Critical Care Nursing

Introductory Complex Care Topics

Criteria for admission into a complex care unit

Commonly encountered critical care situations

Critical care pharmacology and drug calculations

Composure of the interdisciplinary team

Communicating in a critical care setting

Critical Care Nursing Pharmacology *

Cardiovascular drugs

Neurological drugs

Pulmonary drugs

Drugs for cardiopulmonary arrest

Critical Care Diagnostics*

Acid base balance and arterial blood gases (ABGs)

CT scans, PET scans, x-rays

Echocardiograms

Cardiovascular System Critical Care

Arrhythmias

High-grade atrioventricular block

Third-degree atrioventricular heart block

Symptomatic ventricular arrhythmias

Symptomatic bradycardic

Ventricular tachycardia

EKG Interpretation *

Common wave patterns

Conditions associated with patterns

Cardiomyopathies*

Forms of cardiomyopathies

Critical nursing care planning for cardiomyopathies

Carditis

Endocarditis pathophysiology, potential causes and complications, clinical

manifestations, diagnostics, and treatment

Pericarditis pathophysiology, potential causes and complications, clinical manifestations,

diagnostics, and treatment

Myocarditis pathophysiology, potential causes and complications, clinical manifestations,

diagnostics, and treatment

Myocardial Infarction (MI)

Pathophysiology, risks factors, and clinical manifestations of acute myocardial infarction

Diagnostic markers: cardiac enzymes and EKG findings

MI treatment algorithm: pharmaceutical management and treatment priorities

Cardiac catheterization: angiography, and other options

Critical nursing care planning for acute myocardial infarction: assessment, diagnoses,
interventions, and outcomes

Valvular Disorders

Aortic stenosis pathophysiology, potential causes and complications, clinical

manifestations, diagnostics, and treatment

Aortic regurgitation (insufficiency) pathophysiology, potential causes and complications,

clinical manifestations, diagnostics, and treatment

Mitral valve stenosis pathophysiology, potential causes and complications, clinical

manifestations, diagnostics, and treatment

Mitral valve regurgitation (insufficiency) pathophysiology, potential causes and

complications, clinical manifestations, diagnostics, and treatment

Critical nursing care planning for valvular disorders: assessment, diagnoses,

interventions, and outcomes

Gastrointestinal Critical Care

Gastrointestinal Emergencies

Stress ulcer prophylaxis

Nursing management of GI emergencies

Gastrointestinal Bleeds

Upper GI bleeds

Critical nursing care planning for GI bleeds

Acute Pancreatitis

Pathophysiology, common causes, and complications associated with acute pancreatitis

Local complications: pancreatic pseudocyst and abscess

Systemic complications: acute respiratory distress syndrome (ARDS), shock, and

disseminated intravascular coagulation (DIC)

Diagnostics: laboratory values and imaging tests for the pancreas

Primary components of treatment: pain control, fluid and electrolyte replacement,

pancreatic rest, and nutritional support

Critical nursing care planning for acute pancreatitis

Musculoskeletal Critical Care

Musculoskeletal Emergencies *

Fractures

Vertebral and spinal trauma

Critical care nursing management of musculoskeletal emergencies

Pulmonary/Respiratory Critical Care

Ventilators

Evidence-based nursing on ventilator care practices

Types of ventilators and non-invasive ventilation

Oxygenation monitoring

Ventilator-associated pneumonia

Nursing care for patients on ventilators

Respiratory Failure

Acute respiratory failure (ARF)

Adult respiratory distress syndrome (ARDS)

Nursing interventions: prone positioning

Nursing care for patients with respiratory issues

COPD

Asthma: pathophysiology, etiology, patient presentation, diagnostics, treatment, and

nursing management

Emphysema: pathophysiology, etiology, patient presentation, diagnostics, treatment, and

nursing management

Chronic bronchitis: pathophysiology, etiology, patient presentation, diagnostics,

treatment, and nursing management

Plural Effusion

Pathophysiology and etiology of plural effusion

Patient presentation of plural effusion

Treatment approach for plural effusion

Nursing management of plural effusion in critical care

Pulmonary Embolism

Pathophysiology and etiology of pulmonary embolisms

Patient presentation of pulmonary embolism

Treatment approach for pulmonary embolism

Critical nursing care planning for pulmonary embolism: assessment, diagnoses,

interventions, and outcomes

Severe Hemothorax

Pathophysiology, common causes, and clinical manifestations of severe hemothorax

Major risks and complications: hemorrhage, cardiopulmonary arrest, and hypovolemic

shock

Diagnostics: laboratory values and imaging tests

Treatment of hemothorax: pharmacology and collaborative care

Critical nursing care planning for hemothorax: assessment, diagnoses, interventions, and
outcomes

