CRITICAL CARE

NURSING

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CRITICAL

Crucial
Crisis
Emergency
Serious
Requiring immediate action
Thorough and constant observation
Total dependent
(Oxford Dictionary)

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CRITICAL CARE NURSING

The care of seriously ill clients from point of injury or illness until
discharge from intensive care

Deals with human responses to life threatening problems -trauma

/major surgery
(Mary,L.S., Deborah, G.K. & Marthe, J.M. 2005)

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CRITICAL CARE NURSE

care for clients who are very ill

provide direct one to one care
Responsible for making life-and death decision
At high risk of injury or illness from possible
exposure to infections
Communication skill is of optimal importance

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CRITICALLY ILL CLIENT

At high risk for actual or potential life-threatening health problems

More ill
Required more intensive and careful nursing care

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6
 DEFINITIONS

CRITICAL CARE :
CRITICAL CARE IS A TERM USED TO
DESCRIBE AS THE CARE OF PATIENTS
WHO ARE EXTREMELY ILL AND WHOSE
CLINICAL CONDITION IS UNSTABLE OR
POTENTIALLY UNSTABLE.

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CRITICAL CARE UNIT :
IT IS DEFINED AS THE UNIT IN WHICH
COMPREHENSIVE CARE OF A CRITICALLY
ILL PATIENT WHICH IS DEEMED TO
RECOVERABLE STAGE IS CARRIED OUT.

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CRITICAL CARE NURSING :
IT REFERS TO THOSE COMPREHENSIVE,
SPECIALIZED AND INDIVIDUALIZED
NURSING CARE SERVICES WHICH ARE
RENDERED TO PATIENTS WITH LIFE
THREATENING CONDITIONS AND THEIR
FAMILIES.

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Critical Care Technology

ECG monitoring Temperature

Arterial Lines Pulmonary Artery Catheter
Oxygen Saturation IABP
Ventilation Extensive use of
Intracranial Pressure Monitoring pharmaceuticals

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The Critical Care Nurse

Specialty dealing with human responses to life-threatening

problems
Requires Extensive Knowledge and a Continual Desire to Learn

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Economic Impact of ICU (1994)
* <10% of hospital beds
* 30% of acute care hospital cost
* >20% of hospital budget
* 1% of GNP expended for ICU care

With aging of the population

Demand for critical care service will increase

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Historical Background

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World War II

Shock wards established

for resuscitation
Transfusion practices in
early stages
After World war-II,
nursing shortage forced
grouping of
postoperative patients in
recovery areas

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Polio epidemic

1950s: use of mechanical

ventilation (iron lung) for
treatment of polio
Development of respiratory
intensive care units
At the same time, general
ICUs developed for sick and
postoperative patients

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History Continued

Collaboration between nurses and physicians

1950s & 1960s CV Disease most common diagnosis
1960s 30-40% mortality rate for MI
1965 1st specialized ICU The Coronary Care Unit
Emergence of Specialized ICUs

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1957

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 ICUs also treat the dying
Isaac Asimov: Life is pleasant.
Death is peaceful. It is the
transition that is difficult

Isaac Asimov: Professor of Biochemistry Boston 18

American Association of Critical-Care
Nurses - AACN
1969 Research
Educational support Publishes 2 journals
Certification Local chapters
Largest professional specialty Political awareness
nursing organization Provides standards of practice
Scholarships

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An Ideal ICU

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Multidisciplinary & Collaborative approach to
ICU care

Medical & nursing directors :

co-responsibility for ICU management
a team approach :
doctors, nurses, R/T, pharmacist
use of standard, protocol, guideline
consistent approach to all issues
dedication to coordination and communication for all
aspects of ICU management
emphasis on research, education, ethical issues,
patient advocacy

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Team Dynamics

A multidisciplinary team to effectively attain specified objective

Physician team leader & critical care nurse manager

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Critical Care Practice Pattern

