NCM 118 Notes Prelim

CRITICAL CARE NURSING GUIDELINES, STANDARDS The expanding healthcare and nursing knowledge
AND COMPETENCIES together with new and evolving healthcare sites,

structures, and technologies all have contributed to the
need and desire for specialty nursing organizations like
INTRODUCTION the Critical Care Nurses Association of the Philippines,
Inc. (CCNAPI) to revisit the existing statements of its
The health care industry all over the world has been Standards of Nursing Practice to provide clear and
undergoing significant changes over the past two updated statements regarding the scopes of practice
decades and the Philippines has been part of these and standards of critical care nursing. This will ensure
transformational events having great impact on the continued understanding and acknowledgment of
quality of nursing practice. There are new expectations nursing’s varied specialty professional contributions in
in the way nurses and the nursing practices are to be today’s healthcare environment.
delivered particularly now that there are many
challenges that besiege the nursing profession as a
consequence of the complexities of globalization. The CCNAPI Standards of Practice of 1982 has been
revisited and revised to be aligned with the 2005BON
statements of the 11 Core Competencies for Entry Level
Critical care nursing is the specialty within nursing that for Safe and Quality Nursing Care. The CCNAPI Core
deals specifically with human responses to life- Competencies of a Critical Care Nurse are stated
threatening problems1.These problems deal according to the levels of expected behavior defining
dynamically with human responses to actual or the actual knowledge, skills and abilities in the practice
potential life-threatening illnesses. of critical care by a nursing professional. These
statements cover expected behavior of a Nurse
The framework of critical care nursing is a complex, Clinician I, Nurse Clinician II and Nurse Specialist that
challenging area of nursing practice. It utilizes the will serve as the basis for assessing competence in
nursing process applying assessment, diagnosis, critical care practice. The statement of the goals, scope
outcome identification, planning, implementation, and of practice, competencies and standards on the care of
evaluation. The critical care nursing practice is based on the critically ill are all important aspects that are
a scientific body of knowledge and incorporates the emphasized in this paper.
professional competencies specific to critical care
nursing practice and is focused on restorative, curative,
rehabilitative, maintainable, or palliative care, based on The focus of care for the critically ill patient is holistic.
identified patient’s need3. It upholds multi and However, to organize statements in this paper,
interdisciplinary collaboration in initiating interventions physiological focus has been categorized under bodily
to restore stability, prevent complications, achieve and functional systems such as pulmonary system,
maintain optimal patient responses. The critical care cardiovascular system, renal system, neurological
nursing profession requires a clear description of the system and other system.
attributes guidelines and nursing practice standards in
guiding the critical care nursing practice to fulfill this
purpose. The specific objectives of this paper are to:
- To identify Critical Care Nursing Service characteristics

In the Philippines, the Professional Regulation and contributions of nurses to patient care in the
Commission – Board of Nursing (PRC-BON) is specialty.
committed to provide need-driven, effective and - To develop specific competencies required for the
efficient specialty nursing care services of high standard delivery of nursing care in the critical care.
and at international level within the obtainable - To provide a framework for evaluation of nursing
resources. To respond to this mission and commitment, practice within the specialty of critical care.
a PRC-BON Working Group in Developing the Nursing - Provide a basis for the assessment of continuous staff
Specialty Framework was formed in the 1996 to take on development needs in critical care nursing.
the task of setting the process-based framework and - Guide the development of collaborative working
guidelines for specialty nursing services. The Working relationships with other members of the health care
Group members are clinical nurse practitioners, nurse team.
educators and nurse managers.
This process-based framework not only describes the

critical care nursing services in the Philippines, but also
assists critical care nurses to have a better environment with specially trained nurses, appropriate
understanding of what is expected of them from the equipment, adequate medical supplies and other
organization and the public perspectives. members of the health care personnel.
THE RIGHT OF THE CRITICALLY ILL PATIENT
PHILOSOPHY OF CRITICAL CARE NURSING

The International Council of nurses (ICN) views health
care as the rights of every individual regardless of
Critical Care Nursing reflects a holistic approach in financial political, geographical, racial and religious
caring of patients. It places great emphasis on the consideration. This right includes the right to choose or
caring of the bio-psycho-social-spiritual nature of decline care, including the right to accept or refuse
human beings and their responses to illnesses rather treatment or nourishment; informed consent;
than salary on the disease process. It helps maintain the confidentiality and dignity, including the right to die
individual patient’s identity and dignity. The focus of with dignity. It involves both the right of those seeking
caring includes preventive care, risk factor modification care and the providers⁵.
and education to decrease future patient admissions to
acute care facilities.
The World Federation of Critical Care Nurses (WFCCN)
has considered the rights of the critically ill patients,
The Critical Care Nurses of the Philippines, Inc. (CCNAPI) WFCCN has agreed that the statement of the patient’s
is responsible for the promotion of man’s health and right from the ICN covers the requirement for position
welfare for national development. It desires to support statement on the rights of the critically ill patients.
the professional and personal growth and development
of initial core nurses. CCNAPI has organized itself into a
national association committed to the ideals of service CCNAPI being a founding member of WFCCN likewise
to the people, equality, justice and social progress. supports the ICN position statement on Nurses and
Human Rights as stated in Annex I.
In the Critical Care Units, each patient is viewed as a GOALS OF CRITICAL CARE NURSING
unique individual with dignity and worth. The critically
ill patient should receive comfort and provided privacy
in a highly technological environment. In collaboration Critical or intensive care is a complex specialty
with other health care team members, critical care developed to serve the diverse health care need of
nurses provide high level of patient care which includes patients (and their families) with actual or potential life
patient and family education, health promotion and threatening conditions3. It is therefore important that a
rehabilitation. To achieve this holistic care process, clear statement of what critical care nursing wishes to
participation by the patient and his/her family is always achieve and provide should be articulated.
emphasized. At the forefront of critical care science and
technology, critical care nurses maintain professional
competence based on a broad base of knowledge and
experience through continuous education and Goals of Critical Care Nursing include the following:
evidence-based research.
-To promote optimal delivery of safe and quality care to

