for varying length of time. They include presence of illusions, delusions, hallucinations, loss of sense of time and restlessness. Patients faced with difficulty in coping with illness have an increased susceptibility to severe responses of sensory deprivation. Use of touch as a means of communication can reduce sensory deprivation. A time away from the routines or while carrying out care well spent in talking can mean a lot to the patient. Use of clocks and calendars help orient them to date and time. A concern for creating an environment intended to diminish the effects of sensory deprivation should be developed in any critical care unit. Following are the nursing diagnoses applicable for patients undergoing adverse effects in CCU.
  1. Social isolation related to therapeutic management.
  2. Sensory perceptual alteration related to therapeutic environment.
  3. Powerlessness related to loss of control and dependence on others and machines
  4. Communication impaired.
Patients in critical care units face great amount of stress, which is recognized by all health professionals. Nursing has been identified as a stressful occupation. Health authorities 1988 report in the public sector included nursing as one of the four high stress occupations together with police, social works and teaching (Roger D. Poppy N. 1993).34
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:
  1. Stressors specific to the job or task: This include such things as caring for the dying, violent, patients with multiple injuries, counseling the bereaved.
  2. Role ambiguity: This results from lacks of job clarity and uncertanity about the range of task to be performed.
  3. Role conflict: Results from a series of incompatible demands made by the job.
  4. Work Load: Caused by variations in the amount of work one has to do for example things happening too quickly or not having enough things to do.
  5. Interpersonal relations: Stress levels are high when there is poor interpersonal relationship.
  6. Job conditions: The physical nature of the work place, the type of organization its rules and regulations, can produce stress.
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.
R - Recognition
E - Eye contact
L - Listening
A - Attitude
T - Turn
E - Expression
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.
Short term overindulge in drugs, alcohol, smoking, accidents, impulsive behavior, poor relationship with others, poor work performance.
Long term: Marginal family breakdown, social isolation.36
Short term: Headaches, backache, insomnia, indigestion, chest pain, nausea, dizziness, excessive sweating and trembling.
Long term: Heart disease, hypertension, ulcer, poor general health
Short term: Tiredness, anxiety, boredom, irritability, and depression, lack of concentration low self esteem apathy.
Long terms: Depression, neurosis, nervous break down, suicide.
Transference of Stress
Stress can be transferred between different groups. For example when nurses are stressed the patients and family get worried about the quality of care and make more demands in order to ease their stress which in turn makes the nurse more stressed. Thus a vicious circle is created which can only have a negative contribution to patients well being.
When scientists in Australia measured the crucial role of immune system it was found that the lymphocytes are less responsive to antigens after exposure to prolonged stress. Stress and sickness rates were higher during staff shortage (Cop.) G. 1986.
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:
  • Frequent power failure resulting in non functioning of life saving device
  • Blamed for failures of treatment and death of patient
  • Lack of cooperation among staff
  • Lack of adequate work space37
  • Doctors decision to admit patient to CCU against policy of CCU
  • Frequent duty changes
  • Disagreement with physician over patient care treatment.
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
Measures to Combat Stress in Critical Care Units
In most of the studies, stress appears to be more common in younger less experienced low ranking nurses who spend more time with patients. This brings for the necessity of positive ways to help the younger nurses to cope with stress. Individual differences such as education, past experience, culture and personality type also play a key role in determining stress response.
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.
Other Solutions Proposed
  1. Ensure that nursing staff have time for breaks and meals preferably together which can enhance staff morale.
  2. Provide more time off to minimize the effect of stress.
  3. Provide paid mental health days vacation and sabbaticals.
  4. Lower nurse patients ratio to safe and reasonable level.
  5. Provide sufficient number of competent staff at each shift.
  6. Treat nurses with respect accorded to other health professional.
  7. Discourage pressing staff to work on their off days.39
  8. Incorporate critical care nursing in basic nursing program.
  9. Provide orientation and on the job educational program.
CCU nurses should talk to the patients even if they are not getting any response. This will help them to
  • Emphathize with patients
  • Release their own emotions/stress
  • Create a lively atmosphere.
Nursing Process is a deliberate problem solving approach to the health care and nursing needs of patients. It is a data collecting, decision making process that incorporates evaluation and subsequent modification as feedback mechanisms that promote the ultimate resolution of the patient's nursing diagnosis. American Association of Nursing diagnosis defined nursing process as the diagnosis and treatment of human responses to actual or potential health problems. It is the application of scientific problem solving to nursing care, which is used to identify patient's problems to systematically plan, to implement nursing care and to evaluate the results of care.
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.