Open
Closed
transitional

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Open Units

Definition :
any attending physician with hospital admitting
privileges can be the physician of record and direct
ICU care. (All other physicians are consultants)

Disadvantage :
lack of a cohesive plan
Inconsistent night coverage
Duplication of services

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Closed Units
Definition:
An intensivist is the physician of record for ICU
patients. (other physicians are consultants), All
orders & procedures carried out by ICU staff
advantage:
improved efficiency
standardized protocol for care
disadvantage:
potential to lock out private physician
increase physician conflict

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 Transitional Units
Definition:
intensives are locally present shared co-managed
care between ICU staff and private physician
ICU staff is a final common pathway for orders and
procedures
Advantage:
reduce physician conflict, standard policies and
procedures usually present
Disadvantage:
confusion and conflict regarding final authority &
responsibilities for patient care decision
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 ICU Model Care
Full-time intensivist model :

patient care is provided by an intensivist

Consultant intensivist model :
an intensivist consults for another physician to coordinate
or assist in critical care, but dose not have primary
responsibility for care
Multiple consultant model:
multiple specialists are involved in the patient care, (esp.
R/T doctors for ventilators), but none is designated
especially as the consultant intensivist
Single physician model :
primary physician provides all ICU care
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A Good ICU

Well organized
trust
coordinated care
Full-time intensivist: daily round
protocol & policies (eg: how to DC elective
operation when bed not available)
bedside nurses (master degree)
no intern

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A Good ICU

A team:
doctors, nurses, R/T, pharmacists
led by full time intensivists
critical care trained
available in a timely fashion (24hr/day)
no competiting clinical responsibilities
during duty
closed units, if resources allow

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 What are the conditions considered as
Critical?

1. ANY PERSON WITH LIFE THREATENING

CONDITION
2. PATIENTS WITH :
ARF
AMI
CARDIAC TAMPONATE
SEVERE SHOCK

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 HEART BLOCK
ACUTE RENAL FAILURE
POLY TRAUMA, MULTIPLE ORGAN
FAILURE AND ORGAN DYSFUNCTION
SEVERE BURNS

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 NURSING ASSESSMENT

IT IS THE FIRST STAGE OF NURSING PROCESS IN WHICH THE NURSE

SHOULD CARRY OUT A COMPLETE AND HOLISTIC NURSING ASSESS-
MENT OF EVERY PATIENTS NEEDS, REGARDLESS OF THE REASON FOR
THE ENCOUNTER.

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 COMPONENTS OF NURSING ASSESSMENT

1. NURSING HISTORY: Taking a nursing history prior to the

physical examination allows a nurse to establish a rapport
with the patient and family.

Elements of the history include

Health Status
Cause of present illness including symptoms
Current management of illness
Past medical history including familys medical history

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 Social history
Perception of illness
2. Psychological and Social Examination-
Clients perception
Emotional health
Physical health
Spiritual health
Intellectual health
3. Physical Examination : A nursing assessment
includes physical examination, where the observation
or measurement of signs, which can be observed or
measured, or symptoms such as nausea or vertigo,
which can be felt by the patient.

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 The techniques used may include Inspection, Palpation,
auscultation and Percussion in addition to the vital
signs like temperature, pulse, respiration , BP and
further examination of the body systems such as the
cardiovascular or musculoskeletal systems.

Documentation of Assessment: The Assessment is

documented in the patients medical or nursing
records, which may be on paper or as part of the
electronic medical record which can be assessed by all
members of the health care team.

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 CLASSIFICATION OF CRITICAL CARE UNITS

LEVEL - I :
PROVIDES MONITORING, OBSERVATION
AND SHORT TERM VENTILATION. NURSE
PATIENT RATIO IS 1:3 AND THE MEDICAL
STAFF ARE NOT PRESENT IN THE UNIT
ALL THE TIME.

