FAR EASTERN UNIVERSITY

Institute of Nursing
st
1 Semester – AY 2021-2022

NUR 1219- NCM 118 NURSING CARE OF CLIENTS WITH IFE THREATENING CONDITONS
ACUTE ILL/ MULTI ORGAN PROBLEMS / HIGH ACUITY AND EMERGENCY SITUATIONS

MODULE I:
Introduction to Critical Care

OVERVIEW

The module provides with concepts, principles, theories, and techniques of nursing care
of sick adult client with life threatening conditions, acutely ill/ multi-organ problems, high
acuity and emergency situation. The learners will apply knowledge on physical, social, natural,
and health science in a holistic manner.

Learning Outcomes:
1. To identify and understand Critical Care Nursing service characteristics and contributions
that will prepare student nurses to enter the critical care environment.,
2. To develop specific competencies required for delivery of nursing care that focuses on
restoring physiologic and psychological stability to severely ill clients.
3. To provide comprehensive nursing care to correct core body systems alterations for
critically ill patients.
4. To demonstrate knowledge, clinical and technical skills, and decision-making capabilities
pertinent to the management of clinically unstable patients.
5. To demonstrate awareness of the ethical and legal issues that frequently arise in the
nursing care of acute and critically ill patients.
6. To apply documentation that includes reporting up-to-date client
7. To guide the development of collaborative relationship with other members of the health
care team.
8. To identify and understand Critical Care Nursing service characteristics and contributions
that will prepare student nurses to enter the critical care environment.,
9. To develop specific competencies required for delivery of nursing care that focuses on
restoring physiologic and psychological stability to severely ill clients.
10. To provide comprehensive nursing care to correct core body systems alterations for
critically ill patients.
11. To demonstrate knowledge, clinical and technical skills, and decision-making capabilities
pertinent to the management of clinically unstable patients.

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NUR 1219 -MODULE:
Prepared by : CRITICAL CARE Facu lty Le cture rs 20 21
 FAR EASTERN UNIVERSITY
Institute of Nursing
st
1 Semester – AY 2021-2022

NUR 1219- NCM 118 NURSING CARE OF CLIENTS WITH IFE THREATENING CONDITONS
ACUTE ILL/ MULTI ORGAN PROBLEMS / HIGH ACUITY AND EMERGENCY SITUATIONS

12. To demonstrate awareness of the ethical and legal issues that frequently arise in the
nursing care of acute and critically ill patients.
13. To apply documentation that includes reporting up-to-date client
14. To guide the development of collaborative relationship with other members of the health
care team.
TOPIC OUTLINE

I. Introduction to Critical Care:

1. Definition of Critical care

2.Evolution of Critical Care

3.Professional Organizations:

a. American Association of Critical care nurse (AACN)

b. Critical Care Nurse Association of the Philippines (CCNAPI)

II. Standards /Guidelines in Critical Care Nurse practice:

1. Critical care nurse characteristics
1.1. Scope of critical Care nurse
1.1.1. Care provider
a. Direct patient care
b. Indirect patient care
1.1.2. Extended roles as critical care nurse
1.1.3. Educator
1.1.4. Patient Advocate
1.2 Management and Leadership Role
1.3. Research role
2. Trainings of Nurses for Critical care nurse:
2.1. Orientation program
2.2. In-service training program
2.3. Continuing Nursing education
2.3.1. ACLS
2.3.2. Basic Critical care Course
2.3.3. Cardiac/ Neurologic/Respiratory Assessment

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NUR 1219 -MODULE:
Prepared by : CRITICAL CARE Facu lty Le cture rs 20 21
 FAR EASTERN UNIVERSITY
Institute of Nursing
st
1 Semester – AY 2021-2022

NUR 1219- NCM 118 NURSING CARE OF CLIENTS WITH IFE THREATENING CONDITONS
ACUTE ILL/ MULTI ORGAN PROBLEMS / HIGH ACUITY AND EMERGENCY SITUATIONS

3. Quality and Safety emphasis

3.1 Nursing Standard practice
3.1.1 5 Steps in Nursing Process
3.2. Communication
3.2.1 Handoffs and Barriers
3.2.2. SBAR Approach (Situation, Background, Action, Recommendation
3.3 Documentation
3.3.1 Electronic medical records (EMR)
3.3.2. Withdrawal medical treatment forms (DNR/DNI)
3.3.3. Palliative care
3.4. Collaboration
3.4.1. International patient Safety Goals (IPSG)

III. Levels and Categories of Critical care in the Philippines

1. Level 1
2.Level 2
3. Level 3

IV. Factors influence an individual’s response to illness

1. Recollection on Critical Care experience

2. Discharge and health teaching planning
3. Family Bundle

V. Ethico-Moral Practice

1. Ethical principles
2. Code of Ethics for Registered Nurses in the Philippines

• Read the outline handout about Ethico-Moral in handling

Critical ill clients
• Lecture on Ethico-Moral roles and responsibility of Critical Care Nurse

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NUR 1219 -MODULE:
Prepared by : CRITICAL CARE Facu lty Le cture rs 20 21
 FAR EASTERN UNIVERSITY
Institute of Nursing
st
1 Semester – AY 2021-2022

NUR 1219- NCM 118 NURSING CARE OF CLIENTS WITH IFE THREATENING CONDITONS
ACUTE ILL/ MULTI ORGAN PROBLEMS / HIGH ACUITY AND EMERGENCY SITUATIONS

LEARNING CONTENT:

I. Introduction to Critical Care:

1. Critical Care Nursing:

• Critical care nursing is concerned with human responses to life-threatening problems,

such as trauma, major surgery, or complications of illness.
• The critical care nurse's focus encompasses both the patient's and family's responses to
disease, as well as prevention and cure
• Careful monitoring and surveillance to critically ill care management adults remain vital
to good patient outcomes on treatment and monitoring protocols
• Critical care is also called Intensive care unit in hospital setting where patients experience
severe illness or injury that needs a round h clock care by a specially trained team

2. Critical Care Unit:

• a room filled with client attached to interventional technology, equipped facility, staffed
by skilled personnel to provide effective and safe care for patient with a life-threatening
problem that is potentially reversible.

