Critical Care Nursing

Nursing 203

Syllabus Week 1.1

Describe Critical Care Nursing

Roles
What is it that CCU RNs do,
can you define?
Patient Advocacy
Advanced Assessment
Intensive Intervention
High Tech Monitoring
Specialized Care
Communication between all
disciplines

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Nursing 203

Nursing is based on evidence.

It needs to be consistent
It needs to have research backing to
show the best possible results for the
greatest number of patients.

Critical Care Nursing

Nursing 203

Syllabus Week 1.2

Show the importance of holistic care for

the chronically ill patient and family
Sheldon (2000) states:
Patients need to feel that their circumstances and feelings are appreciated
and understood by the health care team member without criticism or
judgment. . . . If patients feel that the attention they receive is genuinely
caring and tailored to meet their needs, it is far more likely that they will
develop trust and confidence in the organization.
Shelton P.J.: Measuring and Improving Patient Satisfaction. New York: Aspen Publishers, 2000.

Critical Care Nursing

Nursing 203

Syllabus Week 1.3

Apply the six phases of the nursing

process in critical care. (You will do this in clinical, be
prepared)

Assessment
Diagnosis
Outcome Identification
Planning
Implementation
Evaluation

Critical
Nursing 203Care Nursing

Syllabus Week 1.4

Compare and contrast interdisciplinary

critical care management models and
tools.
Locate an example care with MD
Case Management-overseeing
on the internet so

Algorithm
Protocols
Practice Guidelines

you can be familiar

with these be able to
define them

Outcome Management-manage outcomes with

tools
Consistent standard of care
Patient functioning and well being (clinical outcomes)

Critical Care Nursing

Nursing 203

Syllabus Week 1.5

Explain ethical principles as they relate to

critical care patients.
Mind

Body

Spirit

It is easy to focus on
all
the technology and
physical aspects of
patient care in the
Critical Care Unit.
Give some examples
of
how you would focus

Critical Care Nursing

Nursing 203

Syllabus Week 1.6

Examine strategies to address moral

distress in critical care nursing.
What is Moral Distress? (This can be very
important to your own sense of right and
wrong)

Moral distress occurs when:

1.
2.

Critical Care Nursing

Nursing 203

Syllabus Week 1.7

Identify and discuss specific

legal isssues
in critical care nursing practice
Autonomy Beneficence
Nonmalficence
Veracity
Fidelity
Justice/allocation of resources
Can you Define these before I do?

Critical Care Nursing

Nursing 203

Syllabus 1.7

Autonomy
Freedom of choice or self-determination
Basic human right
Nurses can get caught in the middle in
ethical situations
Assumes role of patient advocate

Providing more information

Clarifying points
Reinforcing information
Providing support in decision-making process

Critical Care Question

Nursing 203
Nursing
A terminally ill patient has a do not
Syllabus Week 1. 8

resuscitate
(DNR) order per patient request. The
patients
family is opposed to the order. What is the
responsibility of the nurse?
A. Resuscitate the patient until the issue is
resolved
B. Honor the patients request
C. Have the family contact a lawyer

Answer
B. Honor the patients request
First and foremost the nurse has a duty to
honor
the patients request. The patient should not
be
resuscitated. The family can contact a lawyer
if
they wish but that is not the nurses
responsibility.

Critcal Care Nursing

Nursing 203

Syllabus 1.7

Beneficence
Concept of doing good, preventing harm
Requires that one promote the well-being of
patients
Weigh benefits, choosing best principles to
follow

Nonmaleficence
Dictates that one prevent harm and correct
harmful situations
Primary duty for the nurse

Critical Care Nursing

Nursing 203

Syllabus Week 1.7

Veracity
Truth-telling
Underlies the nurse-patient relationship

Fidelity
Faithfulness and promise-keeping to patients
Forms bond between individuals
Extends to the families of patients
Incorporates:
Confidentiality
Privacy

Critical Care Nursing

Nursing 203

Syllabus Week 1.7

Justice
Allocation of resources
Equal access to health care

Medical Futility
Defined as any effort to achieve a
result that is possible but that reasoning
or experience suggest is highly
improbable and that cannot be
systematically reproduced.