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LEVEL - II :
PROVIDES OBSERVATION, MONITORING
AND LONG TERM VENTILATION WITH
RESIDENT DOCTORS. THE 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.

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LEVEL - III :
PROVIDES ALL ASPECTS OF INTENSIVE
CARE INCLUDING INVASIVE
HAEMODYNAMIC MONITORING AND
DIALYSIS. NURSE PATIENT RATIO IS 1:1

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CLASSIFICATION OF CRITICAL CARE PATIENTS

Level O : normal ward care

Level 1: at risk of deteriorating , support from critical care team
Level 2 : more observation or intervention, single failing organ or
post operative care
Level 3; advanced respiratory support or basic respiratory support
,multiorgan failure

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HIGH DEPENDENCY CARE

Coronary care units (CCU)

Renal high dependency unit (HDU)
Post-operative recovery room
Accident and emergency departments (A&E)
Intensive care units (ICU)

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 TYPES OF CRITICAL CARE UNIT

NEONATAL INTENSIVE UNIT (NICU)

SPECIAL CARE NURSERY (SCN)
PAEDIATRIC INTENSIVE CARE UNIT
(PICU)
PSYCHIATRIC INTENSIVE UNIT (PICU)

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CORONARY CARE UNIT (CCU)

CARDIAC SURGERY INTENSIVE CARE

UNIT (CSICU)
CARDIOVASCULAR INTENSIVE CARE UNIT
(CVICU)
MEDICAL INTENSIVE CARE UNIT (MICU)
MEDICAL SURGICAL INTENSIVE CARE
UNIT (MSICU)

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OVERNIGHT INTENSIVE RECOVERY (OIR)
NEUROSCIENCE / NEUROTRAUMA
INTENSIVE CARE UNIT (NICU)
NEURO INTENSIVE CARE UNIT (NICU)
BURN INTENSIVE CARE UNIT (BNICU)

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SURGICAL INTENSIVE CARE UNIT (SICU)
TRAUMA INTENSIVE CARE UNIT (TICU)
SHOCK TRAUMA INTENSIVE CARE UNIT
(STICU)
TRAUMA NEURO CRITICAL CARE
INTENSIVE CARE UNIT (TNCC)

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RESPIRATORY INTENSIVE CARE UNIT
(RICU)
GERIATRIC INTENSIVE CARE UNIT (GICU)

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Types of ICU

General
Medical Intensive Care Unit(MICU)
Surgical Intensive Care Unit
Medical Surgical Intensive Care Unit(MSICU)

Specialized
Neonatal Intensive Care Unit(NICU)
Special Care Nursery(SCN)
Paediatric Intensive Care Unit(PICU)
Coronary Care Unit(CCU)
Cardiac Surgery Intensive Care Unit(CSICU)
Neuro Surgery Intensive Care Unit(NSICU)
Burn Intensive Care Unit(BICU)
Trauma Intensive Care Unit

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 PRINCIPLES OF CRITICAL CARE NURSING

ANTICIPATION : 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 is properly organized in which all necessary
equipments and supplies are mandatory for smooth running of the
unit.

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EARLY DETECTION AND PROMPT
ACTION :
The prognosis of the patient depends on the early detection of
variation, prompt and appropriate action to prevent or combat
complication. Monitoring of cardiac respiratory function is of prime
importance in assessment.

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COLLABORATIVE PRACTICE :
Critical Care, which has originated as technical sub-
specialized body of knowledge has evolved into a
comprehensive discipline requiring a very specialized
body of knowledge for the physicians and nurses
working in the critical care unit fosters a partnerships for
decision making and ensures quality and compassionate
patient care. Collaborate practice is more and more
warranted for critical care more than in any other field.

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COMMUNICATION :

Intra professional, inter departmental and inter personal

communication has a significant importance in the smooth running of
unit. Collaborative practice of communication model

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Prevention of Infection : 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 immunocompromised
state with the antibiotic usage and stress, invasive lines,
mechanical ventilators, prolonged stay and severity of
illness and environment of the critical unit itself.

