(MEDICAL SURGICAL NURSING ii)

TOPIC:ACUTE & CRITICAL CARE

NURSING

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A. ACUTE CARE
INTRODUCTION:
If you talk to a nurse who has worked in a
hospital setting, you are likely to hear about how
much hospital have been changed.
It is true, todays hospitalized clients are sicker
than they were years ago, in part because of
advances in health care technology that have
enabled them to survive diseases and serious
medical condition longer.

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In the past some of the nurses case load
included clients who were nearly well.
Today client who are not acutely ill are
discharged from the hospital and are treated in
out patient setting and by their families or
significant others at home.
Therefore the case load for hospital nurses
today consist of seriously ill clients.

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 ACUTE CARE HOSPITAL

The American Hospital Association defines a

hospital as an institution with the primary
function of providing di­agnostic and
therapeutic client services for a variety of
medical conditions, both surgical and
nonsurgical.

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 Acute care hospitals are distinguished from
long-term care facilities such as nursing
homes, rehabilitation centers, and psychiatric
hospitals by the fact that the average client
stay is less than 30 days.
Such hospitals are one of three types:
1. government,
2. voluntary/not-for-profit, and
3. For-profit.

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POST-ACUTE CARE
Post-acute care is one of the fastest-growing
segments of health care.
It is designed to fill the gap between acute care
and long-term or home care and is identified
by a number of terms, including progressive,
transitional, intermediate, telemetry, or step-
down units.
In some hospitals, nursing units or beds on a
given unit can serve a dual purpose.

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These swing beds can be used either for
acute care or for post-acute care, depending
on the circumstances.
Not all clients experience post-acute care.
If the client can provide his or her own care
at home, discharge to home is appropriate.
Even if some nursing care is still required,
home health care may be used to assist the
client.

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Examples of post-acute clients include those
recovering from myocardial infarction (heart
attack) or open heart surgery; those who must
be weaned from a ventilator; those who need
wound management after burn injury or for
multiple pressure ulcers; those who require
more rehabilitation after stroke or orthopedic
surgery; or those who have complex medical
conditions such as diabetes or digestive or
renal problems.
Care is delivered at a fraction of the cost or at
about 30% of the cost of an acute care unit.

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Post-acute units in a nursing home or
rehabilitation facility include many clients who
are Medicare benefici­aries, whose younger
counterparts with the same level of disability
would receive home care.
Chronic post-acute units manage clients with
little hope of ultimate recovery and functional
independence.
The goal of care for all clients in post-acute care
is to send them home or to a less expensive
level of care, such as to long-term care or
assisted-living centers.
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ENSURING QUALITY HEALTH CARE
DELIVERY
Amid the fast-paced changes occurring in
health care de­livery, health care professionals
remain responsible for ensuring quality client
care.
Quality client care is the outcome of the
integrated health care team approach, which
involves the corporate, and hospital or agency
ad­ministration, medical staff, board of
trustees, employees, community, and client.

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Contract services, community re­sources,
transfer agreements, and the expertise of social
workers or case managers enable client
transitions to al­ternate levels of care to occur
in a continuous, coordi­nated, almost seamless
fashion.
Through work-redesign and skill-mix
reallocation, in­stitutions are focusing goals on
achieving efficient client outcomes.
Work redesign involves studying a job over a
fixed period to discover if and how a certain
job function might be made more efficient.

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Skill mix is determined by studying the ratio of
RNs to LPNs/LVNs and nurse as­sistants on a
unit.
The best skill mix delivers quality care while also
controlling costs.
The "one-level-of-care" philosophy ensures that
clients receive optimal care in all areas of an
institution.

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For example, the same monitoring
pertains when intra­venous (IV)
conscious sedation is administered in the
en-doscopy unit as when general
anesthesia is administered m the
operating room or emergency
department.

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Evidence-based practice is a concept used to
improve: are to achieve client outcomes.
It uses research findings at are grounded in
science along with client character­istics to
guide clinical practice, thereby preventing
practice being directed by tradition or personal
preference and setting the stage for quality
client care.

