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1. Chapter 1
Overview of Critical Care Nursing
Copyright © 2017 Elsevier Inc. All rights reserved.

2. Objectives

1.Define critical care nursing.

2.Describe the evolution of critical care.

3.Discuss the purposes and functions of professional organizations that support
critical care practice.

4.Explain certification options for critical care nurses.

5.Describe standards of professional practice for critical care nursing.

6.Explain the characteristics of critical care nurses.

7.Describe quality and safety initiatives related to critical care nursing.

8.Explain the purpose of evidence-based practice.

9.Describe a healthy work environment.

10.Discuss the need for a collaborative plan of care for the critically ill
patient.

11.Identify current trends and issues in critical care nursing.
Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by
Saunders, an imprint of Elsevier Inc.
2

3. Critical Care Nursing

Deals with human responses to life-threatening
problems (critical illness or injury)

Physiological

Psychological

Focus on both the patient’s and family’s
responses
3Copyright © 2017 Elsevier Inc. All rights reserved.

4. Critical Thinking Challenge
What comes to your mind when you hear the
following terms?

Intensive care

Critical care

ICU and CCU

Trauma
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5. Evolution of Critical Care

Began with polio units (1950s), recovery rooms,
and coronary care units (1960s)

Patient outcomes improved

Intensive Care Units (1970s)
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6. Critical Care in the 21st Century

Specialization

Cardiovascular, neurological, trauma, burn units

Pediatric

Neonatal

Variety of settings

Inpatient

Outpatient

Home care

eICU
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7. Competencies for Acute and
Critical Care Nurses
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8. Professional Organizations

Support critical care nurses and practice

Key organizations

American Association of Critical-Care Nurses

Society of Critical Care Medicine
Copyright © 2017 Elsevier Inc. All rights reserved. 8

9. E.g.:AACN Membership Benefits

Continuing education

Educational scholarships

Research grants

Awards

Student rate for membership

Discounted rate for certification exams
Copyright © 2017 Elsevier Inc. All rights reserved. 9

10. Quick Quiz!
The charge nurse assigns patients based on their
acuity and the level of experience of the critical
care nurses on duty. This is an example of
implementation of:
A.SBAR communication
B.Healthy work environment
C.National patient safety goals
D.Synergy model
Copyright © 2017 Elsevier Inc. All rights reserved. 10

11. Critical Care Certification

Purpose

Validate knowledge

Promote professional excellence

Help nurses to maintain up-to-date knowledge

AACN Certification Corporation oversees CCRN,
CCRN-E, and PCCN certification

Based on AACN synergy model for patient care

Needs of patients and families drive practice
Copyright © 2017 Elsevier Inc. All rights reserved. 11

12. Standards

Guide clinical practice

Establish goals for patient care

Provide assessment of outcomes

AACN Standards for Acute and Critical Care
Nursing Practice

Nursing Process

Expectation of the nurse
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13. Standards of Practice (Bell, 2008)

Evaluate quality of nursing practice

Evaluate own practice

Acquire knowledge and maintain competency

Contribute to professional development of peers

Act ethically

Use skilled communication

Use clinical inquiry and integrate research findings

Consider factors related to safety, effectiveness, and
cost

Provide leadership in clinical setting
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14. Trends and Issues

Critical care patients more complex

Multisystem organ dysfunction

Complicated by aging population

Increasing costs for care

Challenged to reduce costs and length of stay

Transfer of higher acuity patient from the critical care
unit to other units or home
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15. Critical Care Nurse Characteristics

Technical competence

Relationship building

Ability to multitask and set priorities
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16. Critical Thinking Challenge

Discuss strategies for reducing or preventing
stress and burnout in critical care nurses.
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17. Focus on Quality and Safety

Errors and harm must be prevented

Nurses are challenged to reduce errors and
promote a safe environment

Several initiatives

The Joint Commission National Patient Safety Goals

Institute for Healthcare Improvement

Quality and Safety Education for Nurses (QSEN)
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18. National Patient Safety Goals

The Joint Commission National Patient Safety
Goals

Examples relative to critical care nursing
•
Communication
•
Medication safety
•
Reduce infections
•
Reconcile medications
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19. Harms Targeted for Reduction