Respiratory Syndromes

Acute respiratory distress syndrome (ARDS)

Systemic inflammatory respiratory syndrome (SIRS)

Multi-systemic organ dysfunction syndrome (MODS)

Pathophysiology and progression of ARDS, SIRS, and MODS

Diagnostics: laboratory values and imaging tests

Treatment of hemothorax: pharmacology and collaborative care

Critical nursing care planning: assessment, potential nursing diagnoses, interventions, and
outcomes

Multisystem/Multiorgan Critical Care

Shock in Critical Care

Determinants of tissue perfusion

Pathophysiology of shock states: sepsis to septic shock and hypovolemic shock

Common causes of shock and forms of shock

Pharmaceuticals for shock states

Fluid and volume replacement

Critical nursing care planning: assessment, diagnoses, interventions, and outcomes

DKA and HHS in Critical Care

Pathophysiology of diabetic ketoacidosis and hyperglycemic hyperosmolar shock

Comparing clinical manifestations of DKA and HHS

Fluid volume replacement, insulin titration, and potassium

Critical nursing care planning for DKA and HHS: assessment, diagnoses, interventions,
and outcomes

Trauma Care

Principles of trauma management

ABCDE: airway, breathing, circulation, disability, exposure

Primary survey and resuscitation

Secondary survey

Pharmacology in trauma management

The nurses role in trauma care

Burns in Critical Care

Emergency assessment of burns

Pharmaceutical treatment and diagnostics

Critical care nursing management of MVAs

Motor Vehicle Accidents (MVAs)

Emergency assessment and triage

Pharmaceutical treatment and diagnostics

Critical care nursing management of MVAs

Neurological Critical Care

Assessment of the Neurological System in Critical Care

Neurological assessment in the critical care setting

Glasgow coma scale

Cranial nerve assessment

Reflexes assessment

Autonomic Dysreflexia (AD)

Pathophysiology and etiology

Early recognition

Clinical manifestations

Treatment of AD

The importance of teaching awareness to patients with SCI

Critical nursing care planning for AD

Spinal Cord Injury (SPI)

Risk factors linked to SPI

Presentation of severe SPI

Potential complications of vertebral damage

Treatment options

Pharmaceutical management

Critical care nursing management of SPI

Stroke

Ischemic and hemorrhagic strokes

Pharmaceutical treatment

Critical nursing care planning for stroke

Traumatic Brain Injury Critical Care

Scalp lacerations

Skull fractures: Basilar and depression

Concussions and contusions

Hematoma: subdural (acute, subacute, chronic), epidural, subarachnoid, and

intraparenchymal hematoma

Complications: DI, SIADH, cerebral salt wasting, sympathetic storming, cardiovascular

and pulmonary complications, cerebral aneurysm, cerebral hemorrhage, seizures

Increased ICP for Critical Care

Neurological indicators of increased intracranial pressure

Cushings triad

Spinal Cord Injury for Critical Care

Neurological indicators of spinal cord injury

Primary survey and cervical spine precautions

Potential short-term complications of SCI

Urogenital Critical Care

Acute Kidney Injury

Prerenal injury pathophysiology, potential causes and complications, clinical

manifestations, diagnostics, and treatment

Intrarenal injury pathophysiology, potential causes and complications, clinical

manifestations, diagnostics, and treatment

Postrenal injury pathophysiology, potential causes and complications, clinical

manifestations, diagnostics, and treatment

Critical care nursing management of AKI

Dialysis for Critical Care

Indications for dialysis (acute and chronic)