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Crisis Intervention and Stress Reduction :
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 patttern and provide avenues for positive coping.

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 ORGANIZATION OF ICU

DESIGN OF ICU :
1. Should be at a geographically distinct area within
the hospital, with controlled access.
2. There should be a single entry and exit. However, it
is required to have emergency exit points in case of
emergency and disaster.
3. There should not be any through traffic of goods or
hospital staff. Supply and professional traffic should
be separated from public/visitor traffic.

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4. Safe, easy, fast transport of a critically sick pt should
be a priority in planning its location. Therefore, the
ICU should be located in close proximity or ER, OT,
trauma ward etc.
5. Corridors, lifts and ramps should be spacious enough
to provide easy movement of bed/trolley of a critically
sick patient.
6. Close, easy proximity is also desirable to diagnostic
facilities, blood bank, pharmacy etc.
BED STRENGTH:
1. It is recommended that total bed strength in ICU
should be between 8-12 and not less than 6 or not
more than 24 in any case.

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2. 3-5 beds per 100 hospital beds for a Level III ICU or 2
to 20% of the total no of hospital beds.
3. 1 isolation bed for every ICU beds.

BED AND ITS SPACE:

1. 150-200 sq.ft per open bed with 8 ft in between beds.
2. 225-250 sq.ft per bed if in a single room.
3. Beds should be adjustable, no head board, with side
rails and wheels.
4. Keep bed 2 ft away from head wall.

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 ACCESSORIES:
1. 3 O2 outlets, 3 suction outlets (gastric, tracheal and
underwater seal), 2 compressed air outlets and 16
power outlets per bed.
2. Storage by each bedside.
3. Hand rinse solution by each bedside.
4. Equipment shelf at the head end.
5. Hooks and devices to hang infusions/ blood bags,
extended from the ceiling with a sliding rail to
position.
6. Infusion pumps to be mounted on stand or poles.
7. Level II ICUs may require multi channel invasive
monitors.
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8. ventilators, infusion pumps, portable X ray unit, fluid
and bed warmers, portable light, defibrillators,
anaesthesia machines and difficult airway
management equipments are necessary.
STAFFING :
1. Medical Staff the best senior medical staff to be
appointed as an Intensive Care Director or Intensivist.
Less preferred are other specialists from anaesthesia
/ medicine who has clinical commitment elsewhere.
Junior staff are intensive care trainers and trainees on
deputation from other disciplines.
2. Nursing staff The major teaching tertiary care ICU
requires trained nurses in critical care.

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 The no of nurses ideally required for such unit is 1:1
ratio, however it might not be possible to have such
members in our set up. So 1 nurse for 2 patients is
acceptable. The no of trained nurses should also be
worked out by the type of ICU, the workload and work
statistics and type of patient load.
3. Allied Services Respiratory services, Nutritionist,
Physiotherapist, Biomedical engineer, technicians,
computer programmer, clinical pharmacist, social
worker / counsellor and other support staff, guards and
grade IV workers.

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 CRITICAL CARE NURSE

Factors to be considered in recruiting Critical Care Nurses

are:

1. Intra and interpersonal factors

2. Technical Qualifications.
3. Educational background
4. Clinical Experience.

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 Continuous monitoring
Keep ready emergency trolley / crash
Cart
Efficient Individualized Care.
Counseling and information to family.
Application of policies and procedures
Proper records of all activities
Maintain infection control principles.
Keep update with advance
information. 60
QUICK REFERENCE PROTOCOL FOR MANAGING
EMERGENCY IN ICU

Quickly review the patient - Identity,

History , Physical Exam.
Be with the patient, ask for help.
Place the patient in a suitable position.
Attach the cardiac monitor and call for
crash cart.
Maintain ABC Along with expert team
Introduce IV, CV line

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 Administer medication as needed.
Carry on Investigations - ABG, ECG,
Urea, Creatinine, Blood Sugar,
Cardiac enzymes.
Maintain Fluid and Electrolytes .
Record right things at right time
rightly.