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PROVIDING QUALITY CLIENT CARE
Any plan for providing client care involves the
following aspects:
Strategic planning to serve as a guideline for
the continued or expanded services provided
by the health care agency
Budgeting process to assist the institution in
study­ing, spending, and using the information
to reduce costs or maintain them at the
present rate

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Performance improvement plan to show the
steps taken to improve performance based on
monitoring and evaluation of staff performance
Risk management input to identify and
eliminate potential injuries to staff and clients
Utilization review data to explore items such
as acuity levels (a degree of severity of illness
that af­fects the amount and complexity of care
the client requires), outcomes, and costs and
to discover what is and is not effective care

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Client satisfaction survey results, which
gather data from clients at various stages of
their stay in the agency (e.g., Preprocedure,
admission procedure, discharge)

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Physician input to incorporate
professional input into client care
planning
Census data to plot current and future
trends of health care in the organization

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Changes in client population, diagnoses,
programs, or staffing that would necessitate
changes in the type, level, or amount of care are
reviewed on an ongoing basis. Other factors
contributing to quality care include
(1) The adherence to, monitoring of, and
evaluation of care given according
To professional standards;

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(2) Joint Commission on the Accreditatio
of Health­care Organizations
(JCAHO) and Department of Health
criteria; and
(3) Input from other regulatory agencies. In
addition, clinical pathways, Clinical prac­tice
guidelines, standards of practice and care, &
competence Standards serve as models for
professional delivery of client care.

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ETHICAL ISSUES
Ethical issues in acute care commonly occur
when the nurse is caught in the middle
between clients, physicians, administrators, and
other nurses and feels powerless to change the
situation.
 Ethical distress can lead to negative
consequences for everyone involved.

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Nurses are often called on to assist families in
making informed decisions about client care,
and they must be familiar with ethical, legal,
economic, and emotional factors that affect
the family's decision.

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LEGAL ISSUES
Nurses have more responsibility today than in
the past.
Expanded roles open the doors to greater
legal risk.
The nurse's employer is obligated to carry
malpractice insur­ance for its employees.
You should know what is cov­ered in the
policy.
In addition, you should consider car­rying
individual malpractice insurance.

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Proper documentation is crucial to serve as
evidence of the quality of nursing care
provided.
The court still assumes that if something was
not noted in a chart, it was not done.
 Be specific, and document nursing actions
taken and the client's response (e.g., pain
reduction).
If unusual events occur, complete an incident
report.
The benefit of incident reports is that they
allow analysis of adverse client events.

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They should not be treated as a punitive activity
but rather as a method of promoting quality care
and risk management.
Errors are examined to determine whether or
not the error was due to a sys­tem problem (e.g.,
a faulty electrical outlet that leads to a fire or an
improperly mounted side rail that allows a client
to fall).
If a lawsuit is filed, incident reports usually are
not revealed; instead, the court system relies on
the information in the medical record.

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CULTURAL ISSUES
Nurses who practice in the 21st century will be
interact­ing with an increasingly multicultural
American society.
Areas of the United States that had few
immigrants now see people from all over the
world.
This diverse popula­tion requires that nurses be
able to recognize differences

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And to be sensitive to those differences in
perceptions of health and illness, in
communication styles, and in non-traditional
approaches to health care.
Culturally compe­tent care in its broadest sense
is knowing, explaining, in­terpreting, and
predicting nursing care within the knowledge of
the client's cultural and ethnic beliefs and
practices, whether the client is well or sick.

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PERFORMANCE IMPROVEMENT AND
GOALS
Institutions generally seek to enhance their
measurement activities as they relate to
institutional quality indicators.
These indicators generally include the following:
Results of basic clinical indicators
Continuous quality improvement
Access to care issues

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Clinical Indicators with a Focus on High-
Volume, High-Risk, and Problem-Prone Issues
The community/clinic focus includes the following:
Communicable diseases (e.g., TB, HIV)
Low birth weight as a percentage of live births
Births to mothers 10 to 17 years of age as a
percentage of all live births
Percentage of women receiving prenatal care during
the first trimester