Adverse drug events

Infections

Catheter-associated urinary tract infections (CAUTI)

Central line–associated bloodstream infections (CLABSI)

Surgical site infections

Ventilator-associated pneumonia (VAP)

Injuries from falls and immobility

Obstetric adverse events

Pressure ulcers

Venous thromboembolism (VTE)
Copyright © 2017 Elsevier Inc. All rights reserved. 19

20. Importance of Evidence-Based
Practice

Implement practice based on evidence

Evaluate research

Hierarchy of evidence
Copyright © 2017 Elsevier Inc. All rights reserved. 20

21. AACN Hierarchy of Evidence
Copyright © 2017 Elsevier Inc. All rights reserved. 21

22. Quick Quiz!
During report using SBAR, the nurse states, “Since
we have just initiated a potassium replacement
protocol, the patient will need a potassium level
drawn at 1300.” This depicts:
A.Situation
B.Background
C.Assessment
D.Recommendation
Copyright © 2017 Elsevier Inc. All rights reserved. 22

23. Communication

Communication important for safe care

Much information derived from airlines

Crew resource management

Barriers to Effective Handoff Communication

Standardized approaches

SBAR and SBAP
•
Situation
•
Background
•
Assessment
•
Recommendation (Plan)
Copyright © 2017 Elsevier Inc. All rights reserved. 23

24. Collaboration

Create a culture of safety where everyone works
together

Mutual respect

Mutual recognition

Aim during multiprofessional daily rounds at the
bedside

Briefings are another approach
Copyright © 2017 Elsevier Inc. All rights reserved. 24

25. Quick Quiz!
Which of the following is a component of a healthy
work environment?
A.Collaboration
B.Use of many agency nurses
C.Crew-resource training
D.Evidence-based practice
Copyright © 2017 Elsevier Inc. All rights reserved. 25

26. Other Trends and Issues

Reducing hospital readmission rates

Increasing use of technology

Electronic medical records

Physician order entry

Ethical issues associated with prolonging life
and futile treatment

Telemedicine and eICU
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27. Trends and Issues (Cont.)

Aging population

Transfer of patients from the critical care unit
while still acute

Aging workforce
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28. Trends and Issues (Cont.)

Shortage of critical care nurses

Importance of recruitment, orientation, and retention

Ongoing debate about hiring new graduates to work
in critical care units
Copyright © 2017 Elsevier Inc. All rights reserved. 28

29. Chapter 2
Patient and Family Response to the Critical
Care Experience
Copyright © 2017 Elsevier Inc. All rights reserved.

30. Objectives

1. Describe stressors in the critical care environment
and strategies to reduce them.

2. Discuss the impact of critical care hospitalization on
the patient and family.

3. Describe common family needs and family-centered
nursing interventions.

4. Identify strategies for promoting visitation and
family presence in the critical care setting.
Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by
Saunders, an imprint of Elsevier Inc.
30

31. Introduction

Nurses play a unique role in addressing the
needs of patients and families in a busy and
complex environment
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32. Critical Thinking Challenge

Think about the critical care environment:

How would you describe the ICU?

What sights, sounds, and smells do you experience?

What sensations might you experience?

How would your family react to the situation?
Copyright © 2017 Elsevier Inc. All rights reserved. 32

33. Critical Care Environment

Designed for efficient, lifesaving interventions

Patients and families often have little advance
preparation for the environment

Stress

Anxiety
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34. Sensory Overload

Light

Noise

Loss of privacy

Multiple caregivers

Multiple people in and out of unit and room

Lack of nonclinical physical contact

Emotional and physical pain
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35. Sensory Deprivation

Increased perceptual disturbances

Treatment

Visitors

Photos

Soothing music

Lighting
Copyright © 2017 Elsevier Inc. All rights reserved. 35

36. Quick Quiz!
Which device or activity is associated with the
highest noise level?
A.Call bell
B.Pneumatic tube arrival
C.Telephone ringing
D.Television
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37. Modification of Environment

Noise reduction

Acoustical tiles/designs

Soothing music

Private areas for communication between caregivers
and with family members

Adequate lighting

Natural lighting

Night-day synchronization

Design of new units to promote health and
safety
Copyright © 2017 Elsevier Inc. All rights reserved. 37