Major forms of dialysis

Liver Injury in Critical Care

Common causes of liver injury

Fulminant liver disease and chronic hepatic failure

Diagnostics value and imaging for the liver

Cirrhosis, hepatoencephalopathy, and ascites

Critical care nursing management of liver injury

Urogenital Emergencies *

Urinary retention

Benign prostate hypertrophy

Resources for Nursing Students on Critical Care

American College of Emergency Physicians (2011). ED Facility Level Coding

Guidelines. Retrieved from http://www.acep.org/Content.aspx?id=30428

The AACN Synergy Model for Patient Care. The American Association of Critical Care
Nurses. Retrieved from http://www.aacn.org/wd/certifications/content/synmodel.pcms?
menu=#Nurse

American Thoracic Society. (1998). Research priorities in respiratory nursing. American

Journal of Respiratory and Critical Care Medicine, 158(6), 2006-2015. Retrieved from
http://www.atsjournals.org/doi/full/10.1164/ajrccm.158.6.ats798#.UmDT397n_IU

Baker, S. N., & Weant, K. (2012). Management of acute agitation in the emergency
department. Advanced Emergency Nursing Journal, 34(4), 306-318. Retrieved from
http://www.nursingcenter.com/lnc/CEArticle?an=01261775-20121100000004&Journal_ID=646631&Issue_ID=1454646

Cvijanovich, N. Z., Cook, L. J., Mann, N. C., & Dean, J. M. (2003). Population-based
assessment of pediatric all-terrain vehicle injuries. Pediatrics, 108(3), 631-635. Retrieved
from http://pediatrics.aappublications.org/content/108/3/631.abstract

Deutschman, C. S., Ahrens, T., Cairns, C. B., Sessler, C. N., & Parsons, P. E.
(2012). Multisociety Task Force for Critical Care Research: Key issues and
recommendations. American Journal of Critical Care, 21(1), 15-23. Retrieved from
http://ajcc.aacnjournals.org/content/21/1/15.full

Dittrich, K. (2007). Critical Care: ACLS update: A new role for medications.
Nursing, 37(12), 56. Retrieved from http://www.nursingcenter.com/lnc/JournalArticle?
Article_ID=757400&Journal_ID=54016&Issue_ID=757324

Maiocco, G. (2002). Posters give nursing staff consistent information. Critical Care
Nurse, 22(2), 152. Retrieved from http://ccn.aacnjournals.org/content/22/2/152.full

Vella, K., Goldfrad, C., Rowan, K., Bion, J., & Black, N. (2012). Use of consensus
development to establish national research priorities in critical care. BMC Journal, 320,
976-981. Retrieved from http://www.bmj.com/content/320/7240/976?variant=full-text

Basics Concepts of Critical Care Nursing

Critical Care Nursing Class Notes on Basic Concept
Introductions

Introduction of Critical Care Topics

Welcome to Critical Care!
Complex Care Intro Topics

The complex care arena: interdisciplinary team composure, communication, and the work
environment

Critical care theory framework: the Synergy Model from the AACN and the nurses role
in the care of the critically ill patient

Admission criteria, what it means to be critical, and commonly encountered situations

in the complex care unit

Environmental factors for the patient: visiting, the effects of family, sleep, stressors,
noise, light, temperature, communication, delirium risk

Assessment of the critical care patients family and meeting the needs of the family
members

Like other areas of nursing, critical care is driven by the nursing process. This framework
includes assessment, diagnosis, outcomes identification, planning, implementation, and
evaluation.

The Critical Care Arena

Examining the Arena of Critical Care

Members of the interdisciplinary team (IDT)

The Synergy Model from the AACN

Elements that contribute to a health work environment

The Critical Care Interdisciplinary Team (IDT)

Physicians: Intensivists (critical care physician), Radiologist, Neurologist, Nephrologist,

and other specialists

Surgeons: trauma surgeons, thoracic surgeons, cardiovascular surgeons, and other

specialists

Other providers: Nurse Practitioner (NP), Physician Assistant (PA)

Registered Nurse (RN) with special certifications in critical care and ACLS (advanced
cardiovascular life saver)

Respiratory Therapist (RT)