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Breast cancer rates & mammography statistics
Immunization rates
Return visits to the same level of care or visit
within 72 hours to a higher level of care
Accessibility, availability,& acceptability of care
Appropriateness and relevance of care (e.g.,
based on diagnostic laboratory work,
symptomatology)
Appropriateness of treatment frequency
Intake system

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Provision for information on an emergency or
after-hours basis
Client education
Consultation
Documentation including, for example,
transfers and advance directives
Availability of emergency carts/equipment
Use of leasing for expensive/alternative
resources

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Client record
Client rights, including advance directives,
informed consent, and special concern for
abuse victims and for those with cultural
diversity.
Consumer satisfaction and judgment input
JCAHO indicators
Human resource management
Organization performance

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 THE FUTURE OF ACUTE CARE HOSPITAL
NURSING
The following are a few of the trends that will
influence the delivery of care in hospitals:
As technology makes care in other settings
more affordable, the acuity of clients in hospitals
will increase, which will prompt the use of
master's prepared, acute care nurse
practitioners and clinical nurse specialists in the
acute care setting.

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The 79 million baby boomers as well as their
aging parents will present an unparalleled
need for health care.

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Health care will be directed at populations
rather than individuals. Examples include
hospitals providing flu shots, community
education programs, and screenings.
Bioterrorism concerns will result in acute care
hospitals taking the lead for disaster
preparation. The skills of nurses working in
acute care will be utilized in a variety of
settings.
A growing number of health care workers and
clients will be immigrants and speak English as a
second language.
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There will be continued emphasis on cost
containment with projected cuts in entitlement
programs.
The hospital work force may be a virtual work
force with a core of flexible workers and, based
on acuity and census, other workers who
contract for periods of time. Examples include
employee health, accounting, computer
personnel, and nursing staff.
The length of a shift for nurses and rate of error
will be examined.

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CONCLUSIONS
Acute care hospital-based nursing has
changed.
Years ago, clients could stay in the hospital
until they felt well enough to go home.
Cost-containment issues have demanded that
clients today spend as little time as possible in
acute care and quickly move to less expensive
areas for care.

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Professional nurses are the cornerstone of
high-quality care during these shortened stays.
All health care providers are trying to
maintain excellence in health care during
these changing times, and it is essential that
nursing do so as well because excellence in
health care is the primary reason the client is
hospitalized.

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B. CRITICAL CARE
INTRODUCTION:
The first step inside an intensive care unit, or ICU, can
be overwhelming.
The machinery is complex, medications are potent,
stress and worry are visible on the faces of the families,
and alarms seem to sound endlessly.
The ICU can be intimidating and confusing.
The reality is that the ICU is a place where skilled
nurses, doctors, technologists, pharmacists, respiratory
therapists, & others competently care for the sickest
clients in the hospital.

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Their efforts are rewarding: More than 96% of
clients admitted to the ICU are discharged alive.
20 Although formally this specialty is less than
40 years old, clients with life-threatening
illnesses have been organized into specific
geographical areas for many years before
designated critical care units were developed.

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Florence Nightingale in the 1880s detailed the
benefits of grouping postoperative clients
together to optimize their care and recovery.
John Hopkins Hospital in Baltimore
developed a three-bed postoperative
neurosurgical unit in the early 1890s.
In 1927 a unit specifically for premature
infants was established in Chicago.

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DEFINITION OF CRITICAL CARE:

Criticalcare is a term used to describe "the

care of patients who are extremely ill and
whose clinical condition is unstable or
potentially unstable.“

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HISTORY OF CRITICAL CARE
Nursing and technology continued to evolve
in the 20th century to meet the ever-changing
needs of society and its population.
During World War II, "shock Wards" were
developed to meet the needs of injured
solders.
After the war, a nursing shortage spurred the
development of post-anesthesia care units
(PACUs) to ensure prompt attentive care for
clients emerging from anesthesia.

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By 1960 almost every hospital in the United
States could boast of such recovery rooms.
During the late 1940s, the polio epidemic
required the use of iron lungs as well as
tracheotomy procedures and manual ventilation
to support clients with respiratory paralysis.
The physical needs were so great that intensive
nursing care was required by these clients.
In the 1950s, mechanical ventilation was
developed.