Critical Care Nursing

Nursing 203

Syllabus Week 1.7

Ethical foundation for Nursing

Practice
Framework for the profession
Based on 3 elements:
The professional code of ethics
The purpose of the profession
The standards of practice of the professional

Critical Care Nursing

Nursing 203

Syllabus Week 1.7

Code of Ethics
Developed by the profession
Look up online

Delineation of its values and

relationships with and among members
of the profession and society

Question
What purpose does the ANA Code of Ethics
serve?
A. Provides a framework for addressing moral
distress
B. Provides a description of expected nursing
roles and
responsibilities
C. Provides recommendations for managing care
and
treatments for specific diseases
D. Provides guidance for analyzing ethical

Answer
D. Provides guidance for analyzing ethical
issues for the nursing profession
The American Nurses Association (ANA)
Code of
Ethics for Nurses provides the major
source of
ethical guidance for the nursing
profession. The
Code of Ethics for Nurses serves as the
basis for

Critical Care Nursing

Nursing 203

Syllabus Week 1.7

Code of Ethics for Nursing

Nursing is concerned with:

Protection of patient health

Promotion of patient health
Restoration of patient health
Prevention of patient illness
Alleviation of patient suffering

Can you identify one intervention

from each for the CCU nurse?

Critical Care Nursing

Nursing 203

Syllabus Week 1.7

Steps in Ethical Decision Making

1.
2.
3.
4.
5.
6.
7.
8.

Identify the health problem.

Define the ethical issue.
Gather additional information.
Delineate the decision maker.
Examine ethical and moral principles.
Explore alternative options.
Implement decisions.
Evaluate and modify actions.

Critical Care Nursing

Nursing 203

Syllabus Week 1.7

Administrative Law and Licensing

Statues
Health care agencies/boards
Governed by administrative law
These guys make the rules

Critical Care Nursing

Nursing 203

Syllabus Week 1.7

Negligence and Malpractice

Four elements of negligence and
malpractice:
1. Duty and standard of care
2. Breach of duty
3. Causation
4. Injury or damages

Critical Care Nursing

Nursing 203

Syllabus Week 1.7

Negligence
The doing of something which a reasonably prudent person
would not do, or the failure to do something which a
reasonably prudent person would do, under circumstances
similar to those shown by the evidence. It is the failure to use
ordinary or reasonable care.

ordinary or reasonable care

That care which a person of ordinary prudence would use in
order to avoid injury to themselves or others under
circumstances similar to those shown by the evidence. You will
note that the person whose conduct sets the standard is not
the extraordinarily cautious individual, nor the exceptionally
skillful one, but a person of reasonable and ordinary prudence.
Black H. C. (1998). Blacks Law Dictionary. 9th ed. St. Paul, MN: West
Publishing Company

Question
Which of the following situations is an
example
of malpractice?
A. The patient gets out of bed against
nursing
advice and falls and breaks a hip.
B. The nurse makes derogatory
comments about
the patient in the medical record.
C. The nurse gives the wrong medication
to a
patient and the patient dies as a

Answer
C. The nurse gives the wrong
medication to a patient and the
patient dies as a result. The nurse
giving the wrong medication to a
patient and the patient dying as a
result is an example of
malpractice. It meets the 4 required
elements of malpractice.

Critical Care Nursing

Nursing 203

Syllabus Week 1.7

Legal Duties of Critical Care Nurses

Observe
Assess
Conduct ongoing observations and
assessments
Recognize significance of information
Report
Plan, implement, and evaluate care

Critical Care Nursing

Nursing 203

Syllabus Week 1.7

Legal Duties of Critical Care Nurses

cont-

What happens if
you dont do these?
if

Respond to changes
Interpret and carry out orders
Take reasonable measures to ensure
patient safety
Exercise professional judgment
Properly perform procedures
Follow hospital policies and procedures
Record and document

Critical Care Nursing

Nursing 203

Syllabus week 1.7

Six General Areas of Nursing Negligence

1. Improper administration of treatments
2. Improper administration of medications
3. Inadequate or false written and verbal
communication
4. Insufficient supervision of patients
5. Improper postoperative treatment and
wound care
6. Incorrect perioperative instrument or
sponge

Critical Care Nursing

Nursing 203

Syllabus week 1.7

Nurse Practice Act

Right to practice and right to
employment
Monitor practice, implement standards of
care
Enforce rules and regulations
Issue sanctions and license revocation
Disciplinary action for unauthorized
practice,
negligence or malpractice, These are your
rights as an RN
incompetence,

Critical Care Nursing

Nursing 203

Syllabus Week 1.7

Specific Patient Care Issues

Informed consent and authorization for
treatment

Valid consent
Consent must be informed and timely

Diagnosis, condition, prognosis, material

risks and benefits of treatment, explanation
of procedure or treatment, providers of
treatment, and probable outcome

Critical Care Nursing

Nursing 203

Syllabus Week 1.7

Specific Patient Care Issues

(continued)
The right to accept or refuse medical
treatment and the law of advance
directives
The right to informed consent
The right to refuse treatment
Withholding and withdrawing treatment
Ethical, legal, and practical problems

Critical Care Nursing

Nursing 203

Syllabus Week 1.7

Advanced Directives and the Patient

Self-Determination Act (1990)
All adults must be provided written
information on an individuals rights under
state law to make medical decisions,
including the right to refuse treatment and
the right to formulate advance directives
Living will
Durable power of attorney for
care
Whathealth
is the difference
between these?
POLST Form

Critical Care Nursing

Nursing 203

Syllabus Week 1.8

Assess informational needs of

families of critically ill patients.
What do they need to know?
How do they get information?
If you dont know answers, where do you
find them?