With the advances in sophisticated biomedical the critically ill patients and their families by providing
technology and knowledge, critical care nurses are able highly individualized care so that the physiological
to continuously monitor and observe patients for dysfunction as well as the psychological stress in the
physiological changes to confront problems proactively ICU are under control;
and to assist patients achieve and maintain an optimum
level of functioning or a peaceful death.
-To care for the critically ill patients with a holistic
approach, considering the patient’s biological,
In other words, this nursing philosophy of the CCNAPI is psychological, cultural and spiritual dimensions
accomplished by looking after critically ill patient in an regardless of diagnosis or clinical setting;
Level 1
-To use relevant and up-to-dateknowledge, caring Should be capable of providing immediate resuscitation
attitude and clinical skills, supported by appropriate for the critically ill and short term cardio-respiratory
technology for the prevention, early detection and support because the patients are at risk of deterioration;
treatment of complications to facilitate recovery. Has a major role in monitoring and preventing
complications in “at risk” medical and surgical patients;
Must be capable of providing mechanical ventilation
-To provide palliative care to the critically ill patients in and simple invasive cardiovascular monitoring;
situations where their health status is progressing to Has a formal organization of medical staff and at least
unavoidable death, and to help the patients and one registered nurse.
families go through their painful sufferings. 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
On the whole, critical care nursing should be patient- specialties; and
centered, safe, effective, and efficient. The nursing Has a nurse: patient ratio of 1:1 for all critically ill
interventions are expected to be delivered in a timely patients.
and equitable manner.
Level 2
LEVELS & CATEGORIES OF CRITICAL CARE PROVISIONS Should be capable of providing a high standard of
WITHIN PHILIPPINES general critical care for patients who are stepping down
from higher levels of care or requiring single organ
support/support post-operatively;
With respect to the physical set-up and supporting Capable of providing sustainable support for
facilities of critical care units in the Philippines, the mechanical ventilation, renal replacement therapy,
Department of Health (DOH) Standards requires the invasive hemodynamic monitoring and equipment for
critical care units / intensive care unit to be a self- critically ill patients of various specialties such as
contained area, with the provisions for resources that medicine, surgery, trauma, neurosurgery, vascular
will support critical care practice. Currently, the DOH is surgery;
reviewing these standards to come-up with updated Has a designated medical director with appropriate
requirement. intensive care qualification and a duty specialist
available exclusively to the unit at all times;
The nurse in-charge and a significant number of nursing
In 2003, the Philippine Society of Critical Care Medicine staff in the unit have critical care certification; and
(PSCCM), Society of Pediatric Critical Care Medicine A nurse: patient ratio is 1:1 for all critically ill patients.
(SPCCM) and the CCNAPI stratified the care provisions
in critical care practice into different levels and Level 3
categories to make it similar to its counterparts
overseas with the goal of having effective utilization Is a tertiary referral unit, capable of managing all
and organization of resources. Hence, as a guide, aspects of critical care medicine (This does not only
CCNAPI will incorporate these standards into this include the management of patients requiring
guideline. advanced respiratory support but also patients with
multi-organ failure);
Has a medical director with specialist critical / intensive
Levels of Care Provision care qualification and a duty specialist available
exclusively to the unit and medical staff with an
The role of a particular critical care unit will vary, appropriate level of experience present in the unit at all
depending on the staffing, facilities and support times;
services as well as the type and number of patients it A nurse in-charge and the majority of nursing staff have
has to manage. Taking into consideration the intensive care certification; and
recommendation of the Guidelines on Critical Care A nurse: patient ratio is at least 1:1 for all patients at all
Personnel and Services published in 2003 by the Critical times.
Care Medicine⁴, the critical care service provision in the
Philippines can adapt theses guidelines and apply the 3
levels of classifications accordingly: Categories of Critical Care Unit
The Critical Care Unit can be categorized according to should have the relevant qualification in the specialty of
patients’ age group or medical specialties. the respective Unit.
A. Age Group
B. Neonatal SCOPE OF CRITICAL CARE NURSING
C. Pediatric
D. Adult The scope of critical care nursing is defined by the
dynamic interactions of the critically ill patient/family ,
Specialty the critical care nurse and the critical care environment
to bring about optimal patient outcomes through
In the existing environment, majority of the Critical nursing proficiency in an environment conducive to the
Care Units in the Philippines provide service for patients provision of this highly specialized care4.
of various specialties. They are labeled as General ICUs.
In certain hospitals, the critical care unit / service is Constant intensive assessment, timely critical care
dedicated to the following specific groups: interventions and continuous evaluation of
management through multidisciplinary efforts are
- Medical required to restore stability, prevent complications and
- Surgical achieve optimal health. Palliative care should be
- Cardio-thoracic instituted to alleviate pain and sufferings of the patient
- Cardiac and family in situations where death is imminent.
- Respiratory
- Neurosurgical Critical Care Nurses are registered nurses, who are
- Trauma trained and qualified to practice critical care nursing.
They possess the standard critical care nursing
System Operation of Critical Care Units competencies in assuming specialized and expanded
roles in caring for the critically ill patients and their
The operation of critical care units can be classified into family. Likewise, each critical care nurse is personally
Open System and Closed System. responsible and committed to continuous learning and
updating of his/her knowledge and skills. The critical
A. Open System care nurses carry out interventions and collaborates
patient care activities to address life-threatening
The admitting and other attending doctors dictate situations that will meet patient’s biological,
management, change management or perform psychological, cultural and spiritual needs.
procedures without consultation or communication
with a Critical Care Specialist. A Critical Care Specialist
may be available for advice or be consulted to provide The critical care environment constantly support the
interventional skills (optional). No designated person interactions between the critically ill patients, their
who assumes the “gatekeeper” role. family and the critical care nurses to achieve desired
patient outcomes. It entails readily available and
accessible emergency equipment, sufficient supplies
B. Closed System and effective support system to ensure quality patient
care as well as staff safety and productivity.
Management is coordinated by a qualified Critical Care
Specialist. The critical / intensive care specialist has
clinical and administrative responsibility. There is a CRITICAL CARE NURSE QUALIFICATION
multi-disciplinary team of specially trained critical care
staff. The “intensivist” is the final common pathway for
all medical decision-making including the decision to
admit or discharge patients. A critical care nurse is a licensed professional nurse who
is responsible for ensuring that all critically ill patients
Irrespective of the ICU “System” Operations, i.e. open and their families receive optimal care.
system or closed system, or a mixture of the two, there
should be a designated group of registered nurses
under unique management to provide highly
specialized care to the critically ill patients. The nurse To be able to work in a critical care area other
in-charge and the majority of nursing staff in each unit requirements are necessary and may vary depending on
the institution. In the nursing schools, critical care
nursing is considered an elective subject and the 1. Care Provider
exposure of students to critical care practice may not
be enough to prepare them for the complexity of A. Direct patient care
critical care nursing practice once these student nurses
become licensed professional nurses. Therefore, it is - Detects and interprets indicators that signify the
necessary that the health institution as employer varying conditions of the critically ill with the assistance
provide newly hired nurses with a basic critical care of advanced technology and knowledge;
nurse specialty education and orientation prior to the - Plans and initiates nursing process to its full capacity
deployment in the critical care areas. In the Advanced in a need driven and proactive manner;
Practice Nursing level, the advanced practice nurses in - Acts promptly and judiciously to prevent or halt
the critical care, must earn an advanced degree either deterioration of patients’ condition when conditions
at the master’s or doctorate level in nursing. warrant, and
- Co-ordinates with other healthcare providers in the
provision of optimal care to achieve the best possible
outcomes.
CRITICAL CARE NURSING WORKFORCE
B. Indirect patient care – Care of the Family
The CCNAPI adopt the Position Statement of the World Understands family needs and provide information to
Federation of Critical Care Nurses on the Provisions of allay fears and anxieties and
Critical Care Nursing Workforce also called” the Assists family to cope with the life-threatening situation
Declaration of Buenos Aires” ratified in the full council and/or patient’s impending death.
meeting last
August 27, 2011 at the Sheraton Hotel, Buenos Aires, 2. Extended roles as critical care nurses
Argentina.
Critical care nurses have roles beyond their professional
The declaration presents guidelines universally boundary. With proper training and in accordance with
accepted by critical care professionals, which should be established guidelines, algorithms, and protocols that
adopted to meet the critical care nursing workforce and are continuously reviewed and updated, critical care
the system requirements of a particular country or nurses also perform procedures and therapies that are
jurisdiction. The declaration states the specific central otherwise done by doctors. Such procedures and
principles governing the provision and provides for therapies are:
specific recommended critical care nursing workforce
requirement. The complete declaration is attached as a. Sampling and analyzing arterial blood gases;
Annex II to this guideline.
b. Weaning patients off ventilators;
ROLES OF THE CRITICAL CARE NURSES c. Adjusting intravenous analgesia / sedations;
d. Performing and interpreting ECGs;
In response to the changes and expansions within and e. Titrating intravenous and central line medicated
outside the healthcare environment, critical care nurses infusion and nutrition support;
have broadened their roles in the practice levels.
Competencies of critical care nurses are honed and f. Initiating defibrillation to patient with ventricular
developed to achieve their roles in practice, fibrillation or lethal ventricular tachycardia;
management / leadership and research.
g. Removal of pacer wire, femoral sheaths and chest
tubes,and
Practitioner Role
h. Other procedures deemed necessary in their
The critical care nurses execute their practice roles 24- respective institutions under a clinical protocol.
hours a day to provide high quality care to the critically
ill patient.
3. Educator C. Utilization of guidelines in the evaluation of research
study or report
As an educator, the critical care nurse must be able to: D. Application of the research process in improving
patient care infusing concepts of quality improvement
Provides health education to patient and family to in partnership with other team-players.
promote understanding and acceptance of the disease
process thus facilitate recovery and
Participates in the training and coaching of novice
healthcare team members to achieve cohesiveness in ADVANCED PRACTICE LEVEL
the delivery of patient care.
The development of the Advanced Practice Nursing is