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The physical needs were so great that intensive nursing
care was required by these clients.
In the 1950s, mechanical ventilation was developed.
Again it was found that care of clients requiring
ventilatory support was more efficient when clients
were grouped together in a single unit.
Soon general ICUs were developed for other very ill
clients.
By 1958, 25% of community hospitals in the United
States with more than 300 beds reported having at least
one ICU.

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By the end of the 1960s, almost every
hospital in the United States had at least one
ICU.
Today more than 5000 ICUs exist in the
United States; many of them very specialized,
caring for highly specific groups of clients.
Examples include cardiovascular, trauma,
neurologic, surgical, cardiovascular surgical,
pediatric, respiratory, transplantation, burn,
neonatal, spinal cord injury, and medical ICUs
to name a few.

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Examples include cardiovascular, trauma,
neurologic, surgical, cardiovascular surgical,
pediatric, respiratory, transplantation, burn,
neonatal, spinal cord injury, and medical ICUs
to name a few.
20 day stays in critical care units are
common, and 80% of Americans will
experience the critical care unit as a client or
a family member.

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 REASONS FOR ADMISSION TO THE
INTENSIVE CARE UNIT
The most common reasons for admission to
ICU are for intensive monitoring and life-
supportive care or for intensive nursing care
that cannot be provided on a general medical
surgical floor.
Clients may be admitted following surgery,
from the emergency room, or from the other
floors within the hospital.

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 Common conditions necessitating admission to
ICU include the following:
• Respiratory difficulties impairing the client's ability to
ventilate or oxygenate:
These problems often include disorders such as
pneumonia, pulmonary embolism, drug overdose, and
respiratory distress.
Ventilators, also called respirators, may be required to
assist with breathing.
The use of these devices requires intense monitoring
and skilled care providers to assess both the equipment
and the client's response.

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Circulatory problems such as hypotension (low
blood pressure) or cardiac rhythm disorders:
Clients may have had a myocardial infarction
(heart attack), may be bleeding from internal or
external wounds, or may have irregular heart rhythms
that have become life threatening.
The term hemodynamically unstable is used to
describe these clients.
Clients are routinely placed on cardiac rhythm
monitors.
They also may require sophisticated monitoring of
cardiac output and pressures within the heart.
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Neurologic changes, such as loss of
consciousness or changes in mental status:
Intensive monitoring of the client's neurologic
status provides needed data on the progress or
deterioration of the brain's perfusion.
Clients with head injuries, brain surgery,
stroke, or spinal cord injury are admitted to
the ICU for frequent reassessment.

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Life-threatening infection or the risk of infection,
such as burn wounds or sepsis, requires intensive
care to control the blood pressure and maintain
perfusion of the heart, brain, lungs, and kidneys.
Clients with sepsis or large open wounds require
very intensive care for medication administration and
fluid management.
Metabolic problems, such as abnormal electrolytes
from diabetes, renal failure, or acid-base imbalances
require intensive monitoring and medication titration
to control and treat complications.

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Clients who have had open heart surgery,
thoracic surgery, brain surgery, extensive
abdominal surgery, or orthopedic surgery are
admitted postoperatively to the ICU for
monitoring.

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Clients who have less invasive
procedures, but have a personal history
of cardiac or pulmonary disease, may also
be admitted for observation and frequent
assessment

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 NEEDS OF THE CRITICALLY ILL CLIENT
AND FAMILY
1.Clients in the ICU are at a most vulnerable
stage.
2.Not only do these clients have great physical
needs, but their emotional, psychological, social,
and environmental needs must be identified.
3.Critically ill clients often experience pain,
immobility, disorientation, and sleep deprivation.
4.They can feel isolated, anxious, and depressed.

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5. Fears about their treatments, the unknown,
and even death are not unusual.
6. Everything in their environment is stress
producing unusual machines, loud noises,
equipment alarms, constant light, and
constant attention, staff conversations,
physical restraints, lack of privacy,
inadequate control of pain and anxiety, and
separation from significant others.