Registered Dietitian (RD)

Techs and aides: Certified Nursing Assistant (CNA), Patient Care Technician (PCT),
Primary Care Technician, and Trauma Care Technicians

Emergency transporters: paramedic, emergency medical technician (EMT)

Non-medical team members: law enforcement officer (police and detectives) and patient
advocates

Supportive staff and administrators: patient transport technician and others

The Synergy Model

What is the Synergy Model?
The Synergy Model is framework that links practice to patient outcomes. Its a patient-centered
nursing practice model for complex care developed by the American Association of Critical-Care

Nurses. The model outlines the components that are conducive to the complex care arena and
environment. It matches the nurses competencies to the needs of the patient by assigning the
sickest patients to the most experienced nurse as they probably have the most competencies
(Grudge Match Nurses: how come you talk about EBP but cant place a foley?) and evaluates the
relationship between clinical practice and outcomes. The focus is on patient-derived outcomes,
including functional change, behavioral change, trust, satisfaction, comfort, and quality of life.
The model also addresses nurse-derived outcomes: the nurses actions are evaluated. The broad
emphasis is over physiological changes, absence of complications, provided care, and treatment.
Components of the Synergy Model for Critical Care

Resiliency

Vulnerability

Complexity

Resource availability

Participation in care

Participation in decision-making

Predictability

Admissions Criteria for Critical Care

What It Means to be Critical
The American Association of Critical Care Nurses defines admission criteria to be for those who
are at high risk for actual or potential life-threatening health problems (2005). A critical illness
or injury is an acute impairment of one or more vital organ systems in which the patients
survival is jeopardized (Department of Health and Human Services). Critically ill patients have
complex physiologic and hemodynamic perturbations
Common Situations for Critical Care Admissions

Trauma perpetrations: MVA, contusions, abrasions, fractures, hemorrhage

Cardiovascular perpetrations: myocardial infarction

Neurological perpetrations: stroke

Neurological findings: altered level of consciousness

Pulmonary findings: altered breathing patterns, dyspnea, low oxygen saturation, use of
accessory muscles

Cardiovascular findings: hypotension or hypertension, bradycardia or tachycardia

Integumentary findings: mottled skin

Nutritional Needs

The role of nutrition for the critically ill patient is vital to the recovery process

Fever from serious illness increases the metabolic demands of the body

Serious burns require increased caloric and protein needs to heal

The Critical Care Environment

Visiting in Critical Care
Evidence based practice states that the ICU should have open-visiting hours. Open-visiting hours
is not synonymous with 24-hour visiting. As the nurse is the patients advocate, its important
to analyze the effects that visitors have on the patient. While some visitors can help the patient
relax, others can bring undue stress. Educate family members and caregivers on the effect they
are having on the patient; for example, does the patients pulse and blood pressure skyrocket when they visit? Or does the patient show physiological signs of comfort in
their presence? Its also important to bear in mind that caregivers are extremely prepositioned to
burnout, so remind them to go home and get some rest, eat well, and take time for themselves.
Family members that are willing to learn and able to communicate tend to have the best effects
on the patients outcome.
The Role of the Family
Keep in mind that the family members serves a pivotal role in critical care. Remember that the
family is also in crisis and disequilibrium. The nurse must assess the family unit and determine
who-is-who within the family structure.
Assessing the Family

Determine the family structure, and function

Inquire about the spiritual and cultural needs of the family

Determine how the family copes with stress

Communicate effectively and consistently with the family: listen, use vocabulary that
matches their level

Consider what factors may promote the familys comfort

Provide for visitation and personalize the environment

Personalizing the Complex Care Unit

Enable the patient and family to personalize the setting as much as possible within the
framework of hospital policies. For instance, it may help to allow them to bring in a favorite
pillow, pajamas, or to place family photographs in the room. Also recognize the importance of
maintaining a relaxing environment thats conducive t to recovery. Give them a sense of privacy
while still being able to monitor them.
Poor communication leads to increased rates of errors