4. Patient Advocate the future direction in the Philippines and to be bench
marked with other countries. For now, a thorough
The critical care nurses’ role includes being an advocate study of Advanced Practice in critical care is being
– someone who acts or intercedes on behalf or another. undertaken to align with the PRC- BON initiative on
Typically, the critical care nurse may be in the best specialization framework.
position to act as the liaison between patient and family
and other team members and departments because
they are the healthcare professionals with the most The current global healthcare environment demands
interpersonal contact with the patients. To perform this critical care nurses to have advanced knowledge and
function adequately, the nurse must be knowledgeable skills to provide the highest possible level of care to the
about the involved in all aspects of the patient’s care critically ill patients. CCNAPI supports the following
and have a positive working relationship with other descriptions of advanced practice roles.
team members. The critical care nurses are expected to:
Acts in the best interests of the patient and

Monitors and safeguards the quality of care which the Expanded Roles
patient receives.
A. Nurse Specialist / Clinical Nurse Specialist
Management and Leadership Role
The education and preparation of the critical care nurse
The critical care nurse in her management and practitioner is provided by the respective hospitals.
leadership role will be able to assume the following CCNAPI recommends that a graduate study or a
responsibilities: master’s degree program should support the
development of critical care nursing specialization goes
Performance of management and leadership skills in beyond the basic baccalaureate nursing degree.
providing safe and quality care; Advanced educational preparation refers to the critical
Accountability for safe critical care nursing practice; care nursing educational program run by the university
Delivery of effective health programs and services to offering Advanced Nursing Studies or other recognized
critically-ill patients in the acute setting; advanced critical care program offered in the
Management of the critical care nursing unit or acute Philippines and overseas.
care setting;
Taking the lead and supervision of nursing support staff,
and
Utilization of appropriate mechanism for collaboration, A registered nurse who is a nursing degree holder,
networking, linkage –building and referrals. should have more than 3 years of uninterrupted
practice experience in the critical care field.He/she can
function as a critical care nurse specialist when he/she
Role in Research has attained advanced education and expertise in
caring patients with critical problems. He/she is also
A. The critical care nurse’s role in research will entail eligible to be certified by the PRC- Board of Nursing as a
the following responsibilities: Clinical Nurse Specialist.
B. Engage self in nursing or other health – related
research with or under the supervision of an
experienced researcher;
The critical care nurse specialist is responsible for - To develop, foster and maintain a level of knowledge
building up nursing competencies in the ICU entity. He / about the norms, values, beliefs, patterns of illness,
She contributes to continuous improvement in critical health and care needs of the people;
care nursing through staff and clients education and - To analyze and evaluate critical care nurses specialty
uphold quality nursing guidelines on patient care skills and their evolving roles;
through clinical research and refinement of ICU - To review current studies and researches and to
Standards. examine contextual issues that will enable evaluation
and synthesis of new knowledge, traditional techniques,
religious and cultural influences to be applied in nursing
practice, particularly evidence-based nursing practice,
B. Acute Care Nurse Practitioner and
- To exercise professional judgments expected of them
Acute Care Nurse Practitioner (ACNP) in the critical care in the critical care clinical setting.
unit takes lead in developing evidence-based practices
to meet changing clinical needs and facilitates patient
care processes across professional and organizational TRAINING OF NURSES FOR CRITICAL CARE SERVICES
boundaries. The qualification of Acute Care Nurse
Practitioner (ACNP) includes: should have the The institution / hospital should provide training
recommended number of post registration (licensed opportunities to ensure staff competencies. This will
experience) nursing experience which are spent in the enable the nurses working in the critical care units to
critical field, exhibiting in –depth professional cope with the complexities and demands of the
knowledge and skills. An Acute Care Nurse Practitioner changing needs of the critically ill patients. The
(ACNP) is a holder of: a) clinical master’s degree in a following training activities should be supported by the
clinical nursing specialty (Medical-Surgical) such as higher level of management to maintain a high
Critical Care Nursing or b) master’s degree in nursing or standard of care:
related discipline such as management together with
recognized critical care training qualifications. The
Acute Care Nurse Practitioner executes the nursing Orientation Program / Preceptorship and Mentoring
team leader’s responsibilities as designated in the Program
position of Advanced Nurse Practitioner.
New recruits to the critical care units shall attend an
orientation program and be given opportunities to work
under senior staff supervision. Experienced staff in the
C. Outcome Specialist unit should be readily available for consultation.
Outcome management has been introduced into the

healthcare system to ensure achievement of quality In-Service Training Program
and cost-effectiveness in the delivery of patient care.
Some critical care units have adopted clinical pathways a. Unit / hospital based training courses / workshop /
(e.g., Critical Pathways, Protocols, Algorithms and seminar at hospital level
Orders) in the management of specific diseases such as
Acute Myocardial Infarction and Cardio-thoracic b. On-the-job training and bedside supervision
Surgeries. Qualified nurse experts are involved in the
development and implementation of patient outcomes Critical Care Nursing Program (Post Graduate Specialty
management. Program)
Critical Care Nurses Association of the Philippines, Inc.

recommends that all practicing CCN shall continuously
CHALLENGES OF CRITICAL CARE NURSES update their knowledge, skills and behavior through
active participation in Critical Care Nursing Education or
its related field.
The challenging needs that the advanced critical care

practitioner will face from the critical care nursing The following are categorization of critical care nursing
service and its environments demand for them to education:
consider the following objectives:
- Post Graduate Courses
- Post graduate courses are part of higher education
taken after a Bachelor’s Degree that are accredited - Advanced/Comprehensive Critical Assessment
from the Commission on Higher Education (CHED) or - Critical Care Practitioner
the Professional Regulation Commission—Board of - End-of-Life and Palliative Care
Nursing (PRC-BON).
STANDARDS OF CRITICAL CARE NURSING PRACTICE
It is recommended that this course has been reviewed,
evaluated and endorsed to the accrediting body by the
Critical Care Nurses Association of the Philippines, Inc. Critical care specialty addresses the management and
support of patients with severe or life-threatening
Likewise it is further recommended that the World illness. The goal of critical care nursing is to promote
Federation of Critical Care Nurses policy statement of optimal adaptation of critically ill patients and their
education shall be used as a framework for designing a families by providing highly individualized care, so that
critical care nursing program. (Please see Declaration of the critically ill patients adapt to their physiological
Madrid, 2005 Annex I) dysfunction as well as the psychological stress in the
Critical Care Unit or Intensive Care Unit (ICU). To
Certification Course achieve this, standards should be developed to serve as
a guide for monitoring and enhancing the quality of
Certification courses provides recognition and intensive care nursing practice.
designation earned by a professional nurse after
completing with satisfaction the requirements of the
course and has earned qualification to perform a job or
task. Care standards for critical care nursing provide
measures for determining the quality of care delivered,
The certification courses should be recognized and and also serve as means for recognizing the
accredited by the Professional Regulation competencies of nurses in intensive care specialty.
Commission— Board of Nursing (PRC-BON) or other
authorized accrediting body.
Procedures standards for critical care nursing practice
This shall include but not limited to the following: provide a step-by-step guideline for nurses to carry out
day-to-day nursing procedure in a most appropriate
- Advanced Cardiac Life Support manner.
- Pediatric Advanced Cardiac Life Support
- Newborn Resuscitation
- Continuous Renal Replacement Certification The following 11 Standards are intended to furnish
- Advanced Intravenous therapy nurses with directions in providing quality care and
- Stroke Nursing excellence in Critical Care Nursing:
Continuing Professional Education (CPE)