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Core Competencies

Patient Care
Medical Knowledge
Professionalism & Ethics
Interpersonal Communication Skills
Practice-based Learning and Improvement
Systems-based Practice

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 Evaluation of ACCP Board
Procedure Log Books
Monthly Evaluations

In Training Exams

Review Lectures

Error Reporting

QI PROJECTS
Tauma MAn

FCCS

THCI
Patient Care X X X X X X X X

Medical Knowledge X X X X X X X

Practice Based Learning and Improvement X X X X

Interpersonal and Communication Skills X X X

Professionalism X X X X

Systems-Based Practice X X X X

Prof. Dr. R S Mehta, BPKIHS 64

Family Need of the Critical Care Patient

Information major source of anxiety and litigation (legal issues)

Reassurance can reassure care is being given
Convenience access to the patient

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 Job description
Patient care
Multidisciplinary rounds
Bed allocation/triage
Infection control
Protocol development
Quality control/assurance
Education
Residents, fellows, med students, nurses, respiratory therapists, nurse
practitioners
Research
Quality assurance projects
Clinical trials
Database-driven projects

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General Concept, Setting and
Principle of Critical Care
Nursing

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Who are critically ill patient?

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 Critical illness are grouped by the system of the body;
A. Cardiac System
1. Acute myocardial infarction with complications
2. Cardiogenic shock
3. Complex arrhythmias requiring close monitoring and intervention
4. Acute congestive heart failure with respiratory failure and/or
requiring hemodynamic support
5. Hypertensive emergencies
6. Unstable angina, particularly with dysrhythmias, hemodynamic
instability, or persistent chest pain
8. Cardiac tamponade or constriction with hemodynamic instability
9. Dissecting aortic aneurysms
10. Complete heart block

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B. Pulmonary System .
1. Acute respiratory failure requiring ventilatory support
2. Pulmonary emboli with hemodynamic instability
3. Massive hemoptysis

C.Neurologic disorder
1. Intracranial hemorrhage
2. Meningitis with altered mental status or respiratory compromise
3. Central nervous system or neuromuscular disorders with
deteriorating neurologic or pulmonary function
4. Status epilepticus
5. Severe head injured patients

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D. Drug Ingestion and Drug Overdose
1. Hemodynamically unstable drug ingestion
2. Drug ingestion with significantly altered mental status with
inadequate airway protection
3. Seizures following drug ingestion

E. Gastrointestinal Disorders
1. Life threatening gastrointestinal bleeding including hypotension,
angina, continued bleeding, or with comorbid conditions
2. Hepatic failure
3. Severe pancreatitis

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F. Endocrine
1. Diabetic ketoacidosis complicated by hemodynamic
instability, altered mental status, respiratory insufficiency,
or severe acidosis
2. Severe hypercalcemia with altered mental status,
requiring hemodynamic monitoring
3. Hypo or hypernatremia with seizures, altered mental
status
4. Hypo or hypermagnesemia with hemodynamic
compromise or dysrhythmias
5. Hypo or hyperkalemia with dysrhythmias or muscular
weakness
6. Hypophosphatemia with muscular weakness

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G. Surgical
1. Post-operative patients requiring hemodynamic
monitoring/ventilatory support or extensive nursing care

H. Miscellaneous
1. Septic shock with hemodynamic instability
2. Hemodynamic monitoring
3. Environmental injuries (lightning, near drowning,
hypo/hyperthermia)

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Admission Criteria in ICU
The ICU admission decision may be based on
several models utilizing prioritization, diagnosis,
and objective parameters models.