Basis for Care in Critical Care Nursing
  1. Maslow's Hierarchy of Needs
  2. Roy's Adaptation Model
Maslow's Hierarchy of Needs
Abraham Maslow divided the human needs into physical and psychosocial needs. Maslow defined five levels of needs physiological well being, physical safety, affection, love and relationship, self-esteem and self-actualization. Basic human needs are met or unmet in many ways. Lower level needs always remain but because there is a reduction in need tension, the person is is able to move to higher level needs. A person's pursuit of higher level needs indicates that he is moving toward psychological health and well being. Such a hierarchy of needs is a useful organizational frame works for assessment of patients strengths, limitations and need for nursing interventions. It is applicable in assessing, planning, implementing and evaluating patient care.
It includes the understanding and acceptance of others in both giving and receiving love and feeling of belonging to others, friends, peers and families, neighborhood and communities. When this needs is not met they feel lonely and isolated. They may withdraw physically and emotionally or they may become overly demanding and critical. These behaviors are a cue that unmet needs are present. Nurses should consider these needs while planning 40care for a patient especially in critical care unit where the visitors are not allowed to enter. Including family and friends in the care of patients is a challenge for a critical care nurse. Establishing a nurse client relationship based on mutual understanding and trust communication and respect for privacy.
Self Esteem Needs
The next highest priority on the hierarchy is self-esteem, the need to feel good about oneself, to feel pride and a sense of accomplishment self esteem gives the individual confidence and independence. Self esteem is affected by many factors when a persons role changes such as loss of job position. It can be seriously affected because responsibilities and relationships have also changed. Other factors, which may affect self-esteem, is body image. Nurses can meet client's self-esteem needs by accepting values and beliefs encouraging clients to set attainable goals and facilitating family support.
Self Actualization
Mallow estimated that only 1% reach self-actualization. It is the need to reach ones potential through full development ones unique capabilities. The process of self-actualization is one that continues throughout life. Maslow lists following qualities when one achieves self-actualization.
  • Acceptance of self and others
  • Focus of interest on problems outside of self-ability to the objective.
  • Feeling of happiness and affection for others.
  • Respect for all persons.
  • Ability to discriminate between good and evil.
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.
Applying Maslow's theory
Maslow's Hierarchy of needs is applicable in assessing and implementing and evaluating client care. Several nursing diagnosis on basic level of needs. It provides for route to holistic care. The Hierarchy of basic needs allows the nurse to place the client on the health illness continuous and to incorporate the health models in meeting the needs in critical care units, as in any other healthcare set up. It can be used with all ages, in all health care setting and in both health and illness. As the nurse identifies and carries out interventions to meet needs he or she must remember that this is only a frame work or guide line and that in actuality each individual persons set priorities and meets needs that are most important to that person. Basic human needs are related and may require nursing actions at more than one level at a given time. In a critical care unit patient is forced to rely much on the nurses to meet even the basic needs. The nurse whose responsibility is to help the patient meet his needs and resolve his problems must recognize the fact that some problems can be neither eliminated nor solved. In relation to such a patient, the nurse's role is to help him to make nature objective, compensatory, mechanisms for the continued existence.41
Roy's Adaptation Model
Sister Callista Roy first published her conceptual model of adaptation in the 1970's. The focus of Roy's model is the set of processes by which a person adapts in a clarified biopsychosocial system in constant interaction with a changing environment. When the demands of environmental stimuli are too great or the person's adaptive mechanism are too low, the person's behavioral responses are ineffective for coping.
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.
zoom view
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.
Steps of Nursing Process
  1. Assessment: Is the foundation of the nursing process accurate date collection leads to identification of the clients health status, which may assist in formulating nursing diagnoses and direction for nursing implementation and alleviation of clients problems. The main focus of data collection is the client's responses to these problems. These responses can be biophysical, psychosocial or spiritual in nature. Thus it is the organized and systematic and purposeful collecting of data about a patient or family's current or future health which is essential to permit grouping or clustering of data for analysis.
Types of Data
Subjective: It is the data of individual view of situation, e.g. pain.43
Objective data: It is observable data. Respiratory rate, Blood pressure, weight edema.
Methods of data collection: Data are collected by means of three methods. Interview, observation and physical measurements.
Interview: Pertinent history is collected. It allows the nurse to acquire specific information required for diagnosis and planning. It facilitates nurse patient relationship. The nurse needs to control the direction of interview. The nurse should use the least amount of authority necessary to obtain the information needed within the time allowed. Subjective data are obtained through effective communication and interviewing skills.