1. The critical care nurse functions in accordance with
Continuing Professional Education Programs is a type of legislation, common laws, organizational regulations
education that consist of updated knowledge and other and by-laws, which affect nursing practice.
pertinent information that will help the Critical Care
Nurse to attain broader understanding of criticalcare 2. The critical care nurse provides care to meet
practice and its related field. The goal includes Critical individual patient needs on a 24-hour basis.
Care Nurses development of skill, behavior that will
help them view the critically ill person in a holistic 3. The critical care nurse practices current critical care
dimension nursing competently.
CCNAPI recommends that all practicing CCN shall 4. The critical care nurse delivers nursing care in a way
ensure the they continuously update their knowledge, that can be ethically justified.
skills and behavior through active participation in
related critical care nursing education and must earn at 5. The critical care nurse demonstrates accountability
least 20 credit units per year. for his/her professional judgment and actions.
The updated educational component includes but not

limited to the following:
6. The critical care nurse creates and maintains an
environment which promotes safety and security of 9. The critical care nurseutilizes the nursing process in
patients, visitors and staff. an explicit systematic manner to achieve the goals of
care.
7. The critical care nurse masters the use of all essential
equipment, available services and supplies for 10. The critical care nurse carries out health education
immediate care of patients. for promotion and maintenance of health.
8. The critical care nurse protects the patients from 11. The critical care nurse acts to enhance the
developing environmental induced infection. professional development of self and others.
The Structure-Process-Outcome model is used. Emphasis is put on management systems, nursing activities and
interactions between the nurse and the care recipients, as well as the outcomes of nursing care provided.
Standard Statement 1: The critical care nurse functions in accordance with legislation, common laws, organizational
regulations and by-laws, which affect nursing practice.
STRUCTURE CRITERIA PROCESS CRITERIA OUTCOME CRITERIA

1. A copy of the Code of Professional The critical care nurse:1.Gains access 1. Patient/Family states that his/her
Conduct for Nurses in the Philippines to relevant ordinances and rights are protected.
established by the PRC-BON is organizational regulations. 2. Patient’s privacy is not violated.
available. 1. Maintains current nursing 3. Patient expresses satisfaction to
2. A copy of the Philippine Nursing registration with the Professional the quality treatment and service
Law of 2002 (RA 9173) is available. Regulation Commission and that he/she is lawfully entitled to.
3. A copy of the organizational membership to the accredited 4. Legible, dated, signed and
regulations, policies and procedures professional organization and accurate nursing records are
are available. CCNAPI. maintained.
4. A copy of the CCNAPI Guidelines 2. Fulfills the duty of care in
for Critical Care Nursing. accordance with the laws.
5. Other Laws such as but not limited 3. Practices in accordance with the
to the Patient’s Bill of Rights organizational regulations, by-laws,
(PhilHealth) policies and procedures.
4. Practices in compliance with the
scope of nursing practice and the
equitable duty of confidence to
deliver nursing care in a way to
safeguard the rights, privacy, well
being and interests of every patient.
5. Ensures that informed consents

have been obtained prior to carrying
out nursing procedures and medical
treatment.
6. Maintains legible, dated, signed
and accurate nursing records to fulfill
the legal responsibilities.
Standard Statement 2: The critical care nurse provides care to meet individual patient needs on a 24-hour basis

1. An explicit policy for selection of The critical care nurse: 1. There is documented evidence
nursing staff is established. 1. Demonstrates knowledge and that critically ill patients receive
2. A recognized manpower indicator responsibility in line with policies and quality intensive nursing care in a
to calculate staffing level is used. procedures stipulated by the unit. continuous manner.
3. Nurses with appropriate 2. Participates in the development of 2. The staffing level is sufficient to
qualification to practice intensive staffing patterns with flexibility to meet daily patient care
care nursing are available at all give optimum patient care on a 24- requirements.
times. hour basis.
4. A contingency plan is available. 3. Practices intensive care nursing in
a continuous manner
Standard Statement 3: The critical care nurse practices current critical care nursing competently

1. The critical care nurse possesses The critical care nurse: 1. The critical care nurse
the knowledge required for the care 1. Maintains standards of nursing demonstrates competency according
of the critically ill. practice and professional behavior to his/her experience and knowledge
2. The critical care nurse has determined by the organization base.
knowledge and skills in assessing requirements and Scope of Nursing 2. There is documented evidence
patient’s needs, planning, Practice (RA 9173). that care provided is individually
implementing and evaluating the 2. Demonstrates possession of assessed, planned, implemented and
care provided. psychomotor skills required for the evaluated.
3. There is always a nursing expert care of the critically ill.
available in the ICU. 3. Shares knowledge and expertise
4. There is a mechanism in place to with others through teaching
provide continuing nursing programs, clinical supervision and
education. research activities.
5. There is a system in place to 4. Demonstrates effective
monitor the competency level of interpersonal skills in communicating
critical care nurses. with patients and families, physicians
and other members of the health
team.
Standard Statement 4: The critical care nurse delivers nursing care in a way that can be ethically justified.

1. The information regarding The critical care nurse: 1. Patient/Family states that his/her
patient's rights and responsibilities is 1. Complies with the Code of rights and dignity are protected.
available for patients and families. Professional Conducts for Nurses in 2. Patient/Family states that he/she
2. A mechanism for identification Philippines as determined by the is adequately informed and
and resolution of ethical issues Professional Regulation Commission. adequately supported in decision
related to the care of the critically ill 2. Provides care with respect for making.
is established. patient’s dignity. 3. All perceived unethical incidents
3. A copy of the Code of 3. Acts as patient advocate in terms are recorded and reported.
Professional Conducts for Nurses in of respecting patient’s rights and
Philippines is available. interests.
4. Materials such as books, journals 4. Maintains confidentiality of
and training programs on nursing information as appropriate.
ethics are available. 5. Informs and supports patient in
his/her decision making regarding
his/her well-being.
6. Acknowledges honestly the
limitations of personal knowledge
and skills and takes steps to remedy
such deficits.
7. Reports perceived unethical
incidents to the appropriate person.
Standard Statement 5: The critical care nurse demonstrates accountability for his/her professional judgment and
actions.

1. The philosophy of critical care The critical care nurse: 1. The critical care nurse
nursing is available. 1. Accepts responsibility to deliver demonstrates ability to justify
2. The unit objectives to guide safe nursing care to critically ill his/her own actions and judgment.
nursing activities are available. patients. 2. No professional misconduct is
3. Policy and procedure manuals 2. Take responsibility to clarify reported.
approved by the hospital are unclear instruction and question
available. inappropriate intervention.
4. A mechanism is available to 3. Practices within the guidelines and
ensure the eligibility of nursing protocols issued by hospitals and
practice. professional organizations.
5. An audit system to ensure safe 4. Audits nursing practice regularly.
nursing practice is established. 5. Makes sound and independent
clinical judgments based upon
ongoing monitoring of critically ill
patients and evidence-based
practice.
6. Recognizes on level of
competence and limitation; and
seeks appropriate plan of self-
development.
Standard Statement 6: The critical care nurse creates and maintains an environment which promotes safety and
security of patients, visitors and staff.