3. Evolution:

• Crimean War (1850s) – nurses created a separate area near the nursing station for
critically injured British soldiers
• 1927 – Dr. Walter Dandy of John Hopkins Hospital arranged for a special area for
increased monitoring of his postoperative neurosurgical patients
• WWII - shock units were created to care for the severely wounded and postoperative
patients
• 1952 – Polio epidemic – Dr. Bjorn Ibsen described the provision of this respiratory care.
Mechanical ventilators first became commercially available in the 1960s, followed by
increasing use of automated monitoring of vital signs with alarms.
• 1959 – first modern critical care units opened at the University of Southern California
and the University of Pittsburgh, both staffed by specially trained critical care physicians.

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Prepared by : CRITICAL CARE Facu lty Le cture rs 20 21
 FAR EASTERN UNIVERSITY
Institute of Nursing
st
1 Semester – AY 2021-2022

NUR 1219- NCM 118 NURSING CARE OF CLIENTS WITH IFE THREATENING CONDITONS
ACUTE ILL/ MULTI ORGAN PROBLEMS / HIGH ACUITY AND EMERGENCY SITUATIONS

Common conditions that require critical care:

1. Heart problems
2. Lung problems
3. Multiple Organ failure
4. Brain trauma
5. Blood infections (sepsis)
6. Drug- resistant infections
7. Serious injury (vehicular accident, burns)
8. Any person with life threatening condition (Airway, Breathing, Circulation, Disability,
Exposure)

Common Characteristics of Critical Care Units

1. A nurse-to-patient ratio of 1:1 or 1:2.
2. Critically ill patients. - deals with life threatening health problems
3. Patients with multiple diagnoses.
4. Specialized equipment: Continuous EKG, blood pressure, and oxygen saturation monitors.
multiple IV pumps, arterial lines, pulmonary artery catheter, endotracheal tubes,
ventilators, chest tubes, urinary catheters, central venous lines, and nasogastric tubes
and/or g-tubes.
5. Isolation precautions.
6. Restricted visiting hours.
7. Bedside computers for documentation

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NUR 1219 -MODULE:
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 FAR EASTERN UNIVERSITY
Institute of Nursing
st
1 Semester – AY 2021-2022

NUR 1219- NCM 118 NURSING CARE OF CLIENTS WITH IFE THREATENING CONDITONS
ACUTE ILL/ MULTI ORGAN PROBLEMS / HIGH ACUITY AND EMERGENCY SITUATIONS

Types of Intensive Care Unit:

Types Description
Coronary care unit (CCU) Patients specifically with life threatening
cardiac conditions ex. myocardial
infarction, cardiac arrest, pre-post heart
catheterization, chest pain, pre-post open
heart surgery
Cardiovascular intensive care unit (CICU) post cardiac bypass,
Others: post-op thoracic aneurysm, repair
abdominal aneurysm repair,
thoracotomies
Surgical intensive care unit (SICU) A specialized service in large hospitals
that provides patients recover after
extremely invasive surgery. Often patients
may have other medical conditions that
require close monitoring
ex. Whipple’s procedure, Orthopedic
restrictions, Extensive abdominal repair.
This is managed by surgeons,
anesthesiologist
Trauma intensive care unit Patients with various types of injuries and
several diagnoses.
Nurses in this area must be prepared in
any types of wounds and patient care

Pediatric intensive care unit (PICU) Pediatric patients with life threatening
conditions.
E, severe asthma, diabetic ketoacidosis,
traumatic neurological injury, surgical
cases (if the patient has a potential rapid
deterioration or if a patient requires close
monitoring
Neonatal intensive care unit (NICU) Cares for neonatal patients who have not
left hospital after birth.
Ex. prematurity and associated
complications, congenital disorders
congenital diaphragmatic hernia),
complications resulting from the birthing
process

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NUR 1219 -MODULE:
Prepared by : CRITICAL CARE Facu lty Le cture rs 20 21
 FAR EASTERN UNIVERSITY
Institute of Nursing
st
1 Semester – AY 2021-2022

NUR 1219- NCM 118 NURSING CARE OF CLIENTS WITH IFE THREATENING CONDITONS
ACUTE ILL/ MULTI ORGAN PROBLEMS / HIGH ACUITY AND EMERGENCY SITUATIONS
Neurological intensive care unit Patients treated for brain aneurysms, brain
tumors, stroke, post neurologic surgeries
Isolation intensive care units Patients that need to be isolated that is
suspected or diagnosed with contagious
disease and need medical isolation care

High dependency unit An intermediate ward for patients who

require close observation, treatment and
nursing care that cannot be provided in a
general ward
Others called it step-down unit,
intermediate care area, or progressive care
unit

4. Professional Organizations:
a. American Association of Critical Care Nursing (AACN) – established in 1969 – this
association promotes the health and welfare critically ill patients by advancing the art and
science of critical care nursing and supporting work environments that promote
professional nursing practice.