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7 Alteration of sleep quality and quantity in the
critically ill client can have important adverse
consequences, including impaired immunity and
healing, an increase in oxygen consumption and
carbon dioxide production, negative nitrogen
balance, and stimulation of the "fight or flight"
response of the sympathetic nervous system.
An over­whelming sense of powerlessness is the
overall recurrent theme verbalized by critically
ill clients.

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8. Characteristics' of hopelessness can actually
impede recovery and lead to specific
behavioral and physiologic changes.
9. Because of airway devices, medications, or
physical pathology, many critically ill clients
cannot communi­cate their needs well, making
their situation even more stressful.
10. Even with the best of circumstances and nurs­
ing care, critically ill clients can experience
delirium, of­ten called ICU psychosis.

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11.The critical care nurse has a great
responsibility in controlling the environment
to avoid or diminish the stressors that are
specific to the critically ill client.
12.Allowing open visitation as able, providing
appropriate day and night cycles of activity and
sleep, and controlling noise and conversation
can allow the client a more restful and
therapeutic recovery.

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13. Providing privacy and explaining all
equipment, noise, and activities can be
comforting measures for the critically ill client
as well as his or her family.
14. Designing some type of simple com­
munication system to allow the client at least
to answer "yes" or "no" questions is
important.
15.The nurse must adequately assess the client's
analgesia and sedation needs.

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16.Often few overt clues are evident that the client
requires such medications.
17.Looking at subtle changes in vital signs or
behavior and routinely providing sedation and
analgesia are frequently required.
18.lastly, the nurse may need to control open
visitation to balance clients' needs for rest with
families' needs to be close to their loved one.

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CRITICAL CARE NURSING
"Critical care nurses concentrate specifically
on the care of clients with life-threatening
problems."
Interventions for these clients must be
adjusted continually based on constant
monitoring of their response to treatment.
Because of the multidisciplinary nature of
critical care, co­ordination of care is essential.

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The critical care nurse is primarily
responsible for such coordination.
 Continuous nursing vigilance is the key to
this nursing specialty and can make a
significant difference in client outcomes.
The critical care nurse does not just use the
latest ma­chines and technologies to provide
highly technical nursing, although maintaining
technological devices is crucial.

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Creating an environment that promotes
healing or an optimal health level in a
nurturing, caring manner is especially essential
for a critically ill client to ensure positive
optimal outcomes."
Often complementary and alternative
therapies, such as massage, prayer, music
ther­apy, and therapeutic energy provision,
assist the critical care nurse in providing such
a healing environment.

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Providing such care must include not only the
client but also his or her family members and
significant oth­ers.
Many times the critically ill client does not
remem­ber his or her ICU stay; however, the
time in the critical care unit is often a
significant emotional event and is traumatic
for his or her loved ones.
Often the only cop­ing mechanism families
have is hope.

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It is extremely es­sential that the critical care
nurse foster this coping mechanism because
hope can fortify a family's inner strength and
helps the family members look beyond the
present situation of pain and suffering.
Nurses have a fiduciary relationship with their
clients and families; in other words, nurses
have an ethical and legal obligation to act in
their best interest.

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The American Association of Critical-Care
Nurses (AACN) defines this advocacy as
"respecting and supporting the basic values,
rights and beliefs of the critically ill client."
Further delin­eates the advocacy role of the
critical care nurse.

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 Family Needs in the Intensive Care Unit
 The top nine priorities of critical care families were as follows
1. Assurance that the best care was being given
to their family member by caring Personnel
2. To feel that there was hope
3. To know the prognosis
4. To understand how the client was being treated
medically
5. To be reassured that it is all right to leave for a
while.

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6. To feel accepted by hospital staff
7. To feel someone is concerned for the
family's health
8. To feel the hospital personnel care about
the client
9. To have explanations given in terms that
can be understood.

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Implications
As shown by this list of priorities, nursing can
do much to alleviate many of the stressors
that face our critical care patients and family
members.
Much can be accomplished by listening to
clients and their families and by taking time to
meet their needs.
Nurses have the knowledge base and the
opportunities to address and meet almost all
of the priorities listed here.