The Critical Care Working Environment

The Importance of a Healthy Critical Care Environment
A healthy work environment is inherent to the success of a critical care unit. It affects staff and
patient safety. The work environment also influences patient outcomes. Retention of competent
nursing staff and other members of the interdisciplinary health care team are dependent upon the
work environment. Therefore, its important for the nurse to understand what elements are
conducive to a healthy work environment and what potential sources of stress exist. The AACN
has developed guidelines to create and maintain a healthy work environment, and the benefits
affect everyone involved.
Ubiquitous Sources of Staff Stress in a Critical Care Setting

Technology: state-of-the-art technology also requires state-of-the-art education to train

those responsible for using complex equipment

Poor communication: communication has a direct impact on patient safety and the tone of
the work environment

Unstandardized practice: inconsistency leaves gaps in the continuum of care

The Six Standards of a Healthy Work Environment from the AACN

1. Skilled communication
2. True collaboration: True collaboration is necessary to take truly quality care. This may
involves several disciplines.

3. Effective decision making: Must understand how the hospital culture works. Must know
whats going on with the patient to answer questions succinctly through critical values.
After implementing an intervention, it must be evaluated to determine if it was effective
or ineffective and then plan for the next step. This also includes the ability to anticipate
the providers actions. This involves an thorough understanding of the patients history,
diagnosis, treatments, and other aspects
4. Appropriate staffing
5. Meaningful recognition
6. Authentic leadership (Vollers, Roberts, Dambaugh, & Brenner, 2009)
Emphasized Principles in the ACCNs Health Work Environment Standards

Recognition is a central element

Nurse-to-patient ratio

An adequate mix of skills

Summarized from the AACNs Healthy Work Environment Standards and an Empowering Nurse
Advancement System, 2009

Communication in Critical Care:

The most vital outcome of skilled and effective communication between the Critical Care
Nurse and the healthcare provider is patient safety
Communication in a Critical Care Setting

Skilled communication is the lifeblood of the critical care setting (Vollers, Roberts,
Dambaugh, & Brenner, 2009)\

It involves multidisciplinary unity and collaboration of nurses, healthcare providers, and

other medical professionals, along with administrative leaders, the chief executive officer,
and supporting staff

Communication in the critical care setting has a direct impact on patient outcomes

The importance of the Critical Nurses communication skills are ranked in the
same category as clinical skills

Its imperative for the communication between the provider and nurses to remain strong

The most vital outcome of skilled and effective communication between the Critical Care
Nurse and the provider is patient safety

Communication can come in the form of face-to-face methods such as giving and
receiving report, staff meetings, and technological communication methods such as
email, phone calls, the Intranet (the internal network of the facility thats available only to
employees, and possibly volunteers, and students), and the content of the facilitys
website

Clinical Nurse Advancement System (CNAS)

The Clinical Nurse Advancement System (CNAS) is practiced in many hospitals. Its composed
primarily of staff nurses that represent each unit, the system functions to develop specific job
descriptions and responsibilities for nurses and governs the advancement process. This system
keeps nurses accountable and allows them to advance from the clinician I level up to IV, based
upon performance, competence, experience, and knowledge with an emphasis placed on
education and certification. Some CNASs support nursing grand rounds, a presentation
conducted by staff nurses to help attendees learn new content pertaining to a focused topic. This
also assists nurses in developing their public presentation skills and generates further discussion
regarding presented topic, allowing for vital input from patients, family members, and staff.
CNASs promotes multidisciplinary unity and collaboration through the enhancement
of communication skills, encourages clinicians to be involved in research through article
publication, further education, and present new information at regional and national conferences.
Members of the CNAS may also serve on other interdisciplinary committees such as
anticoagulation, ethics, infection control, pharmacy, and safety/quality improvement (Vollers,
Roberts, Dambaugh, & Brenner, 2009)

AACN Standards
The Six Standards of the American Association of Critical-Care Nurses
1. Assessment
2. Diagnosis
3. Outcomes identification
4. Planning
5. Implementation
6. Evaluation

Standard # 1: Assessment

Assessment: data is collected from a holistic perspective

All potentially valuable sources are used to collect data, including the patient, family, and
other team members through the use of interview, observation, analytical models, and
problem-solving tools

The assessment process is driven by current and anticipated needs

Relevant assessment findings are communicated to other team members and documented