The Nurse Caring for Acute and Critically Ill Patients:

1. Systematically evaluates the quality and effectiveness on nursing practice

2. Evaluates own practice in relation to professional practice standards, guidelines, statutes,

rules, and regulations

3. Acquires and maintains current knowledge and competency in patient care

4. Contributes to the professional development of peers and other healthcare providers

5. Acts ethically in all areas of practice

6. Uses skilled communication to collaborate with the healthcare team to provide care in a safe,
healing, humane, and caring environment

7. Uses clinical inquiry and integrates research findings into practice

8. Considers factors related to safety, effectiveness, cost, and impact in planning and delivering
care

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NUR 1219 -MODULE:
Prepared by : CRITICAL CARE Facu lty Le cture rs 20 21
 FAR EASTERN UNIVERSITY
Institute of Nursing
st
1 Semester – AY 2021-2022

NUR 1219- NCM 118 NURSING CARE OF CLIENTS WITH IFE THREATENING CONDITONS
ACUTE ILL/ MULTI ORGAN PROBLEMS / HIGH ACUITY AND EMERGENCY SITUATIONS
9. Provides leadership in the practice setting for the profession

Data from Bell, L. (2008). AACN Scope and Standards for Acute and
Critical Care Nursing Practice. Aliso Viejo, CA: American Association
of Critical-Care Nurses.

b. Critical Care Nurses Association of the Philippines, incorporated (CCNAPI) – February

1977 – a national organization of nurses interested in the field of critical care nursing. This
organization is accredited as a Provider of Continuing Professional education by the Professional
Regulation Commission (PRC). They provide continuing educational activity which CCNAPI
aims to achieve excellence and pursue ongoing improvement in all its educational activity. Their
nursing philosophy is accomplished by looking after critically ill patient in an environment with
specially trained nurses, appropriate equipment, adequate medical supplies, and additional health
care professionals.

5. Certifications for Critical care Nurse in the Philippines

a. Registered Nurse
b. Intravenous training (IVT nurse)
c. BLS/ ACLS training
d. Critical Care course program (optional) -highly advantage

II. Standards in Critical Care Nurse practice:

Care standards for critical care nursing provide measures for determining the quality of care
delivered, also serve as means for recognizing the competencies of nurses in the intensive care
specialty.
11 Standards for critical care nurse provide quality care and excellence:
1.The critical care nurse functions in accordance with legislation, common laws,
organizational regulations and by-laws, which affect nursing practice.
2. The critical care nurse provides care to meet individual patient needs on a 24-hour
basis.
3. The critical care nurse practices current critical care nursing competently.
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NUR 1219 -MODULE:
Prepared by : CRITICAL CARE Facu lty Le cture rs 20 21
 FAR EASTERN UNIVERSITY
Institute of Nursing
st
1 Semester – AY 2021-2022

NUR 1219- NCM 118 NURSING CARE OF CLIENTS WITH IFE THREATENING CONDITONS
ACUTE ILL/ MULTI ORGAN PROBLEMS / HIGH ACUITY AND EMERGENCY SITUATIONS

4. The critical care nurse delivers nursing care in a way that can be ethically justified.
5. The critical care nurse demonstrates accountability for his/her professional judgment
and actions.
6. The critical care nurse creates and maintains an environment which promotes safety
and security of patients, visitors, and staff.

7. The critical care nurse masters the use of all essential equipment, available services and
supplies for immediate care of patients.
8. The critical care nurse protects the patients from developing environmental induced
infection.
9. The critical care nurse utilizes the nursing process in an explicit systematic manner to
achieve the goals of care.
10. The critical care nurse carries out health education for promotion and maintenance of
health.
11.The critical care nurse acts to enhance the professional development of self and
others.

A. Roles of Critical Care Nurses:

1. Care Provider
a. Direct patient care
(1) Detects and interprets indicators that signify the varying conditions of the critically
ill with the assistance of advanced technology and knowledge.
(2) Plans and initiates nursing process to its full capacity in a need-driven and
proactive manner.
(3) Acts promptly and judiciously to prevent or halt deterioration when conditions
warrant.
(4) Co-ordinates with other healthcare providers in the provision of optimal care to
achieve the best possible outcomes.
b. Indirect patient care – Care of the family
(1) Understands family needs and provide information to allay fears and anxieties.

9|P ag e
NUR 1219 -MODULE:
Prepared by : CRITICAL CARE Facu lty Le cture rs 20 21
 FAR EASTERN UNIVERSITY
Institute of Nursing
st
1 Semester – AY 2021-2022

NUR 1219- NCM 118 NURSING CARE OF CLIENTS WITH IFE THREATENING CONDITONS
ACUTE ILL/ MULTI ORGAN PROBLEMS / HIGH ACUITY AND EMERGENCY SITUATIONS
(2) Assists family to cope with the life-threatening situation and/or patient’s
impending death.
c. Extended Roles as critical care nurses – perform procedures beyond their professional
boundary following clinical protocols
Ex. Weaning patients from ventilators, performing and interpreting ECG’s, adjusting
analgesia/sedations, titrating intravenous and centra line medications
d. Educator –
(1) Provides health education to patient and family to promote understanding and
acceptance of the disease process and to facilitate recovery.
(2) Participates in the training and coaching of novice healthcare team members to
achieve cohesiveness i
(3) n the delivery of care.
e. Patient Advocate –
(1) Acts in the best interest of the patient.
(2) Monitors and safeguards the quality of care which the patient receives.