1. Written policies and procedures The critical care nurse: 1. Accidents are minimized.
exist to minimize the risks of 1. Implements agreed policies to 2. Hazardous incidents are
environmental hazards. minimize the risks of environmental documented and reported.
2. A policy exists to ensure staff hazards. Such policies and 3. A safe environment for patients,
knows the correct use of new procedures shall include the visitors and hospital staff is provided
equipment. prevention of fire and bio-medical and maintained.
3. Copies of Occupational Safety and hazards.
Health Ordinance and Regulation 2. Demonstrates knowledge of and
(OSHO & OSHR) are available. responsibility for implementation of
4. A copy of the guidelines on all aspects of the fire and bio-
Manual Handling Operations is in medical safety program.
placed. 3. Evaluates the effectiveness of
5. An established mechanism exists preventive measures for controlling
for reporting and auditing incidents. and counteracting the hazards
6. The critical care nurse is cognizant periodically.
of various rules and regulations
governing the use of medical 4. Ensures that the patient’s safety is
appliances for caring critically ill protected through the planning and
patients. design of the unit:
7. Resource persons are available to
the intensive care staff at all times to - Adequate space per patient bed,
provide service and advice on the with allowance for potential
safe use of medical appliances. equipment.
- Adequate space for support areas.
- Adequate electrical outlets.
- Adequate illumination.
- Adequate fire exits.
- Windows, clocks, calendars
- Sewage and sinks
- Life-supporting systems, including
medical gases, suction outlets and
emergency power availability.
- Emergency call system.
- Auxiliary lighting system
5. Reports any environmental
situation or defect, which is
dangerous to
patient/visitors/hospital staff.
Standard Statement 7: The critical care nurse masters the use of all essential equipment, available services and
supplies for immediate care of patients.

1. An inventory of essential routine The critical care nurse:1. Participates 1. Harm to patient from equipment
and emergency equipment is in mandatory equipment training failure is prevented.
established and reviewed regularly. ensuring safe, efficient and effective 2. Harm to patient from deficiencies
2. Access of above No. 1 to service utilization. of service and supply system is
provision is stipulated. 2. Participates in establishing written prevented.3. There is written
3. Emergency equipment, policies and procedures for ordering, document for all equipment being
medication and supplies are readily reordering, monitoring and replacing checked for proper functioning on a
accessible. equipment, medication and supplies regular basis.
4. Policies and guidelines for needed.
acquisition, preparation, utilization, 3. Reviews inventory of all
cleaning and maintenance are equipment at regular intervals and
available. ensures functionality through
5. Policies for ordering, monitoring preventive maintenance program.
ad replacing equipment, medication 4. Ensures that all necessary
and supplies for the intensive care equipment and supplies are readily
unit are in place. available at all times, and in proper
working order.
5. Is familiar with the available
hospital services, such as laboratory
and pharmacy services during
emergency situations.
Standard Statement 8: The critical care nurse protects patients from developing environmental induced infection.
1. Written infection control policies The critical care nurse: 1. The outbreak of infection is
are established.2. Immunization 1. Demonstrates knowledge of controlled.
programs for all critical care nurses various infectious conditions 2. The infection rate in the intensive
are provided when condition requiring isolation and precaution. care unit is reduced or stays low.
warrants.3. In-service programs 2. Adheres to the defined policies, 3. Decreased infection incidents are
regarding current infection control procedures and guidelines for reported and documented.
practices are provided. control of infection.
4. Necessary protective devices are 3. Reviews and revises infection
available for standard precautions. control policies and procedures
5. Isolation facilities are provided to regularly.
cohort and contain infectious 4. Works collaboratively with
outbreak. infection control nurses for
6. A standing work group composing controlling infection.
of staff of critical care and infection
control units for controlling infection
is established.
7. An ongoing system for reporting,
reviewing and evaluating infection
incidents are established.
Standard Statement 9: The critical care nurse utilizes the nursing process in an explicit systematic manner to achieve
the goals of care.

A. Performance of Health The critical care nurse: 1. Individualized patient assessment
Assessment is performed in an accurate,
1. Guidelines for critical care nurse 1. Utilizes collected data to establish continuous and systematic manner.
to perform health assessment are a list of actual and potential patient 2. There is documented evidence
available. problems/needs. that patient’s physical, psycho-social
2. An agreed conceptual model for and spiritual needs are identified.
guiding nursing practice is available. 2. Collaborates with the patient, 3. The intensive care nurse is
3. The Health Assessment form is family and other health care team cognizant of the current condition of
available for documentation of members in the identification of each patient under his/her care.
patient data. problems/needs. 4. Patient’s data are kept up-to-date.
4. Experienced staffs are available to
give advice on health assessment to 3. Formulates appropriate nursing
less-experienced staff. diagnosis relevant to the patient’s
5. The critical care nurse possesses condition wherein the nurse has the
the knowledge and skills in ability and experience to implement
performing physical examination and plan of care
psycho-social assessment.
4. Establishes the priority of
B. Formulation of nursing problems/needs according to the
diagnoses/identification patient actual/potential threats to the There is documented evidence that
problems in priority of patient’s patient. nursing diagnoses are formulated.
needs Patient problems are identified
5. Documents prioritized nursing according to priority of needs.
1. References to guide formulating diagnoses/patient problems in the
nursing diagnoses/identifying patient patient record.
problems are available.
6. Updates nursing diagnoses/patient
2. Guidelines for formulating nursing problems when patient’s condition
diagnoses/identifying patient changes.
problems are established.
3. Experienced staffs are available to

advise nurses in formulating nursing The critical care nurse:
diagnoses/identifying patient
problems. 1. Develops goals for each nursing
diagnosis/patient problem.
4. The critical care nurse possesses
the knowledge and skills to make 2. Plans appropriate nursing
accurate nursing diagnoses to interventions in collaboration with
identify patient problems. the patient, family and other health 1. Patient care reflects the identified
care team members whenever patient problems/needs.
necessary. 2. The planned care reflects
C. Planning for Collaboration of Care appropriate nursing interventions.
3. Devises an individualized care
1. References and information on plan.
nursing care plans are available.
4. Communicates the plan with those
2. Experienced staff advises novice involved in caring the patients
nurses in care planning when
appropriate. 5. Updates planned nursing actions
in accordance with changes in
3. The critical care nurse possesses patient health status.
knowledge and skills to devise an
individualized care plan pertinent to 6. Provides coordinated continuity of
patient needs. care.
4. An agreed nursing care delivery 7. Identifies activities through which

model and medical treatment care will be evaluated.
protocol, algorithm are available.
8. Documents the nursing care plan
in patient record.
D. Implementation of Planned
Nursing Care
1. The critical care nurse possesses The critical care nurse:

the knowledge and skills in
implementing the agreed care plan. 1. Utilizes accepted principles for 1. The agreed nursing care plan is
nursing interventions according to implemented.
2. Standards of nursing care and the dynamic environment.
practice are established. 2. A nursing intervention record for
2. Implements care according to individual patient is kept.
3. Experienced staffs are available to standards and protocols.
give advice on the implementation of 3. The identified goals for individual
care. 3. Implements the planned care in patient care are achieved
collaboration with the patient, family
4. Appropriate equipment for the and other health care team
implementation of the agreed care members.
plan is available.
4. Implements the planned care in an
5. A policy to ensure the continuity organized and humanistic manner.
of patient care is in place.
5. Integrates current scientific
knowledge with technical and
E. Evaluation of Outcome of Nursing psychomotor competencies.
Care
6. Provides care in such a way as to
1. The critical care nurse possesses anticipating and preventing
the knowledge and skills to evaluate complications and life-threatening
the implemented care. situations.
2. Experienced staff are available 7. Provides individualized and

who advises nurses on the continuous care to achieve identified
evaluation of delivered care. goals.
3. A policy is available to evaluate 8. Documents interventions in

patient’s responses to nursing care in patient’s records.
a continuous manner.
9. Reviews and modifies
interventions based on patient’s
progress.
The implemented care is evaluated

and documented.
The critical care nurse:
1. Collects data for evaluation within

an appropriate time interval after
intervention.
2. Compares the patient’s responses

with expected outcomes.
3. Determines the causes of

significant differences between the
patient’s responses and the expected
outcomes.
4. Reviews and revises the plan of

care based on the evaluation.
5. Documents evaluation findings in

patient record.
Standard Statement 10: The critical care nurse carries out health education for promotion and maintenance of
health.