A. Prioritization Model
This system defines those that will benefit most
from the ICU (Priority 1) to those that will not
benefit at all (Priority 4) from ICU admission.

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Priority 1:

These are critically ill, unstable patients in need of

intensive treatment and monitoring that cannot be
provided outside of the ICU. Usually, these treatments
include ventilator support, continuous vasoactive drug
infusions. Examples of these patients may include
post-operative or acute respiratory failure patients
requiring mechanical ventilatory support and shock or
hemodynamically unstable patients receiving invasive
monitoring and/or vasoactive drugs.

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Priority 2:

These patients require intensive monitoring and may potentially need

immediate intervention. Examples include patients with chronic
comorbid conditions who develop acute severe medical or surgical
illness.

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 Priority 3: These unstable patients are critically ill but have a reduced
likelihood of recovery because of underlying disease or nature of their
acute illness. Examples include patients with metastatic malignancy
complicated by infection, cardiac tamponade, or airway obstruction.

Priority 4: These are patients who are generally not appropriate for
ICU admission. Admission of these patients should be on an individual
basis, under unusual circumstances and at the discretion of the ICU
Director. These patients can be placed in the following categories:

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B. Diagnosis Model
This model uses specific conditions or diseases to determine
appropriateness of ICU admission.
(described above in critically ill patient)

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C. Objective Parameters Model
Vital Signs
Pulse < 40 or > 150 beats/minute
Systolic arterial pressure < 80 mm Hg or 20 mm Hg below the patient's usual
pressure
Mean arterial pressure < 60 mm Hg
Diastolic arterial pressure > 120 mm Hg
Respiratory rate > 35 breaths/minute

Laboratory Values (newly discovered)

Serum sodium < 110 mEq/L or > 170 mEq/L
Serum potassium < 2.0 mEq/L or > 7.0 mEq/L
PaO2 < 50 mm Hg pH < 7.1 or > 7.7
Serum glucose > 800 mg/dl
Serum calcium > 15 mg/dl
Toxic level of drug or other chemical substance in a hemodynamically or
neurologically compromised patient

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Radiography/Ultrasonography/Tomograp
hy (newly discovered)
Cerebral vascular hemorrhage, contusion or subarachnoid hemorrhage
with altered mental status or focal neurological signs
Ruptured viscera, bladder, liver, esophageal varices or uterus with
hemodynamic instability
Dissecting aortic aneurysm

Electrocardiogram
Myocardial infarction with complex arrhythmias, hemodynamic
instability or congestive heart failure
Sustained ventricular tachycardia or ventricular fibrillation
Complete heart block with hemodynamic instability

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 Physical Findings (acute onset)
Unequal pupils in an unconscious patient
Burns covering > 10% BSA
Anuria
Airway obstruction
Coma
Continuous seizures
Cyanosis
Cardiac tamponade

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 Team of Critical Care Unit

Physicians.
The Most Responsible Physician (MRP) is the physician in charge of the patients care
during the current hospitalization. He or she communicates with other members of the
team on a daily basis.
Nurses
Intensive Care nurses are the minute-to-minute critical care providers. They not only
help to provide, but also coordinate most aspects of care delivery. They have received
specialized training in caring for critically ill patients.
Respiratory Therapists
Respiratory therapists have special training and experience in caring for patients with
breathing problems. They work closely with the physician to develop a plan to support
a patients breathing. They set up, monitor and maintain the breathing machines
(mechanical ventilators), and they adjust these machines minute by minute and hour by
hour to best meet the patient's needs.

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Pharmacists
Pharmacists consult with the physician in selecting the right medicines at the
correct dose for patients and also in monitoring drug levels in the body.
Pharmacists also help to decrease medication side effects and provide valuable
information to the team members.

Physical Therapist
They help prevent disabilities and facilitate rehabilitation as soon as possible.

Dieticians
Dieticians calculate the nutritional needs of the critically ill patient and consult
with the physician to provide the patient with the best possible diet, whether
orally or through a feeding tube.