2. Management and Leadership Role:

They oversee patient care, make management and budgetary decisions, set work
schedules, coordinate meetings, and make decisions about personnel. The nurse manager
ensuring that the work of the health care team is supported and contribute inpatient
engagement.

3. Research Role -
(1) Engage self in nursing or other health –related research with or under supervision
of an experienced researcher.
(2) Utilize guidelines in the evaluation of research study or report
(3) Apply the research process in improving patient care infusing concepts of quality
improvement and in partnership with other team-player

B. Trainings of Nurses for Critical Care Unit:

To continuously ensure staff competencies hospitals should provide training opportunities
This will enable critical care nurse to cope on the demands of the changing needs of critically ill
patients.
1. Orientation program/Preceptorship and mentoring program
2. In-service training program
a. Unit/hospital-based training courses/workshops/seminars
b. On the job training and bedside supervision
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Institute of Nursing
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NUR 1219- NCM 118 NURSING CARE OF CLIENTS WITH IFE THREATENING CONDITONS
ACUTE ILL/ MULTI ORGAN PROBLEMS / HIGH ACUITY AND EMERGENCY SITUATIONS
3. Critical Care Nursing Program (Post-graduate specialty program)
a. Pot graduate course in Critical care nursing
b. Cardiac special care nursing
c. Advanced Critical Care Nursing (ACCN) provider course

CCNAPI recommends that all practicing CCN shall ensure that they continuously update
their knowledge, skills, and behavior through active participation in related critical care nursing
education.
This are:
1. Advanced Cardiac Life Support
2. Basic Critical Care Course
3. Cardiac assessment
4. Neurologic assessment
5. Respiratory assessment
6. Continuous renal replacement therapy
7. Advanced pharmacology
8. Advanced Intravenous therapy
C. Quality and Safety:
Quality and safety are essential components of patient care. Patients are at risk for a myriad
of harms, which increase morbidity, mortality, length of hospital stay, and costs for care
1. Nursing Process:

The American Nurses Association (ANA) describes six core standards of practice
a. Assessment: Collection of Data
- conducting interview, review past medical history and records, completing physical
examination current patient status
b. Diagnosis: Analysis of data to determine nursing diagnosis
- this is where the nursing care plan is based. This is the clinical judgement
regarding the patient’s response to actual or possible medical problems.
c. Outcome Identification: Identification of expected outcomes specific to the patient
and/or situation
- Setting short- and long-term goals that are patientoriented and measurable,
Including assessment and diagnosis details. utilizing a standardized care plan or
clinical pathway as a guideline
d. Planning: Development of a plan detailing interventions aimed to achieve expected
outcomes.
e. Implementation: Performance of the interventions noted in the plan of care.
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NUR 1219 -MODULE:
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 FAR EASTERN UNIVERSITY
Institute of Nursing
st
1 Semester – AY 2021-2022

NUR 1219- NCM 118 NURSING CARE OF CLIENTS WITH IFE THREATENING CONDITONS
ACUTE ILL/ MULTI ORGAN PROBLEMS / HIGH ACUITY AND EMERGENCY SITUATIONS
- Documenting the care provided to the patient properly. performing treatment in a
way that minimizes complications and life-threatening issues. involving patients,
families, caregivers, and other members of the health care team
f. Evaluation: Evaluation of the patient’s progress toward achievement of expected
outcomes
- evaluating the status of the patient and the effectiveness of the treatment
2. Communication:
• Effective communication is essential for delivering safe patient care. Communication
breakdowns occur during handoff situations when patient information is being
transferred or exchanged of care.
• Common handoff situations include nursing shift reports, transcription of verbal orders,
and interfacility patient transfers.

A. Report or Handoffs
1. Importance:
Report or handoff involves providing information to the nurse who will be taking over
the care of your patients. It should be given anytime patient care is transferred to another
nurse. This may include at the end of your shift or if a patient is being transferred to
another unit in the hospital.
The report is necessary to educate the incoming nurse about the patients he or she
would be caring for. If critical information is left out of the report, it might have a
negative impact on patient care and safety. The transfer of information from one nurse to
the next should include a chance for the receiving nurse to ask questions and explain any
points that are unclear.
2. Purpose:
The purpose of report is to provide information about the patients you cared for.
Although the information should be in the patient’s chart, it is often more practical to
present a brief synopsis of what is going on with the patient.
It is beneficial to have your notes in front of you when giving a report. When you
first got your report at the start of your shift, you should have taken some notes. In
addition, you will almost certainly have jotted down notes during your workday.

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NUR 1219 -MODULE:
Prepared by : CRITICAL CARE Facu lty Le cture rs 20 21
 FAR EASTERN UNIVERSITY
Institute of Nursing
st
1 Semester – AY 2021-2022

NUR 1219- NCM 118 NURSING CARE OF CLIENTS WITH IFE THREATENING CONDITONS
ACUTE ILL/ MULTI ORGAN PROBLEMS / HIGH ACUITY AND EMERGENCY SITUATIONS
3. Barriers to Effective Handoff Communication:
a. Physical setting – background noise, lack of privacy, interruptions
b. Social setting – organizational hierarchy and status issues
c. Language – differences between people of varying racial and ethnic backgrounds or
geographical areas
d. Communication medium – limitations of communications via telephone, email, or
computerized records versus face to face
B. SBAR Approach:

The SBAR (Situation-Background-Assessment-Recommendation) technique provides

a framework for communication between members of the health care team about a
patient's condition.