1. An education framework for The critical care nurse: 1. Patient demonstrates a positive
intensive care setting is established. 1. Assesses patient’s/family’s attitude towards health promotion
2. An optimal learning environment learning ability or any barriers to and health maintenance.
is created. learning. 2. There is documented evidence
3. A tool for assessing 2. Modifies health teaching that patient/family understands the
patient’s/family’s needs is strategies according to patients health education material.
established. /family’s literacy level.
4. Plans and programs for promoting 3. Establishes good rapport with
and maintaining health are devised. patient and family.
5. The critical care nurse possesses 4. Assists patient in setting short-
competency in the provision of term and long-term goals for the
health education. promotion and maintenance of
health.
5. Plans and implements
individualized health educational
activities.
6. Provides educational information
for patient and family in promotion
and maintenance of health.
7. Facilitates patient’s/family’s ability
to comply with the health education
provided.
8. Documents the teaching-learning
progress.
9. Evaluates the effectiveness of
health teaching and modifies the
approach if necessary.
Standard Statement 11: The critical care nurse acts to enhance the professional development of self and others.

1. A system to offer nurses the The critical care nurse: 1. Patient receives quality nursing
opportunity for continual 3. Assesses patient’s/family’s care based on current scientific
professional development is learning ability or any barriers to knowledge and research findings.
established. learning. 2. The critical care nurse completes
2. An objective performance 4. Modifies health teaching continuing nursing education
appraisal system is available. strategies according to patients programs and demonstrates
3. Professional journals and /family’s literacy level. commitment in further professional
textbooks related to critical care 3. Establishes good rapport with advancement.
nursing are available. patient and family. 3. Expertise in intensive care nursing
4. A mechanism to facilitate career 4. Assists patient in setting short- is developed and respected by
progression program is available. term and long-term goals for the others.
promotion and maintenance of
health.
5. Plans and implements
individualized health educational
activities.
6. Provides educational information
for patient and family in promotion
and maintenance of health.
7. Facilitates patient’s/family’s ability
to comply with the health education
provided.
8. Documents the teaching-learning
progress.
9. Evaluates the effectiveness of
health teaching and modifies the
approach if necessary.
COMPETENCIES FOR CRITICAL CARE NURSES
The competence of critical care nurses together with established nursing standards and the identified core
competencies for registered nurses will result to excellence in critical care nursing practice. This three-pronged
holistic framework ensures quality performance through an adherence to nursing standards, the demonstration of
competencies, and the integration of appropriate nursing model/s into the health care delivery process.
To achieve safe and quality client-centered care, nurses working in the critical care units are envisioned to adopt not
only the stated core competencies of registered nurses but also the specific competencies stipulated in the following
eleven major key responsibility areas:
Safe and Quality Nursing Care
Management of Resources
Legal Responsibilities
Ethico-Moral Responsibilities
Collaboration and Teamwork
Personal and Professional Development
Communication
Health Education
Quality Improvement
Research
Record Management
Key Responsibility Areas Responsibilities / Tasks Competent Behavior Clusters

I. Safe Quality Nursing Care 1. Conducting nursing assessment - obtains comprehensive patient
Description: The critical care/ information from a holistic
intensive care unit (ICU) nurse perspective with the aid of advanced
performs patient health assessment technologies and physical
accurately, continuously, examination techniques, paying
comprehensively and systematically. particular attention to the
The critical care nurse prioritizes the psychosocial impact of the critical
health needs of the patient from a care environment on patients and
holistic perspective. relatives.
- prioritizes the health needs of the
patient based on the assessment
data and communicates this
information to the right people in a
correct and timely manner.
- collects patient’s data in a
systematic, objective and continuous
manner from clinical observation and
monitoring devices.
- ensures pertinent data are clearly
documented and accessible to all
health care team members.
2. Formulating care plans
Description: The critical care Thecritical carenurse:
identifies patient’s problems in - utilizes collected data to establish a
relation to patient’s needs /nurse list of actual and potential patient
develops individualized, holistic and problems/needs.
patient-centered care plans that collaborates with the patient, if
document nursing diagnoses. applicable, family and other health
care team members in identifying
problems/needs and planning of
appropriate nursing actions
accordingly.
- establishes and records the priority
of problem/needs according to the
actual danger or potential threats to
the patient.
- formulates an individualized care
plan with continuous review to
3. Implementing planned care match both the needs of the patient
Description: The critical care nurse and family
implements planned care to achieve
optimal health status of dignified The critical care Nurse:
death of the patient. - carries out planned patient care or
immediate nursing actions in a safe,
comprehensive, effective and
humanistic manner according to
patient’s response.
- adopts evidence based-practice in
the care of the critically ill patients
4. Evaluating patient’s health where applicable.
progress and outcome - assists the patient towards end-of-
Description: The critical care nurse life attaining peaceful and dignified
evaluates the outcomes of nursing death.
care in an explicit, systematic and
ongoing manner. The critical care nurse:
- maximizes clinical skills with
monitoring devices to evaluate the
care process and compares the
patient’s response with expected
outcome.
- identifies the cause for any
significant difference between the
patient’s response and the expected
outcome.
- Identifies potential risk of patients,
such as but not limited to Deep
Venus Thrombosis (DVT), aspiration,
pressures, - infection, fall risk,
malnutrition / starvation, patient
abuse, iatrogenic etiologies revises
5. Maintaining effective c the care plan to ensure patient
communication centered and quality of care to
Description: The critical care patient.
nurse communicates relevant, - implements appropriate and
accurate and comprehensive effective nursing interventions to
information, both verbal and written, help patients and significant others
about the patient’s health status to address hospice, palliative and end-
related health care team members of-life care needs.
and family members.
- reports instantly key changes of
patient’s health condition in an
emergency situations.
6. Acting in emergency situations - monitors and documents relevant
such as rapid deterioration, life- information objectively and
threatening , unstable, and critical systematically.
events - maintains information in an
Description: The critical care accessible and retrievable form.
nurse responds swiftly in a calm and - conducts effective patients and
proficient manner when faced with family health education.
an unexpected or rapidly changing
situation related to the patient or
environment.
7. Demonstrating specific A. Pulmonary careThe critical care