Standard # 2: Diagnosis

Assessment findings are used to develop and prioritize the most appropriate nursing
diagnoses

Diagnoses are validated through interactions with the patient, family, and other team
members and are modified as needed

Diagnoses are documented

Standard # 3: Outcomes Identification

Identified outcomes take into consideration the patients unique situation and are derived
from actual or potential diagnoses

Outcomes are attainable, measurable, include a timeframe, and are modified as needed

The identified outcomes are documented

Standard # 4: Planning

A plan of care is made to achieve the desired outcomes with the collaboration of the
patient and family. It is focused on restoring health, promoting health, minimizing the
risk of complications and providing for continuity of care. This plan establishes priorities,
and takes into consideration the economic impact and resources available to deliver the
care. The nurses skills and competencies must meet the patients needs

Standard # 5: Implementation

The plan of care is delivered through safe methods that involves the input of the patient
and family

Elements may also include health teaching, health promotion, and disease management

All actions taken are documented

Standard # 6: Evaluation

Evaluation performed in a systematic way using ongoing using evidence-based

techniques and involves the collaboration of the patient, family, healthcare providers, as
appropriate

Results are documented and adjustments are made as necessary to achieved the desired
outcomes

Emphasized Principles in the ACCNs Scope and Standards of Nursing Care

Use of current best evidence

Collaboration with the patient, family, healthcare provider, and other team members as
appropriate

Actions to minimize the risk of complications and deliver care in a safe and effective
manner

Documentation to record all actions taken

Summarized from the AACNs Scope and Standards for Acute and Critical Care Nursing
Practice, 2008
Resources for Nursing Students on Critical Care Basics
American Association of Critical-Care Nurses (2008). AACN Scope and Standards for Acute and
Critical Care Nursing Practice. Retrieved from http://www.aacn.org/wd/practice/docs/130300standards_for_acute_and_critical_care_nursing.pdf
American Association of Critical-Care Nurses. The AACN Synergy Model for Patient
Care. Retrieved from http://www.aacn.org/wd/certifications/content/synmodel.pcms?
menu=#Nurse
American Association of Critical-Care Nurses. The Synergy Model in Practice. Retrieved from
http://www.aacn.org/wd/certifications/content/syninpract.pcms?menu=certification
Baker, S. N., & Weant, K. (2012). Management of acute agitation in the emergency department.
Advanced Emergency Nursing Journal, 34(4), 306-318. Retrieved from
http://www.nursingcenter.com/lnc/CEArticle?an=01261775-20121100000004&Journal_ID=646631&Issue_ID=1454646

Deutschman, C. S., Ahrens, T., Cairns, C. B., Sessler, C. N., & Parsons, P. E.
(2012). Multisociety Task Force for Critical Care Research: Key issues and recommendations.
American Journal of Critical Care, 21(1), 15-23. Retrieved from
http://ajcc.aacnjournals.org/content/21/1/15.full
Foster-Edwards, D. (1999). The Synergy Model: Linking patient needs to nurse competencies.
Critical Care Nurse, 19(1). Retrieved from
http://www.aacn.org/WD/Certifications/content/synpract2.content
Khalifezadeh, A., Safazadeh, S., & Mansour, B. A. (2011). Reviewing the effect of nursing
interventions on delirious patients admitted to intensive care unit of neurosurgery ward in AlZahra Hospital, Isfahan University of Medical Sciences. Iranian Journal of Nursing and
Midwifery Research, 16(1), 106-112. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3203289/
Vollers, D., Roberts, C., Dambaugh, L., & Brenner, Z. R. (2009). AACNs Healthy Work
Environment Standards and an Empowering Nurse Advancement System. Critical Care Nurse,
29(6), 20-27. Retrieved from http://ccn.aacnjournals.org/content/29/6/20.short or access the full
PDF document at http://www.aacn.org/WD/CETests/Media/C0962.pdf
Wenham, T., & Pittard, A. (2009). Intensive care unit environment. Continuing Education in
Anaesthesia, Critical Care, & Pain, 9(6), 178. Retrieved from
http://ceaccp.oxfordjournals.org/content/9/6/178.full