• S = Situation (a concise statement of the problem)

• B = Background (pertinent and brief information related to the situation)
• A = Assessment (analysis and considerations of options — what you found/think)
• R = Recommendation (action requested/recommended — what you want)

SBAR is an easy-to-remember strategy for framing any interaction, particularly those

that require a clinician's immediate attention and action. It provides a simple and focused
way to establish expectations for what will be communicated and how between team
members, which is critical for creating teamwork and fostering a patient safety culture.

SAMPLE SBAR Approach Teamwork and Collaboration

Situation: My name is (caregiver): Mary Smith, RN from

the (unit) emergency department. I will be transferring (patient name) John Jones, a (age)
34-year-old (gender) male
admitted (time/date) 3 hours ago with (diagnosis) diabetic
ketoacidosis, to (receiving department) medical ICU. Attending physician is Dr. Michael
Miller.
Background: Pertinent history – type 1 diabetes for 20 years.
on insulin pump; managed pump failure 24 hours ago inappropriately; renal
insufficiency. Summary of episode of care:
• Admitting glucose 648 mg/dL; positive ketones; pH 7.27.
PaO2 90 mm Hg; PaCO2 20 mm Hg; HCO3

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Institute of Nursing
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1 Semester – AY 2021-2022

NUR 1219- NCM 118 NURSING CARE OF CLIENTS WITH IFE THREATENING CONDITONS
ACUTE ILL/ MULTI ORGAN PROBLEMS / HIGH ACUITY AND EMERGENCY SITUATIONS
2 12 mEq/L; K1
3.4 mEq/L; BUN 40 mg/dL; creatinine 1.8 mg/dL; admitting
weight 65 kg; lethargic
• Received 1 L normal saline in field. Normal saline now infusing at 200 mL/hr.
• Received IV bolus of 6.5 units regular insulin at 1300. Insulin infusion of 100 units
regular in 100 mL normal saline
infusing at 7.5 units per hour (7.5 mL/hr). 1500 repeat glucose 502 mg/dL.
• 20 mEq potassium chloride infused in emergency department
• 200 mL urine output last hour – hourly intake and output
• Hemoglobin A1c level 6 weeks ago was 9.2% (patient
report)
Assessment:
• Vital signs: B/P 102/60 mm Hg; Pulse 106 beats/min; Respirations 30 breaths/min;
Temperature 37.5° C
• Intake: 1400 mL Output: 450 mL
• Pain level: 0/10
• Neurological: Lethargic; but responsive to stimuli
• Respirations: Deep with acetone odor noted. Lungs clear.
• Cardiac: S1/S2; no murmurs
• Cardiac rhythm: Sinus tachycardia
• Code Status: Full
• GI: Abdomen soft/slightly distended, hypoactive bowel
sounds
• GU: Voiding frequently. Urine concentrated.
• Skin: Skin dry with poor turgor; intact
• IV: (location) right forearm (catheter size) 18 g (condition)
no redness/edema
• Assessment: Diabetic ketoacidosis secondary to poorly
managed insulin pump failure with gradual improvement of
glucose over past 2 hours
Recommendation:
• Hourly vital signs
• Repeat glucose, K1, arterial blood gas due at 1600 today.
• Continue normal saline at 200 mL/hour for 4 hours
• IV insulin infusion at 6.5 units (6.5 mL) per hour – bedside
glucose monitoring hourly and adjust per protocol
• Monitor urine output hourly
• Contact Dr. Miller with 1600 lab work for further orders
• Refer to diabetes educator and clinical dietitian
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Institute of Nursing
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NUR 1219- NCM 118 NURSING CARE OF CLIENTS WITH IFE THREATENING CONDITONS
ACUTE ILL/ MULTI ORGAN PROBLEMS / HIGH ACUITY AND EMERGENCY SITUATIONS
• Repeat renal profile in am

Example: Nurse/Doctor interaction

Situation:
This is Nurse Jones on the Hematology Ward. I’m calling about Mr John Smith, a
day case patient, because he is breathless, and his heart rate is 120. I am concerned
that might be having a transfusion reaction.

Background:
Mr Smith came in this morning for a transfusion of 2 units of red cells. His
hemoglobin dropped to 80g/L following his last round of chemotherapy and he
was symptomatic during light activity.
His first unit of blood was given over 90 minutes and the second one started half an
hour ago and is over halfway through.
He developed dyspnea within the last 15 minutes, his heart rate has increased
from the baseline observations of 90 and his blood pressure is also elevated.
Assessment:
His current observations are:
Temp: 37.1oC, Pulse: 120, BP: 150/96, Resps: 28, SPO2: 92%
He also looks a little flushed.
I think he is showing signs of circulatory overload, so I have stopped the
transfusion for now and administered oxygen.
I note that he wasn’t prescribed a diuretic on this admission.

Recommendation:
I would like you to come and see the patient immediately.
Is there anything I should do in the meanwhile, or anything you will need as part of
your assessment?