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 AACN'S Advocacy (American
association of critical nurses)
The critical care nurse will do the following:
1. Respect and support the right of the patient
or the pa­tient's designated Surrogate to
autonomous informed decision-making.
2. Intervene when the best interest of the
patient is in question.
3. Help the patient obtain necessary care.
4. Respect the values, beliefs, and rights of
the patient.

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5. Provide education and support to help
the patient or the patient's designated
Surrogates make decisions.
6. Represent the patient in accordance with the
patient's choices.
7. Support the decisions of the patient or the
patient's des­ignated surrogate, or
Transfer care to an equally qualified critical
care nurse.

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8. Intercede for patients who cannot speak
for themselves in situations that Require
immediate action.
9. Monitor and safeguard the quality of care
the patient receives.
10. Act as liaison between the patient, the
patient's family, and health care
Professionals.

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Critical Care Practice Settings and Roles
Critical care nursing is not limited to designated
critical care units.
In 2000 the Department of Health and Hu­man
Services identified that about 31% of all hospital
nurses work with critically ill clients in ICU,
PACU, emergency room (ER) and in step-down
units.
It is not the location of care that is important,
however Critical Care nursing is not nursing in a
specific place; rather, it is nursing with a specific
mind-set that utilizes a specialized body of
knowledge and skills.
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•Critical thinking and clin­ical decision-making
become more consistent the longer the
critical care nurse practices in the critical care
envi­ronment.
The critical care nurse must constantly keep
up with the latest information and become
proficient with more complex new
technologies and treatments.
The need for such nursing skills and
knowledge will only increase as the
population grows older and sicker.
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Today's changes in technology and health care
will keep more of Our population out of the
hospital, but those who are admitted to critical
care units will be more severely ill than ever
before.
Critical care nurses are found in a variety of
formal roles:
bedside nurse, critical care educator,
case management, department manager,
clinical nurse specialist, and
nurse practitioner.
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Only they are with the client on a 24 hours a
day, 7 days a week.
The critical care educa­tor can educate clients;
the case manager can promote appropriate and
timely care; the manager can direct them; the
clinical nurse specialist can help to plan client
care; and the nurse practitioner can order
treatments and medications.

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Although all these roles are important, the
bedside nurses are the backbone of critical
care nursing.
• Ultimately, however, it is the bedside criti­cal
care nurse who coordinates the entire team's
efforts to implement the plan of care and
modify it as needed by the client's response.

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Advance practice nurses in critical care
Advance practice nurses in critical care are
registered nurses with a master's degree who
have a specialty in crit­ical care.
The critical care clinical nurse specialist
(CNS) uses an advanced level of knowledge of
critical care, pharmacology, and
pathophysiology in completing the role of
educator, consultant, manager, researcher,
and practitioner.

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The acute care nurse practitioner (ACNP)
provides advanced nursing care to acutely and
critically ill clients in a wide variety of settings,
including the emer­gency department, ICUs, and
step-down units.
Making rounds, developing a plan of care, and
performing specific advanced procedures are all
tasks the ACNP may do.
Some ACNPs serve as intensivists and may insert
central lines or chest tubes, assist with surgery
or intubation, or complete various functions
once reserved for physicians.
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 CRITICAL CARE PROFESSIONAL
ORGANIZATIONS
Criticalcare practitioners are specifically
supported by two national organizations, AACN
& the Society of Critical CareMedicine.
These organizations provide practice guidelines,
opportunities for networking, educational
programs, professional publications, scholarship
and grant money, research opportunities,
Internet re­sources, and practitioner support.

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In addition, both are considered as the
"official" professional organizations that speak
on behalf of critical care.
Representatives from these organizations are
often asked to testify or provide information
for various national and state leg­islative
organizations.

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CONCLUSIONS
Critical care nursing occurs in a variety of
settings.
Health care will be pressed to provide efficient
and cost-effective services.
Government subsidies of health care may not be
able to keep up with the demand.
An impending shortage of nurses in the next 10
years will challenge our health care institutions.
Aging nurses are retiring or leaving critical care.

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Young or new nurses must step up to meet the
exciting challenges of critical care nursing.
Despite all the challenges of the future, the
center of all health care will still be the client,
and the critical care nurse will be there at the
client's side.

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09/19/14 DHRAVAL 86