Observations are a process of objectively noting date or cues through the use of sense. Nurse use the senses in many ways to observe the client's characteristics of appearance and function, content and process of interaction and relationship environment.
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.
Documenting data: The recovering of subjective and objective data a facilitated by a format, which allows the nurse to note the sequence and methods. The data may be organized in many ways. It may be entered on a database or a health history or assessment form formulated by agency.
Guidelines for data collection: Systematic format is used for data collection; specific nursing and related models are used as guides for data collection. The data are comprehensive and multifocal. Socio economic, political, biophysical, developmental, cultural and psychological and spiritual influences are taken into consideration while collecting data. A variety of sources such as client, family significant others, health care personnel, printed documents and written records are used. In a critical care nurse may not be able to use the client as a primary source of data as much as in other health care setting owing to the severity or emergency nature of the condition at the time of admission. Appropriate methods are used for data collection. The data are verifiable. The data collected by the use of interview observation and measurement can be substantiated and can be used to validate client's statements. The data collection is a continuous process. Data are recorded and communicated appropriately.
Use of Models for Data Collection
Nursing and related models provide systematic direction for data collection. The major concepts provide categories within which to collect data. The general model of Maslow's Hierarchy of needs and Roys Adaptation Model is used as a basis for data collection in the critical care unit.
Roy's Model
Roy provides a multifocal approach in her first levels of assessment of clients four modes of adaptation. The physiological mode includes 44activity and rest, nutrition, elimination, oxygenation, fluid and electrolytes endocrine function, skin integrity, the senses and neurologic function.
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.
Brief discussion of the Nursing Process concept is done with emphasis for the two models that are used as a basis for data collection in Critical Care Unit. Maslow's hierarchy of needs the general model and Roy's adaptation model the nursing model. Due to the complexity of the critical care unit environment the nurse may not be able carry out the assessment immediately after admission. Priority is given for preservation of life and life saving measures and an assessment and care planning can be carried out after the condition is made stable (see Adult Assessment Format on next page).
Therapeutic Management (NPO status)
Nutrition alteration less than body requirement related to anorexia, critical illness
Defining Characteristics
  • Express inability to eat
  • On NPO
  • Is unconscious in critical state of illness
Nursing intervention
  • Monitor food intake and observe food if patient is able to eat habits
  • Note weight loss or gain encourage fluid intake
  • Maintain favourable eating environment
  • If the patient is not able to eat encourage fluid and nutrients
  • Administer enteral feeds/intravenous fluid/parenteral feeds as ordered
  • Maintain intake and out chart.
Sleep pattern disturbance related to anxiety, confusion, activity rest imbalance
Defining characteristics
  • Does not sleep
  • Shows fatigue
  • Many procedures are done.
Nursing intervention
  • Reduce distractions identify and reduce discomforts such as
  • Noise and anxiety
  • Avoid disturbing patients
  • Take measure to increase safety
  • Provide night lights provide identification bracelet
  • Put up side rails
  • Enhance comfort
  • Avoid the use of restraints as far as possible
  • Design a balanced schedule
  • Administer medication as ordered.
Disturbance in self concept, self esteem, body image, role performance
Defining characteristics
  • Loss of body part
  • Threat to life role change due to admission to ICU.
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Nursing intervention
  • Increase self esteem give positive feedback
  • Help patient identify strength and potentials.
  • Encourage effort toward successfully altering life style
  • Encourage adherence to therapeutic regimen
  • Provide instructions
  • Provide explanations.
Activity intolerance—fatigue related to disease process
Defining characteristics
  • Lethargic, not able to carry out activity due to the critical nature of illness
Nursing intervention
  • Provide rest periods during the day
  • Increase the time of night sleep
  • Rearrange routine activities
  • Encourage use of relaxation techniques
  • Mental imagery
  • Administer blood products as ordered if there is blood loss or reduced
  • Hemoglobin.
Defining characteristics
  • Immobile. On support measures
Nursing intervention
  • Keep the skin clean, dry and free of pressure, irritant
  • Turn patient frequently
  • Lubricate skin with lotion
  • Inspect pressure area for evidence of skin redness and break down.
Grieving related to anticipatory loss
Defining characteristics
  • Critical nature of illness
  • Loss of job
  • Loss of status
  • Financial burden
Nursing intervention
  • Encourage verbalization of fears/concerns/questions regarding disease, treatment and future
  • Encourage active participation of patient and or family visit family frequently to establish/maintain relationship and physical closeness
  • Allow for ventilation of negative feelings
  • Allow for periods of crying and expression of sadness
  • Encourage spiritual support
Alteration in comfort-pain related to disease process, procedures
Defining characteristics
  • Verbalizes pain
  • Facial grimacing +
Nursing intervention
  • Assess pain and discomfort, characterized location, quality, frequency, duration.