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NUR 1219 -MODULE:
Prepared by : CRITICAL CARE Facu lty Le cture rs 20 21
 FAR EASTERN UNIVERSITY
Institute of Nursing
st
1 Semester – AY 2021-2022

NUR 1219- NCM 118 NURSING CARE OF CLIENTS WITH IFE THREATENING CONDITONS
ACUTE ILL/ MULTI ORGAN PROBLEMS / HIGH ACUITY AND EMERGENCY SITUATIONS

C. Documentation:
Critical care documentation requires a basic understanding of the nursing process and how to
utilize a care plan. All nurses learn how to complete focus notes (FDAR, SOAPIE). However,
some hospitals, including their critical care units, now use computerized documentation.
1. Electronic Medical Record (EMR)
An electronic (digital) collection of medical information about a person that is stored on a
computer. An electronic medical record includes information about a patient’s health history,
such as diagnoses, medicines, tests, allergies, immunizations, and treatment plans. Electronic
medical records can be seen by all healthcare providers who are taking care of a patient and can
be used by them to help make recommendations about the patient’s care. A blank box is offered
where additional documentation can be entered, such as details and other items pertaining to
tasks performed.
A nurse must remember the nursing process, liability, safety, and patient care when
documenting. It is always necessary to “save,” or store.
Note: “If it was not documented, it was not done”
2. Withdrawal Medical Treatment Forms:
a. Do not Resuscitate (DNR) - DNR orders are only in effect if the patient does not have
a heartbeat or has stop breathing altogether. This is not applied when the person is still
breathing or undergoing treatment. This is a legal and ethical bind where written consent
is a must

A DNR order is not the same as a "do not treat" order. Instead, it simply means that CPR
will not be attempted. Other treatments (such as antibiotics, transfusions, dialysis, or the
use of a ventilator) that may prolong life are still available. These additional procedures
are usually more likely to be successful than CPR, depending on the person's health.
Treatment that maintains the person pain-free for as long as possible.
b. Do not Intubate (DNI) - A DNI or “Do Not Intubate” order means that chest
compressions and cardiac drugs may be used, but no breathing tube will be placed
through mouth into the trachea (windpe0 to help with breathing.
c. Palliative Care - Palliative care is an approach that improves the quality of life of
patients (adults and children) and their families who are facing problems associated with
life-threatening illness.
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Palliative care is explicitly recognized under the human right to health. It should be
provided through person-centered and integrated health services that pay special attention
to the specific needs and preferences of individuals

GUIDELINES FOR EFFECTIVE COMMUNICATION TO FACILITATE END-OF-

LIFE CARE

• Present a clear and consistent message to the family. Mixed messages confuse families and
patients, as do unfamiliar medical terms. The multi professional team needs to
communicate and strive to reach agreement on goals of care
and prognosis.
• Allow ample time for family members to express themselves during family conferences. This
increases their level of satisfaction and decreases dysfunctional bereavement patterns after the
patient’s death.
• Aim for all (healthcare providers, patients, and families) to agree on the plan of treatment. The
plan should be based on the known or perceived preferences of the patient. Arriving at such a
plan through communication minimizes legal actions against providers, relieves patient and
family anxiety, and provides an environment in which the patient is the focus of concern.
• Emphasize that the patient will not be abandoned if the goals of care shift from aggressive
therapy to “comfort” care (palliation) Let the patient and family know who is
responsible for their care and that they can rely on those individuals to be present and available
when needed.
• Facilitate continuity of care. If a transfer to an alternative level of care, such as a hospice unit or
ventilator unit, is required, ensure that all pertinent information is conveyed to the new providers.
Details of the history, prognosis, care requirements, palliative interventions, and psychosocial
needs should be part of the information transfer.

D. Collaboration:
International Patient Safety Goals: (IPSG) - The International Patient Safety Goals (IPSG)
were developed in 2006 by the Joint Commission International (JCI). Health care professionals
have been challenged to reduce medical errors and promote an environment that facilitates safe
practices.

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1. IPSG1 - Identify Patients Correctly

• Using 2 identifiers (Name and ID band)
• Before administering medications, blood, or blood products
• Before providing treatments and procedures
• Policies and procedures support consistent practice in all situations
2. IPSG 2 – Improve Effective Communication
• Complete verbal and telephone order were written down by the receiver
• Read back by the receiver of the order
• Confirmed by the individual who gave the order
3. ISG 3 – Improve the Safety of High Alert Medications

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• Medications involved in a high percentage of error and sentinel events
• Medications that carry a higher risk for adverse outcomes
• Look-a like /sounds -a like medications
• Policies and procedures are developed to address the identification, location, labeling and
storage of high alert medications
• The policies and procedures are implemented
4. IPSG 4 -Ensure Correct Site, Correct -Procedure, Correct Patient Surgery
• Uses an instantly recognized mark for surgical site, identification and involves the patient
in the marking process
• Uses a checklist to verify preoperatively the correct site, correct procedure, and correct
patient and that all documents and equipment needed are on hand, correct, and functional
• The full surgical team conducts and documents a time-out procedure just before starting a
surgical procedure
• Policies and procedures are developed that support uniform process to ensure the correct
site, correct procedures, and correct patient
5. IPSG 5 – Reduce the Risk of Health Care -Associated Infections
• Follow and adapted hand hygiene guideline
• Implements an effective hand hygiene program
• Policies and procedures are developed that support continued reduction of health care –
associated infections (HCAI)
6. IPSG 6 – Reduce the Risk of Patient Harm resulting from Falls
• Implements a process for the initial assessment of patients for fall risk and reassessment
of patients when indicated by a change in condition or medications
• Measures are implemented to reduce fall risk for those assessed to be at risk.
• Measured are monitored for results, both successful fall injury reduction and any
unintended related consequences.

III. Levels and Categories of Critical Care in the Philippines:

Physical set -up and supporting facilities critical care units in the Philippines, the Department
of Health (DOH) Standards requires the critical care units / intensive care unit to be a self-
contained area, with the provisions for resources that will support critical care practice.