Medical Radiation Technologist

Medical Laboratory Technologist

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 Trauma Coordinator
The Trauma Coordinator reviews the plan of care for each trauma patient and in
consultation with the ICU Care Team, makes suggestions regarding patient needs. She
also works closely with the patient and family, and provides teaching and information
to the patient and family about the patients progress and expected outcomes.
Social Worker
Social workers provide professional assistance with the needs of patients and families.
They can help to assess and determine what resources patients and families might be
lacking, providing them with information on agencies to assist with various needs and
generally assisting with other family difficulties.
Clinical Educator
Clinical Educators are nurses who provide ongoing education for ICU nurses on new
practices, protocols and on new equipment. They are up-to-date with the best practices
in ICU and communicate with the Manager and with ICU nurses about all aspects of
nursing practice and education. As an important part of their role, they provide a
comprehensive orientation to nurses new to the ICU Care Team as well as providing
continuing advice, support and education for all nurses in ICU.

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Ward Clerk
ICU Ward Clerks help with communication by answering the phones, processing
physician orders and coordinating some of the patient activities in the ICU.

Pastoral Care
Chaplains are available to minister to the spiritual needs of patients and
families.

Manager
Nurse Managers are nurses with additional experience and education, who are
responsible for the day to day operations of the ICU. In addition to managing the
ICU nursing staff, the ICU Nurse Manager is responsible for the ICU budget and
nursing practices. Nurse Managers are responsible for ensuring that the care in
the ICU is safe. She/he hires ICU nurses and ensures that all nursing staff
members meet the standards established for their performance. She is also there
to assist family members with their needs.

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Thank you

86
 ICU & CCU Services
Nursing Care and Protocols

Prof. Dr. R S Mehta, BPKIHS 87

Critical Care Considerations
F=Feeding/fluid
A=Analgesics
S=Sedation
T=Thrombolytic agents
H=Head elevation
U=Ulcer bed sore
G=Glucose monitoring

Prof. Dr. R S Mehta, BPKIHS 88

Feeding and Fluids

It includes
Enteral feeding
o Oro - gastric and Naso - gastric feeding
o Churn diet
o Dairy and poultry products (Milk, egg, youghort)
o High protein liquid diet
o Medications

Prof. Dr. R S Mehta, BPKIHS 89

 Oral feeding
o Hospital diet
o Bland diet
o Normal diet
o Liquid intake

Prof. Dr. R S Mehta, BPKIHS 90

 Transparenteral diet
o Oliclinomel
Includes:-
Amino acid solution with electrolyte (5.5%) volume 800 ml
Amino acid 44 gram
Na acetate
Na glycerophosphate
KCl

Prof. Dr. R S Mehta, BPKIHS 91

 MgCl2
Sodium
Magnesium
PO4
Acetate
Chloride
Glucose 20% solution with CaCl2

Prof. Dr. R S Mehta, BPKIHS 92

Overall volume of TPN = 2000 ml
Osmolarity = 75 mOsm/L
pH = 6
Amino acid = 44 gram
Total calorie = 1,215 Kcal

Prof. Dr. R S Mehta, BPKIHS 93

Fluids
IV fluids like NS, RL, 5% D, 10% D, DNS

Prof. Dr. R S Mehta, BPKIHS 94

Analgesics

Fentanyl
o It works 600 times more effectively than Morphine and reduces the pain and
increases the pain threshold
o Used in moderate and severe pain
o In ICU 50 100 g per Kg
o Antidote Naloxone 0.05 mg/ Kg

Prof. Dr. R S Mehta, BPKIHS 95

Morphine
o Reduces pain
o Chiefly used in MI
o 2-4 mg dissolved in 10 ml NS
o Antidote: Naloxone
o Supplied by hospital.