knowledge and skills in the critical nurse:
care setting 1. Has an understanding of the
Description: The critical care applied respiratory physiology
nurse provides quality and effective2. Demonstrates nursing
care to patient in the following competencies in:
aspects:  Respiratory assessment
 Respiratory monitoring such
 Pulmonary as clinical observation, arterial
 Cardiovascular blood gases, SpO2, ETCO2
 Neurological  Airway management such as
 Renal suctioning, chest physiotherapy,
 Gastrointestinal oral care, use of airway gadgets
 Endocrine and others
 Peri-operative  Respiratory investigation and
 Trauma therapy such as bronchoscopy,
 Burn tracheostomy, chest physiotherapy
 Organ Transplantation 1. Provides holistic care to
 Control of Infection patients in the following
 Psychosocial and Spiritual Care conditions:
 Before and after thoracic
surgery
 With acute or chronic
respiratory disorders
 On ventilator support
 Being weaned from
mechanical ventilator
 On oxygen therapy
1. Initiates and assists in the
emergency and resuscitative
procedures such as endotracheal
intubation, tracheostomy and chest
drain insertion.
2. Educates and supervises
patients and families on home
oxygen therapy.
B. Cardiovascular care
1. Has an understanding of the
applied cardiac physiology
2. Demonstrates nursing
competencies in:
 Cardiovascular assessment
 Cardiovascular investigation
 Interpretation of
electrocardiogram
 Hemodynamic monitoring
such as non-invasive, arterial
pressure, pulmonary artery
pressure, CVP
 Administration of cardiac
medication
1. Provides holistic care to
patients with the following
conditions:
 Before and after cardiac
surgery
 With cardiac arrhythmias
and heart block
 With cardiac disorders such
as myocardial infarction, Acute
Coronary Syndrome, heart failure,
shock
 On cardiovascular support
such as intra-aortic balloon pump,
ventricular assist devices
1. Initiates and assists in
cardiovascular resuscitation e.g.
cardiac pacing, cardioversion,
defibrillation, pericardiocentesis,
advanced cardiac life support.
C. Neurological care
applied neurological physiology.
competencies in:
 Neurological assessment
 Neurological investigation
patient:
 Before and after neurological
operation
 Suffering from neuro-
medical disorders
 On intracranial pressure
monitoring
D. Renal care
applied renal physiology.
competencies in:
 Renal assessment
 Renal investigation
 Interpretation of blood
biochemistry
patients with renal failure by:
 Peritoneal dialysis
 Hemodialysis
 Continuous renal
replacement therapy (CRRT)
E. Gastrointestinal care
applied gastrointestinal physiology.
patient:
 With gastrointestinal
disorder such as acute pancreatitis,
hepatic failure
 Before and after
gastrointestinal operation
 With gastrointestinal
emergencies such as
gastrointestinal bleeding,
esophageal varices bleeding
 Undergoing different
procedures such as peritoneal
lavage
 Early access and early
feeding using appropriate gadgets.
F. Endocrine care
applied endocrine physiology.
conditions:
 Diabetic emergencies such as
diabetic ketoacidosis,
hyperglycemia, hypoglycemia
 Thyroid storm
 Other endocrine
emergencies
G. Peri-operative care
1. Equips oneself with
knowledge and skills for
implementation of safe, adequate
evidence-based care of clients
during the pre-, intra- and post
operative procedures
conditions:
 Before and after different
types of operations
 With wounds and drains.
competencies in pain assessment
and pain management
H. Trauma care
1. Has an understanding on the
mechanism of different types of
injury.
competencies in:
 Primary and secondary
assessment
 Stabilization, transfer and
transport of trauma patients
 Emergency and resuscitative
procedures
c. Provides holistic care to patients
with different types of trauma
I. Burn care
1. Has an understanding of the:
 Applied skin physiology
 Mechanism of injury
associated with burn and inhalation
injury
competencies in:
 Burn assessment
 Burn resuscitation such as
airway, breathing and circulation
 Burn wound care
patients with burn
2. . Educates patient on long
term skin care
J. Organ transplantation care

1. Demonstrates knowledge in
brain stem death test
2. Identifies potential organ
donor
3. Provides holistic care to:
 Potential donor
 Perioperative transplant
patient
d. Identifies potential risk associated
with organ transplant and takes
appropriate actions
K. Pain Management
1. Applies evidence-based
practices on pain prevention
2. Selects appropriate
assessment and intervention tools
and techniques in collaboration
and consultation with other team
members (such as WHO Pain
Ladder or other similar framework)
3. Demonstrate management
capabilities of clients using
pharmacological and non-
pharmacological interventions.
L. Prevention and Control of

Infection
principles of prevention of infection
2. Complies with infection
prevention and control guidelines
3. Demonstrates competency
in handling and preventing
infection
4. Monitors patient’s treatment
compliance and the related
outcome
5. Provides health education on
infection control to the patients
and relatives
M. Psychosocial and spiritual care

1. Identifies the psychosocial
and spiritual needs of ICU patent
and his/her families
competence in communication and
counseling skills
3. Supports the family during
the loss, grieving and bereavement
process
4. Provides psychosocial care
such as music therapy, therapeutic
touch and relaxation therapy to
patient and his/her family
according to their needs
N. Miscellaneous
The critical care nurse provides
holistic care to patients with the
following problems:
 Drug overdose
 Hematological failure
 Obstetrical emergencies
 Pediatric emergencies
 Near drowning
 Thermal injuries – heat
stroke, hypothermia

1. Demonstrates specialty
knowledge in managing within the
organization
2. Uses organizational core
values and objectives in line with
II. Management of Resources 1. Managing within the organization daily work
Description: The critical care3. Follows organizational
nurse understands the vision, policies, procedures and protocols
mission and core values of the4. Participates in organizational
organization and facilitates the initiatives by contributing
achievement of the organizational constructive proposals for
goals. improvement
5. Strengthens and develops
critical care delivery in paced with
rapid advanced technologies
6. Maximizes effective resource
utilization

1. Motivates subordinates to
achieve assignments and goals by
providing them with the rationale
for performing the task;
considering and accepting their
2. Empowering subordinates suggestions when appropriate; and
Description: The critical care
nurse achieves targets through reinforcing good practice
subordinates using the processes2. Collaborates tasks and
and techniques associated with deploys subordinates according to
motivating, coaching, delegating and their capabilities and job
supervising. experiences, to allow immediate
delivery of critical care services in
crisis management
3. Encourages subordinates to
participate in specialty activities,
and stimulates their innovation in
critical care nursing development

1. Creates a favorable working
environment that maximizes the
production of high quality critical
care delivery
2. Establishes effective
3. Assisting in maintaining a safe feedback loop between health care
and healthy working environment teams, patients and relatives
Description: The critical care3. Contributes to the
nurse carries out activities to assist in maintenance of occupational
maintaining a favorable working health and safety, and prevention
environment. of occupational hazard ensuring
positive practice environment.
4. Establishes effective linkages
between inter and intra
departments and hospitals to share
updated specialty information and
different experiences, thus
preparing the organization to cope
with continuous external changes
more efficiently
5. Reports any unfavorable
environment which may have a
negative impact on the patient’s
physical, psychological and social
well being as well as the process of
rehabilitation.
The critical care nurse:a.

Demonstrates awareness of the
relevant ordinances and
organizational regulations that have
legal regulations such as Code of
Professional Conduct for Nurses and
Fulfilling legal responsibilities and
the Philippines Nursing Law of 2002
III. Legal Responsibilities acting as patients advocate
(RA 9173).b. Acts based on ethical
Description: The critical care nurse
principles and ensures that no action
functions in accordance with
or omission is detrimental to the
common law, ordinance and
safety of patients.
regulations influencing nursing
practice. c. Familiarizes with the legal
procedures for organ transplantation
and be sensitive to organ
preservation management and
family support.
d. Ensures that informed consent has
been obtained prior to carrying out
invasive and non-invasive
procedures and medical treatment,
particularly when patient or/and
family does not have complete
information to make an informed
decision.
e. Facilitates delivery of
comprehensive explanation to
patient/family if indicated to
empower them to make responsible
choice.
f. Maintains legible, dated signed and
accurate nursing records to fulfill
legal responsibilities.
g. Is aware of self-limitation and
seeks advice and supervision from
senior if a delegated task or
responsibility is felt to be beyond
current training or ability, (e.g.,
informs seniors that he/she has no
experience and training in caring
patient undergoing continuous renal
replacement therapy).
h. Reports any unfavorable
environment which may have a
negative impact on the patient’s
physical, psychological and social
well being as well as the process of
rehabilitation.
a. Has respect for patient / family
rights including confidentiality
b. Conducts intensive care nursing

practice and makes sound
IV. Ethico-Moral Practice Practicing ethico-moral standards of independent clinical judgment in a
the nursing profession. way that can be ethically justified
Description: The critical care nurse
demonstrates the appropriate c. Aware of the importance of open
application of knowledge in nursing discussion with others about his/her
practice, which complies with the own views on ethical dilemmas
code of professional conduct,
d. Reports all perceived unethical
principles of autonomy, beneficence
incidents to responsible person such
and justice. She / He also accepts
as but not limited to, responsible use
personal responsibility for one’s own
of technology (clinical or
professional judgments and actions
administrative); use of
as well as consequence of one’s
communication devices not related
behavior.
to clinical practice
e. Maintains professional decorum in
dealings with patient, family and co-
workers.