  • Reassure that pain is real and care will be taken
  • Assess other factors contributing to pain
  • Administer analgesics to promote optimum pain relief within the order
  • Assess patients behavioral responses to pain and pain experience
  • Collaborate with patient, physician and other health care members
  • Teach new strategies for pain relief such as distraction, imagery, relaxation
Most vital issue in this field of critical care nursing is that of communication. This takes many forms of communication between 49patient and nurse, between nurse and doctor, between patient and relatives. Communication can be of two types, verbal and nonverbal. This chapter explores the issues related to communication in critical care nursing.
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.
Fundamentals of Communication Theory
Communication is a social skill and is learnt through socialization. The environment is where interaction takes place. Exploration is the knowledge derived form both information and transaction theories offer a framework 51from which an understanding of the interrelationship between the components of the communication process may be realized. (French.1987; Pegano and Ragan. 1992; wilmort, 1987).
Information Theory
The four elements of communication are the sender, the message, the transmission channel and the receiver. These elements are linked and may be represented by the communication model given below.
Communication Model
Transmission channel
Decoding process
Makes meaning
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.
The Transational Nature of Communication
In the model above communication process is in a unidirectional fashion. But in many occasions communication is a transactional process in which both participate, play the role of a speaker, listener, observer, encoder, decoder, sender and receiver at the same time and participants affect each other in behavior. The transactional model of communication enables us to focus on the important function of listening, interpreting and giving feedback of checking out accuracy of the interpretations of the message received.
Interpretation and Feedback
The skilled communicator checks the accuracy of the messages given and received through feedback mechanism. This is particularly important for a nurse when communicating with a person who has difficulty in encoding messages due to impairment of brain function and memory loss. A person who is anxious or in high emotional state may have difficulty in expressing.
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.
Interference is anything that will distort or prevent the message being sent or being received. These include the degree of sill of communicator, noise, use of jargon, attitudes, values socialization, physical, mental 52limitations, degree of experience and knowledge relating the message.
Barriers to Effective Communication
Encoding Failure
Problems arise in thought process due to impaired brain function, delirium, memory impairment, brain damage as in hemorrhage or brain injury and emotional factors.
Transmission Failure
The Patient in critical care unit may be intubated or sedated or restricted in movement, for invasive and noninvasive procedures and may be experiencing muscle weakness due to pathophysiology or use of drugs. These will impair the person's ability to speak or communicate.
Channel Interference
Channel interference is due to channel overload or attention overload. That is when two people are speaking at one time or when one is speaking too rapidly.
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.
Perceptual Failure
Impairment of person's ability to receive sensory stimuli may be limited by reduced visual field resulting in lack of eye contact and facial expression. Patient may have functional loss of sight, hearing and loss of touch. Certain drugs may cause perceptual failure such as blurred vision. The extreme sensory impairment is unconsciousness. Auditory sensation returns before motor ability and that is why a critical care nurse communicates verbally and non-verbally with unconscious patient even when he does not show signs of receiving.
Decoding Failure
Receiver may have difficulty in making sense of the message received. It may be difficulty with language or medical technical language that is used. Confusional states, pain, exhaustion and drug therapy may interfere with a person's ability to derive meaning from the message received.
Remedial Action
The skill and ability of the nurse to identify and act on the causes of communication failure will enable communication problems to be minimized. The remedial measures are:-
  • Simplify the message
  • Strengthen the stimuli
  • Change the channel
  • Give feed back.
  • Give support, encouragement and reinforcement.
Verbal Communication
Speech is a unique characteristic of human communication. Complex task of communication is carried out without being aware of what is being done. Words have recognized 53meaning but meaning of a word may change depending on the context of communication.
Nonverbal Communication
It is used subconsciously to express feeling, beliefs, attitudes and emotions. They have the potentials of conveying more than what is being said. Facial movements, gaze, eye contact, gestures, body movements, body posture, touch and body contact are usual modes of nonverbal communication.
Distance is proximity between people gives important signal.
  • Intimate distance 18 inches – Nurse and patient
  • Personal distance 18 inches -, 4 ft. between family and friends
  • Social distance 4 - − 12 ft – professional
  • Pubic distance (12 ft public speaking).
Communication is an important aspect of care in critical care units. Critical care nurse has to develop wide range of skills to carry out effective communication in critical care units. She needs to be aware of the modes of communication and barriers to effective communication so that she can carry out effective communication with patients, family and the other members of the team.
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