Critical Care Nursing

Nursing 203

Syllabus Week 1.9

Apply teaching learning theory to

the critical care setting.
Be prepared to teach something in
class to show understanding of this
concept.
When teaching an adult patient, tasks being
taught should focus on current problem.
True
False

Critical Care Nursing

Nursing 203

Syllabus Week 1.9

A. True
Adults bring a wealth of experience to the
learning environment that must be
recognized and promoted in educational
techniques. Because their orientation to
learning is life centered, the tasks being
taught should focus on current problem
resolution.

Critical Care Nursing

Nursing 203

Syllabus Week 1.9

Assessment Questions for the Critically Ill Patient

and their Family

What brings you to the hospital? Can you tell me more?

What have you been told so far about your your family
members) condition and plan of care?
What is the most important thing for you to know right
now?
What would you like to know? What information can I give
you right now?
Who are your main support people?
Has anything like this ever happened to you (your family)
before?
Have you (your family) ever been in an intensive care unit
or hospital before?

Critical Care Nursing

Nursing 203

Syllabus week 1.9

Factors Affecting Patient Readiness to

Learn

Physiological stressors
Psychological stressors
Sociocultural stressors
Financial stressors
Environmental stressors

Define a barrier in each

of these areas.

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Critical Care Nursing

Nursing 203

Syllabus week 1.9

Essential Critical Care Information for

Patient/Family
Orientation to the various care providers and
the services they deliver
Orientation to the unit environment
Orientation to the unit routines and plan of
care

Visiting hours, frequency of monitoring and

nurse
assessments, venipunctures, daily weights,

and
special shift routines (extremely important)
(continued)

Critical Care Nursing

Nursing 203

Syllabus week 1.9

Essential Critical Care Information for

Patient/Family

Explanations regarding reasons for equipment, monitors, and

associated alarms
Explanations of all procedures and expected
sensations/discomforts both in and off the unit
Medications given
Drug name, reason for receiving, and side effects to
report to nurse/others
Immediate plan of care
Transition to next level of care
Reason for transfer, environment, staffing, and availability
of care providers
Discharge plan
Medications, diet, activity, pathophysiology of disease,
symptom management, special procedures and
associated equipment, when to call health care provider,

Critical Care Nursing

Nursing 203

Syllabus Week 1.9

Education Plan of Care

Expected outcomes
Choose a critical
disease process
Objectives
and practice,
practice,
Content to be taught
practice,
someones life
Interventions
may depend on
you
Available education materials
Appropriate teaching strategies

Critical Care Nursing

Nursing 203

Prior to educating a patient what do

you need to know?
Ready to learn?
Language
Comprehension level
Remember age affects our ability to learn

Critical Care Nursing

Nursing 203

Syllabus week 1.9

Question
Which of the following educational
methods
would be best for teaching a patient
how to
check his or her blood sugar? Why?
A. Lecture
B. Discussion
C. Demonstration and practice

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Critical Care Nursing

Nursing 203

Syllabus week

Answer
C. Demonstration and practice
Demonstration involves acting out a procedure
while
giving appropriate explanations to provide the
learner
with a clear idea of how to perform a task.
Patients
can then practice the skill and can be given
feedback
Your own footer
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about their performance. This method works best

Critical Care Nursing

Nursing 203

Syllabus week 1.9

Strategies to Enhance Education

Get the patients attention
Information must be important to patient
Stick to the basics
Use simple everyday language
Make the most of your time
Teachable moments
Reinforce learning

Critical Care Nursing

Nursing 203

Syllabus week 1.9

The Older Adult

Cognitive changes
Process information more slowly
Physical changes
Presbyopia, cataracts, glaucoma, and
macular
degeneration affect the vision,
more
susceptible to over sedation,
doesnt bounce
back like a younger patient, more
easily toxic

Critical Care Nursing

Nursing 203

Syllabus week 1.9

Question
Which of the following strategies should be
used to facilitate learning the older adult?
A. Schedule sessions for later in the day.
B. Keep sessions short.
C. Withhold all pain medication 1 hour
before the
session.
D. Written instructions should be printed
in
purple ink.