Prof. Dr. R S Mehta, BPKIHS 96

 Acetaminophen and NSAIDs
o Often more effective than opioids in reducing pain from pleural or pericardial
rubs, a pain that responds poorly to opioids.
o particularly effective in reducing muscular and skeletal pain
o Tab form: 500mg OD

Prof. Dr. R S Mehta, BPKIHS 97

Sedatives

Benzodiazepines
1. Midazolam
oShort acting sedatives and hypnotics
oIn intubated patients
oDose 0.01- 0.05 mg/Kg for several hours

Prof. Dr. R S Mehta, BPKIHS 98

Benzodiazepines

2. Diazepam
Adult dose = 0.2 0.5 mg/ Kg
Not given in MI patients

Prof. Dr. R S Mehta, BPKIHS 99

Dissociative Anaesthesia
Ketamine
Adult dose= 1 3 mg/kg IV

Prof. Dr. R S Mehta, BPKIHS 100

Propofol
o Arousal is rapid 10- 15 min
o Used in neuro cases and those with increased ICP, during tracheostomy
procedure

Prof. Dr. R S Mehta, BPKIHS 101

Inotropes

Dopamine
Dobutamine
Nor- adrenaline

Prof. Dr. R S Mehta, BPKIHS 102

Thrombolytic agents

TEDS compressive stocking

SCD (Systematic Compressive Device)
LMWX
Heparin flush

Prof. Dr. R S Mehta, BPKIHS 103

Head elevation

Head is elevated to 30 degree.

Prof. Dr. R S Mehta, BPKIHS 104

Ulcer

Two hourly position change

Back care in each shift
Oxygen therapy
Each shift dressing of pressure sore
Air mattresses

Prof. Dr. R S Mehta, BPKIHS 105

Glucose monitoring

RBS as prescribed
Insulin therapy
Careful monitoring of signs of Hypoglycemia
(trembling, clammy skin, palpitations, anxiety, sweating, hunger, and
irritability)

Prof. Dr. R S Mehta, BPKIHS 106

Infection control

Hand washing before, during and after the procedure

Sterility maintenance during procedures
Use of disinfectants
Weekly high wash
Monthly culture test of health personnel, equipments
and infrastructures
Regular inspection by infection control team
Each shift CVP dressing

Prof. Dr. R S Mehta, BPKIHS 107

Specific equipments used in ICU and CCU

Ventilators
Infusion pumps
Cardiac monitors
Defibrillator
ABG machine
ECG machine

108
Drugs used in CCU

Aspirin
Clopidogrel
Nitroglycerine
Atorvastatins
LMWX
Morphine

109
Sedation score in ICU is done by RASS

(Richmond Agitation Sedation Scale = RASS)

110
RASS
(Richmond Agitation Sedation Scale)
Number Characteristics Definition Intervention
+4 Combative Violent, immediate Restrain and
danger to staff sedate

+3 Very agitated Aggressive, pull or Restrain and

remove tubes sedate
+2 Agitated Frequent non Restrain and
purposeful movement, sedate
fights ventilator
+1 Restless Anxious movement but Sedate
not aggressive or
vigorous
0 Alert and calm

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Number Characteristics Definition Intervention
-1 Drowsy Not fully alert but has Verbal
sustained awakening, stimulation
eye contact to voice
(>10 sec)
-2 Light sedation Briefly awakens, eye Verbal
contact to voice stimulation
(<10sec)
-3 Moderate Moderate or eye Verbal
sedation opening to voice but no stimulation
eye contact
-4 Deep sedation No response to voice Physical
but movement or eye stimulation
opening to physical
stimuli
-5 No response No response to voice or Physical
physical stimuli stimulation

112
 It may seem a
strange principle to
enunciate (articulate)
as the very first
requirement in a
Hospital that it should
do the sick no harm.
[1859]

Prof. Dr. R S Mehta, BPKIHS 113

Thank you!!!

Prof. Dr. R S Mehta, BPKIHS 114