Critical Care Nursing

Debbie L. Dempel

History of Critical Care & ICUs

1930s Introduction of Recovery
Rooms
WWII & Korean War Concepts of
triage and specialty nursing
Late 1950s beginning of Critical
Care Units
Early Technology
2

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
3

American Association of CriticalCare Nurses - AACN

1969
Educational
support
Certification
Largest
professional
specialty nursing
organization
Scholarships

Research
Publishes 2
journals
Local chapters
Political awareness
Provides standards
of practice

Critical Care Now

Critical Care Now

Nursing shortage
Half of patients in
ICUs >65
In US critical
care beds account
for 8% of all
hospital beds

20% of patients
spends time in a
critical care unit
Downsizing
Goal: provide high
quality, holistic
care

Critical Care Technology

ECG monitoring
Arterial Lines
Oxygen
Saturation
Ventilation
Intracranial
Pressure
Monitoring

Temperature
Pulmonary Artery
Catheter
IABP
VAD
Extensive use of
pharmaceuticals

The Critical Care Nurse

Specialty dealing with human
responses to life-threatening
problems
Requires Extensive Knowledge and
a Continual Desire to Learn

CCRN
Critical Care Certification by AACN
Requires:
Clinical hours working in an ICU
Successful completion of an exam
Requires continuing education and
clinical hours for recertification

Critical Care Clinical Nurse

Specialist (CCNS)
Advanced practice nurse
Licensed by the State
Five Roles of a CNS:

Patient & staff educator

Consultant
Administrator
Researcher
Expert practitioner
10

Acute Care Nurse Practitioner

(ACNP)
Advanced practice nurse
Licensed by the State
Provides comprehensive care to
select critically ill patients

11

The Critical Care Patient

Physiologically Unstable
At Risk for Serious Complications
Require Intensive and Complicated
Nursing Support and/or Advanced
Technology

12

Common Problems of Critical

Care Patients - Nutrition
Address it early
Goal: prevent or correct nutritional
deficiencies
Parenteral
Enteral

13

Common Problems of Critical

Care Patients - Anxiety
70-80% of patients
Indicators agitation, increased
BP, increased HR, verbalization,
restlessness
Treatment

14

Common Problems of Critical

Care Patients - Pain
70% reported moderate to severe
pain
5th vital sign
Leads to anxiety, agitation,
increased myocardial oxygen
consumption, delays wound
healing
15

Common Problems of Critical

Care Patients Impaired

Patient on the ventilator

Communication
Use of medications
Nursing Interventions

16

Common Problems of Critical

Care Patients Sensory
ICU Psychosis
Really Delirium
Perceptual
Problems
15-40% of patients
Alteration in mentation
Psychomotor behavior
Alterations in sleep
Predisposing factors
17

Common Problems of Critical

Care Patients Sleep

Poor sleep/wake cycles

Deprivation
Lack of REM sleep
Predisposes patients for delirium
Treatment

18

Family Need of the Critical Care

Patient
Information major source of
anxiety and litigation
Reassurance can reassure care is
being given
Convenience access to the
patient

19

Arterial Lines
Catheter placed in an artery
Pressure from the artery is transmitted
to a transducer by a column of fluid and
converted in a pressure tracing
Transducer must be placed at the
Phlebostatic Axis 4th intercostal space
Radial artery is the most common site

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Phlebostatic Axis

21

Arterial Lines - Waveform

Systole aortic valve opens, blood
ejected from LV, sharp rise in
waveform
Dicrotic Notch closure of the
aortic valve, signifies the beginning
of diastole
Diastole lowest point recorded on
the waveform
22

Arterial Lines - Waveform

23

Pulmonary Artery Catheter

(Swan-Ganz Catheter)
Evaluate heart disease, shock states,
compromised CO, and fluid status
Also used to evaluate a patients
response to treatment
Catheter placed through a central
vein to the right atrium, right
ventricle, and into the pulmonary
artery
24

Pulmonary Artery Catheter

(Swan-Ganz Catheter)
Measures Intracardiac Pressures
Measures Cardiac Output
Able to Obtain Mixed Venous Blood
Samples

25

Pulmonary Artery Catheter

(Swan-Ganz Catheter)
1.
2.
3.
4.
5.

Pulmonary Artery Port

Central Venous Port
Injectate Port
Thermister Connection
Balloon Inflation Valve

26

PA Catheter

27

PA Catheter Insertion

28

Preload
Volume within a cardiac chamber at
the end of diastole
Pulmonary Capillary Wedge Pressure
estimates the left ventricular enddiastolic pressure, 6-12 mm Hg
Central Venous Pressure right
ventricular end-diastolic pressure, 28 mm Hg
29

Afterload
Refers to the forces that oppose
ventricular ejection
Systemic arterial pressure,
resistance of the aortic valve, and
mass and density of the blood
Systemic Vascular Resistance

30

Cardiac Output
Volume of blood pumped by the
heart in 1 minute
Normal: 4-8 L/minute
Doesnt take into account body size
More specific is Cardiac Index size
adjusted by Body Surface Index

31

Intraaortic Balloon Pump (IABP)

Balloon Catheter placed in the
descending thoracic aortic arch
Balloon inflation timed to begin to
inflate at the time the aortic valve
closes time of early diastole
dicrotic notch

32

IABP
Augments aortic pressure and
forward flow
Increases coronary perfusion
When balloon deflates at end of
diastole and aortic valve opens
negative pressure pulls blood
forward
33

A: Systole-balloon
Deflated, facilitates
Ejection of blood to
Periphery
B: Early diastole
Balloon begins to
Inflate
C: Late diastole
Balloon is totally
Inflated, augments
Aortic pressure &
Increases coronary
perfusion
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IABP - Goals
Support patients with inadequate
CO
Support patients with inadequate
BP

35

IABP Common Indications

1.
2.
3.
4.

Cardiogenic shock
Left ventricular failure
Cardiomyopathy
Bridge to transplant

36

IABP - Contraindications
Aortic aneurysm
Aortic dissection
Severe PVD
Aortic Valve Insufficiency

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