Critical Care Nursing

Nursing 203

Syllabus week 1.9

Answer
B. Keep sessions short.
Learning can be facilitated by scheduling
teaching
sessions early in the day, keeping sessions
short,
and managing pain prior to learning. Colors in
the
blue end of the spectrum are difficult for the
older

Critical Care Nursing

Nursing 203

Syllabus Week 1.9

Documentation
What was taught?
To whom?
Verbalized, return demo, how did they
show they understood?
Nurses teach every shift but if it is not
documented it is not done!
Give examples of simple teaching that might be
forgotten

Critical Care Nursing

Nursing 203

Syllabus week 1.9

Illiterate Patients

Use simple language

Provide frequent examples
Use teach-back or return demonstration
Pictures, diagrams, and
audio/videotapes can be helpful

Critical Care Nursing

Nursing 203

Syllabus Week 1.

Interpreters and Interpreter Phones

Look at the patient not the interpreter
Speak to the patient, dont use tell
him
Know what you want to say in advance
Ask for a return demonstration so you
know learning has taken place.

Critical Care Nursing

Nursing 203

Syllabus Week 1.9

Preparation for Transfer

Fear of the unknown
Explanations to relieve anxiety

Transfer destination
Reason for transfer
Nurse who will assume care of the patient
Expected changes in care
Expected self-care
Visiting hours and notification of family

Critical Care Nursing

Nursing 203

Syllabus Week 1.10

Psychosocial Alterations
Anxiety and Pain
Powerlessness
Hopelessness
Spiritual Distress

Understand
how these
apply to the
patient in CCU
define
measures to
alleviate

Critical Care Nursing

Nursing 203

Syllabus Week 1.10

Examine measures that are useful in

reducing stress.
Coping mechanisms

Suppression
Use of Family Support
Denial
Sharing Concerns
Trust
Hope
Spiritual beliefs and Practices

Critical Care Nursing

Nursing 203

Syllabus Week 1.11

Assess the impact of illness on the

patients family and on family functioning.
How are they functioning
Helpful
Hostile
Overly concerned
Think of ways you would interact with each type of
family

Critical Care Nursing

Nursing 203

Syllabus Week 1.12

Examine safety issues in the critical care

environment.
Cords/Plugs emergency versus regular power
supply
Fall Risk
Restraints
Endotrachial Intubation

Critical Care Nursing

Nursing 203

Syllabus Week 1.13

Assess changes in sleep pattern

resulting from sleep apnea and
critical care environment and
interventions.
Sleep stages
NREM vs REM whats the difference?
Url link to youtube for REM example
http://
www.youtube.com/watch?v=SRwmDSkwpxk

Sleep cycles

Critical Care Nursing

Nursing 203

Syllabus Week 1.13

Abnormal Sleep
Sleep Apnea Syndrome
Obstructive Sleep Apnea

Medications and altered sleep

Medical management-What?
Nursing management-What?

(see chart in Urden pp40-41)

Critical Care Nursing

Nursing 203

Nutrition
Types of diets in the Critical Care Unit
Cardiac
Low Na, Low fat

Renal
Low protein

Enteric feeding
NGT placement is checked by xray the first time then
by air insertion/aspiration

TPN
High glucose, great medium for infection, isolated line
High glucose can cause increased CO2 levels on vent pt

Critical Care Nursing

Nursing 203

PAIN
Very subjective
Use a pain scale for better consistency
between nurses and patient
Remember geriatric patients are more
sensitive to pain medications
If giving ANY medication to pediatric
patient must check with a second nurse

Critical Care Nursing

Nursing 203

Sedation Medications
Short and Long acting
It is always preferable to use a sedation
scale for consistency in medication
Any patient on a continuous sedation
drip should be on a protocol and have a
sedation vacation every 24 hours to
allow them to wake up, and attempt to
breath on their own
Anytime a pt is on a neuromuscular

Critical Care Nursing

Nursing 203

Syllabus week

Define: Death with

Dignity
Watch this presentation on death with
dignity:
http://
www.youtube.com/watch?v=OU284t4axQ0
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Critical Care Nursing

Nursing 203

Death with Dignity

Should allow the patient to be kept
comfortable
Should be explained fully to the family,
we still care for the patient, turn, keep
them comfortable, we just dont
intervene if their heart or breathing
stop.
Palliative Care Nurses are very
important to help the family during a

Week One is Done!

See you next week.

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