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A. Level of Care:
1. Level 1 –
• Should be capable of providing immediate resuscitation for the critically ill and short-
term cardio-respiratory support because the patients are at risk of deterioration.
• Has a major role in monitoring and preventing complications in “at risk” medical and
surgical patients
• Must be capable of providing mechanical ventilation and simple invasive cardiovascular
monitoring.
• Has a formal organization of medical staff and at least one registered medical officer
available to the unit at all times
• A certain number of nurses including the nurse in-charge of the unit should possess post-
registration qualification in critical care or in the related clinical specialties; and has a
nurse: patient ratio of 1:1 for all critically ill patients.
2. Level 2 –
• Should be capable of providing a high standard of general critical care for patients who
are stepping down from higher levels of care or requiring single organ support/support
post-operatively.
• Capable of providing sustainable support for mechanical ventilation, renal replacement
therapy, invasive hemodynamic monitoring, and equipment for critically ill patients of
various specialties such as medicine, surgery, trauma, neurosurgery, vascular surgery
• Always has a designated medical director with appropriate intensive care qualification
and a duty specialist available exclusively to the unit
• The nurse in-charge and a significant number of nursing staff in the unit have critical care
certification; and A nurse: patient ratio is 1:1 for all critically ill patients.
3. Level 3 –
• Is a tertiary referral unit, capable of managing all aspects of critical care medicine (This
does not only include the management of patients requiring advanced respiratory support
but also patients with multi-organ failure
• Always has a medical director with specialist critical / intensive care qualification and a
duty specialist available exclusively to the unit and medical staff with an appropriate
level of experience present in the unit.
• A nurse in-charge and most nursing staff have intensive care certification; and A nurse:
patient ratio is at least 1:1 for all patients always.

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B. Level of Acuity:
Acuity levels help nurse managers set appropriate staffing levels in acute care, long-term
care and other treatment and rehabilitation settings., patients requiring a greater degree of
observation and intervention from nurses receive a higher acuity rating.
Patients with high levels of acuity must be monitored frequently to ensure that they
progress or remain stable. Nurses must monitor these patients on a regular basis since they
can swiftly deteriorate. As a result, increased staffing levels are required in high-acuity units
and facilities. Acuity scales are frequently used by nurse managers to determine how many
nurses are required for specific shifts.
IV. Factors influence an individual’s response to illness
Many factors influence an individual’s response to critical illness. Stressors related to both
treatment and the critical care environment affect patients. Many individuals suffer from
posttraumatic stress disorder (PTSD) after treatment in a critical care setting
Pain is a major issue for all critically ill patients, whether conscious or not. It may be induced
directly by disease, through invasive procedures, or from routine interventions such as
suctioning, turning, and bathing.

1. PATIENTS’ RECOLLECTION OF THE CRITICAL CARE EXPERIENCE

• Difficulty communicating
• Pain
• Thirst
• Difficulty swallowing
• Anxiety
• Lack of control
• Depression
• Fear
• Lack of family or friends
• Physical restraint
• Feelings of dread
• Inability to get comfortable
• Difficulty sleeping
• Loneliness
• Thoughts of death and dying

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2.Discharge and health teaching plan

Many critically ill patients can recover from their illnesses and injuries. Even though leaving
from a critical care unit signifies progress toward recovery, many patients are discharged
“quicker and sicker” either to units that care for patients in lesser acuity or long-term care
hospitals or transfer to their own home.
Transfer or discharge from the critical care unit often results in stress for both patients and
families.
Discharge planning and teaching patients and their families are essential nursing interventions
to improve patient and family outcomes. One technique used to facilitate teaching and learning is
the teach-back method, in which patients and family members are asked to repeat the
information and instructions they have been given.
a. Geriatric Concerns:
Some elderly patients have a diminished ability to adapt and cope with the major physical
and psychosocial stressors of critical illness. Anxiety and fears are some concerns of the geriatric
critically ill patients, the elderly patient is at greater risk of negative outcomes.
b. Family Members:
The family is an integral part of the healing process of the critically ill patient, and critical
care nursing interventions must also focus on the family.
The concept of treating the patient and family as an inseparable entity, realizing that the
illness or injury of one family member usually impacts all other family members, is known as
family-centered care.

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The FAMILY Bundle:

Five Steps to Helping Your Patient’s Family
EPICS family bundle. (From Knapp S. Effects of an Evidence-based Intervention on Stress
and Coping of Family Members of Critically Ill Trauma Patients. Unpublished Dissertation,
University of Central Florida, Orlando, Florida; 2009.)

COMMUNICATE
EVALUATE PLAN INVOLVE Answer questuions
determine how
Assess quckly family honestly
Family to best meet participation Provide information SUPPORT
background needs Be family advocate
Discuss care Encourage
Otehr stressors Plan family with family conversation Provide assistance,
Coping skills participation Simple direct resources
Organize Inquire how family is
Needs patient care
ENHANCING COMMUNICATION
meetings WITH FAMILY MEMBERS: doing Show concern
Desire to be Encourage Invite Assist in
involved touching suggestions communccation with
VALUE PRINCIPLES: other providers

V—Value what the family tells you

A—Acknowledge family emotions
L—Listen to the family members
U—Understand the patient as a person
E—Elicit (ask) questions of family members
From Lautrette A, Darmon M, Megarbane B, et al. A communication
strategy and brochure for relatives of patients dying in the ICU.
New England Journal of Medicine. 2007;356(5):469-478

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Bedside HANDOVER in Critical Care Units:

1. Airway – if Intubated check ET tube. the cuff is locked(inflated) and the number placement of
ET tube is intact (markings-length of ET tube)
2. Breathing – check chest rises, symmetrical (equal expansions), auscultate chest even with
mechanical ventilator attached, (secured) appropriate oxygen level set-up
3. Circulation – Touch patient to feel if warm or cold (upper and lower extremities), skin color,
check IV lines (no obstructions, IV sites), check appropriate IV drops on different IV drugs,
Check all lines or contraptions attached (proper label with date and time)
4. Disability and Drugs – check body weaknesses, mobility, the drugs effects right dosage,
regulations), neuro and motor assessment.
5. Exposure and Environment – look under the blankets – abdomen, pressure areas, catheters,
skin integrity, edematous (if any), leg compressions, eye care (no blink), mouth care

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Common Equipment in Critical Care Units:

1.Endotracheal tube (ET):
An ET tube is a tube that is inserted through the patients’ mouth into their windpipe. It is used
in the ICU for patients who are having difficulty breathing because of a lung problem, or for
patients who are not awake enough to breathe for themselves. The ET Tube is connected to
tubing which is connected to a ventilator.

2. Mechanical Ventilator:
The ventilator has different setting, and it is adjusted
according to the needs of a patient. Sometimes the patient is taking
their own breaths and we support these, or sometimes we need to set
the ventilator to give them each breath. The nurse at the bedside will
be able to explain the level of support that your relative needs, and why.

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3. Tracheostomy:
A surgical procedure where a hole is made in a patient’s neck and a small tube is inserted into
their windpipe. The tracheostomy tube is then attached to the ventilator, or oxygen support. A
tracheostomy is sometimes and option to patients who require long term ventilation, difficult
weaning from the ventilator, and patients with copious secretions. When a patient no longer
requires ventilator support and only needs oxygen therapy, oxygen tube can be connected to the
tracheostomy.

4. Arterial Line:
This is a line that goes into the patients’ artery.
It allows the nurse to see the blood pressure continuously
and also allows the nurse to take bloods when required.
It is a red line that usually goes into a patients arm and
is connected to the cardiac monitor (the box that
looks like a tv) and shows the blood pressure constantly.

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5. Cardiac Monitor:
A cardiac event monitor is a device that you control to record
the electrical activity of your heart (ECG). This device is about
the size of a pager. It records your heart rate and rhythm.
Cardiac event monitors are used when you need long-term
monitoring of symptoms that occur less than daily.
Continuous cardiac monitoring allows for prompt identification
and initiation of treatment for cardiac arrhythmias and other conditions.

6. Infusion Pumps:
Majority of these patients will need these pumps.
These are pumps that you will see beside the patient, and they
control the amount of medication or fluid that a patient
receives and how fast or slow it can be given. You will see
fluids and bags of medication hanging over these on a pole.
The fluid or medication flows through plastic lines and passes
through the pump and into the patient.

7. Central Line:
This is a line that goes in through one of the large blood vessels in the neck or the groin. This
line allows us to give multiple medications at the same time, and to give strong medications that
can only go through a large vessel. The medications flow through the pumps and connect to
these lines into the body. The ICU team usually place this line in the ICU, or sometimes it is
done in theatre before an operation.

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8. Thrombo- Embolic Deterrent Stockings (TEDS):

You may notice the patient is wearing long green socks. These tight-fitting socks help prevent
the development of blood clots in the legs. These clots can form due to the pooling of blood in
veins during long periods of inactivity. Some people wear similar socks when taking a long
flight.

9. Nasogastric Tube:
This tube goes through a patients nose and down into their stomach. It allows us to feed them
when they are too unwell to eat and drink as they normally would or when their appetite is
reduced due to illness. We can also give them medication through this tube.

10. Total Parenteral Nutrition:

Total Parenteral nutrition (TPN) is intravenous administration of nutrition,
which may include protein, carbohydrate, fat, minerals and electrolytes,
vitamins and other trace elements for patients who cannot eat or absorb

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enough food through tube feeding formula or by mouth to maintain good
nutrition status. Achieving the right nutritional intake in a timely manner
can help combat complications and be an important part of a patient’s recovery

11. Urinary Catheter:

. In the ICU, a patient may have a urinary catheter put in place to monitor an hourly output.
This allows us to calculate how much fluid is going in, versus how much is coming out. We can
get ensure that we prevent patients becoming fluid overloaded or dehydrated.

LEARNING RESOURCES:

https://youtu.be/26NadjAnnBc
https://youtu.be/GRn5UbmkrdA

REFERENCES:

Booker, K. J. (2015). Critical Care Nursing: Monitoring and Treatment for Advanced Nursing
Practice (1st ed.). Wiley-Blackwell.

Ccrn, L. M. A. R. A. (2011). Fast Facts for the Critical Care Nurse: Critical Care Nursing in a Nutshell
(1st ed.). Springer Publishing Company.

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Fccm, S. M. P. R. C. C. F. L., Faan, K. D. M. R. A. C. F. G., & Vha-Cm, C. C. R. P. M. M. J. (2012).
Introduction to Critical Care Nursing (Sole, Introduction to Critical Care Nursing) (6th ed.).
Saunders.

Hall, J., Schmidt, G., & Kress, J. (2015). Principles of Critical Care, 4th edition (4th ed.). McGraw-
Hill Education / Medical.

Smeltzer, S. C. (2021). Brunner and Suddarth’s Textbook of Medical Surgical Nursing: In One
Volume (Brunner & Suddarth’s Textbook of Medical-Surgical Nursing) Twelfth, North American
Edition, Combined Volume edition (32105th ed.). Example Product Manufacturer

Prepared by:
Mary Ann Q. Bayani MAN RN

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