38. Quick Quiz!
Which is associated with high levels of noise in the
critical care unit?
A.Alcohol withdrawal syndrome
B.Hypotension
C.Normal oxygen saturation
D.Sleep disruptions
Copyright © 2017 Elsevier Inc. All rights reserved. 38

39. The Critically Ill Patient

Patient responses vary according to:

Age

Developmental stage

Prior illness or hospitalization experience

Family relationships and social support

Coping mechanisms

Beliefs about life and death

Spirituality

Cultural considerations
Copyright © 2017 Elsevier Inc. All rights reserved. 39

40. Top Stressors

Pain

Inability to sleep

Financial
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41. Patients’ Recall About Critical Care

Difficult
communication

Pain

Thirst

Difficulty swallowing

Anxiety

Lack of control

Depression

Fear

Lack of family

Feelings of dread

Discomfort

Difficulty sleeping

Loneliness

Thoughts of dying

Physical restraint
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42. How Would You Feel if This Were
Your Family Member?
Copyright © 2017 Elsevier Inc. All rights reserved. 42
Figure 2-1.If you were the family member and your loved one was this patient,
how would you feel when you saw this situation? (Reprinted with permission,
Cleveland Clinic Center for Medical Art & Photography © 2011-2016. All rights
reserved.)

43. Psychosocial Support

Ensure safety

Reduce sleep deprivation

Reduce noxious sensory overload

Increase pleasant sensory input

Provide reorientation
What are strategies to achieve these goals?
Copyright © 2017 Elsevier Inc. All rights reserved. 43

44. Quality of Life After Critical Care

Discharge from critical care can be difficult for
patients and families

Relocation stress

Fear of abandonment

New routines

New staff

New roommates

Prepare patients and family members for
transfer from the unit
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45. Quality of Life After Critical Care
(Cont.)

Post–critical care symptoms

Fatigue, sleep disturbance

Pain, muscle weakness

Poor concentration, impaired memory

Poor appetite

Posttraumatic stress disorder may develop in
patients or families
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46. Geriatric Concerns

Diminished ability to adapt to, or cope with,
stressors of critical illness

Prolonged length of stay

At greater risk for negative outcomes

Increased mortality

Functional decline

Decreased health-related quality of life
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47. Family Members

Critical illness/injury affects the whole family

Uncertainty

Loss of control
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48. Family Needs

Receiving assurance

Remaining near the patient

Receiving information

Being comfortable

Having support available
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49. Care for the family

Family Bundle(EPICS)

Evaluate

Plan

Involve

Communicate

Support
(From Knapp S. Effects of an Evidence-Based Intervention on Stress and
Coping of Family Members of Critically Ill Trauma Patients: Unpublished
Dissertation, University of Florida, Orlando, Florida; 2009.)
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50. VALUE Mnemonic

Value what the family tells you

Acknowledge family emotions

Listen to family members

Understand the patient as a person

Elicit questions from family members
From Lautrette A, Darmon M, Megarbane B, et al. A communication strategy
and brochure for relatives of patients dying in the ICU. New England Journal of
Medicine. 2007;356(5):469-478.
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51. Unique Approach
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Figure 2-2.EPICS family bundle. (From Knapp S. Effects of an Evidence-based
Intervention on Stress and Coping of Family Members of Critically Ill Trauma Patients.
Unpublished Dissertation, University of Central Florida, Orlando, Florida; 2009.)

52. Family Interventions

Communication

Facilitate visitation

Encourage family involvement in patient care

Consider family presence during procedures
Copyright © 2017 Elsevier Inc. All rights reserved. 52

53. Quick Quiz!
Being present during a code can assist family
members in:
A.Determining the need for a lawsuit
B.Documenting care that was provided
C.Taking a photo of the family member
D.Witnessing that everything has been done
Copyright © 2017 Elsevier Inc. All rights reserved. 53

54. Critical Thinking Challenge

Who should visit the patient?

How can visitation be facilitated?

What factors support family presence during
procedures and resuscitation?
Copyright © 2017 Elsevier Inc. All rights reserved. 54