a. Contributes in various clinical
meetings to provide professional
input in patient care management
such as case conference and risk
management meeting
V. Collaboration and Teamwork 1. Maintaining collaborative
b. Values team members’
relationships in the multi-
participation and joint decision-
disciplinary team
making
c. Seeks opportunities to participate
nurse maintains collaborative
in cross-functional, multi-disciplinary
relationships within the ICU team.
quality improvement initiatives
This relationship contributes towards
the achievement of smooth and
effective team performance in
accomplishing common goals.
1. Demonstrates knowledge of
team concepts (e.g., discuss the
dynamic of teams, participates in
various stages of team growth:
2. Maintaining a cohesive nursing forming, brainstorming, and
team performing)
Description: The critical care2. Demonstrates understanding
nurse establishes and maintains of the structure, functions and
harmonious working relationships purposes of the team
with nursing colleagues 3. Demonstrates understanding
of the role of different team
members and the agreed goals
4. Takes initiatives to
participate in team discussion and
to achieve team goals and
objectives
5. Shows willingness to share
workload when needed
6. Participates in various
intensive care related activities
such as CQI projects, research
activities, infection prevention and
control survey

1. Develops the necessary skills
and initiates efforts to improve
efficiency and effectiveness of
service; seeks opportunities for
VI. Professional and Personal 1. Facilitating the development of further development within the
Development nursing knowledge in clinical setting organization and contributes to the
Description: The critical care training and development needs
nurse takes initiative to support or 2. Facilitates learners to
conduct activities, which promote achieve their training and
the advancement of nursing development needs
knowledge 3. Conducts coaching and
actively participates in the
preceptor ship and mentorship
program.
4. Assists in ward
orientation/induction for new
nurses and alerts them to the
specific requirements in caring of
ICU patients.
5. Assimilates the evidence-
based research findings to further
improve clinical practice
6. Supports or participates in
nursing research
7. Shares and disseminates
evidence-based findings
8. Shares clinical experience
and
9. knowledge with colleagues
10. Applies theoretical
knowledge
11. to practice
12. Identifies areas for
enhancement of nursing
knowledge such as counseling and
communication skills in all areas of
critical care practice
including bereavement process

1. Asserts professionally in the
health care team
2. Shows concerns about the
public interest regarding health
2. Promoting the professional image promotion and maintenance
of ICU nurse 3. Acts in the manner of a
Description: The critical care knowledgeable, competent,
nurse acts in manner that maintains responsible, accountable and
active ongoing involvement in caring professional with critical
activities related to the nursing thinking to achieve the aimed
profession such as ICU conference, objective
workshop and course; and promotes 4. Supports activities run by
the professional image of nursing. professional organization such as
micro-teaching and sharing session
of clinical experiences
5. Promotes spirit of
professional cohesiveness
6. Acts for the collective
interest of the profession
7. Adopts continuous quality
improvement in nursing

1. Uses professionally
acceptable standards or practice to
assess self-performance
2. Demonstrates proficiency in
3. Evaluating own nursing practice
and knowledge to enhance personal providing care to patients receiving
skills different modes of treatment in
Description: The critical care nurse acute settings to achieve intended
assesses self-awareness of his/her outcomes and prevent or minimize
own professional competence adverse outcomes
continuously and independently;3. Demonstrates awareness of
maintains up-to-date nursing individual strength and limitations
knowledge to keep abreast of and the importance of enhancing
nursing trends and nursing standards nursing knowledge
in specialty practice. 4. Seeks additional
information/opportunities to polish
personal skills and qualities e.g.
attending courses/seminars or
reading books on relevant subjects
when unfamiliar clinical situations
with no precedents are
encountered
5. Develops own personal
development plans that include
attending in-service ICU courses,
ICU scientific meetings, overseas
ICU conferences, tertiary
educational programs and reading
ICU specialty journals/literature,
etc.
6. Shares up-to-date ICU
nursing knowledge and current
practice with nursing colleagues
The ICU nurse:

1. Develops the necessary skills
VII. Communication Communicates with individual and initiates efforts to improve
patient and/or groups and with efficiency and effectiveness of
other members of the health care communication;
team
2. Uses a range of appropriate
communication strategies which
nurse takes initiative to
will have effective outcome such as
communicate with individual and /
but not limited to Hand-off
or groups and with other members
communication, use of SBAR on
of the health team to facilitate care
referral, use of ICU flow sheet .
and management of the patients.
3. Encourages the use of non-
verbal / alternative communication
techniques including information
technologies where appropriate to
elicit appropriate communication.
4. Responds rapidly and
appropriately to the needs of the
critically ill patients, their
significant others and the members
of the health team

1. Assesses comprehensively
VIII. Health Education Provides appropriate health the needs and learning barriers of
education based on comprehensive critically-ill clients, family and their
learning needs of the patient and significant others
family 2. Provides refined health
Description: The critical care education plan which is
nurse makes thorough assessment of individualized and comprehensive
the learning needs of the patient and based on the client’s needs
family for the provision of health3. Demonstrates ability to
education to assist the patient and develop and use appropriate
family towards a productive life learning tools for health education
4. Conducts health education
to significant others of
the critically-ill clients with
emphasis on basic concepts of the
disease process
5. Facilitates the thorough
understanding of the critically ill
client’s significant others regarding
the disease process and course of
management to enable them to
participate in the care process
6. Demonstrates ability to
appraise outcome of the health
education
7. g. Integrates the helping and
coaching role of a nurse during
expressed need of the client, his
family and significant others

1. Demonstrates in-depth
IX. Quality Improvement Proactive in theimplementation of
understanding and facilitates the
changes as a consequence of quality
achievement of the organization’s
improvement initiatives
mission, vision and goals through
quality improvement
nurse demonstrates positive
attitudes towards change for
2. Identifies areas for quality
improvement initiatives
improvement
3. Establishes effective
feedback loops between the
organizations, health teams,
patients and significant others
pertaining to quality improvement.
4. Facilitates the
implementation of new policies,
changes in implementing rules and
regulations for quality
improvement.
5. Utilizes available and existing
data to support quality
improvement initiatives.
X. Research Supports a positive climate for The critical care nurse:

research within the practice setting 1. Demonstrates active
Description: The critical care involvement in research activities
nurse maintains currency of2. Incorporates evidence-based
knowledge and practice based on and research findings into nursing
relevant research findings practice.
3. Identifies areas of practice
for which further research is
indicated
4. Seeks continuous
improvement of professional
practice through research activities.
XI. Record Management Ensures that written information The ICU nurse:
conforms to legal and ethical1. Demonstrates ability to
framework document information in a
Description: The critical care comprehensive and clear manner
nurse maintains accurate and within the legal and ethical
updated documentation of the care framework.
for the critically ill patients 2. Protects and safe guards the
document conforming legal and
ethical framework and institutional
policies.
3. Demonstrates effective and
appropriate methods of
documenting information
4. d. Analyzes variances in the
data recorded for improvement of
client care
PLANNING AND ORGANIZATION OF INTENSIVE CARE
SERVICES
 INTENSIVE CARE is defined as the provision of

sophisticated life support.
 Used for a variety of adult and pediatric patients.
 In a setting of close monitoring.
 A policy guideline to be developed for planning an
ICU by the hospital.
 A policy guideline to be developed for planning an
ICU by the hospital by framing a committee
LOCATION:
 Should be CENTRALLY located with easy
access to emergency and other wards, OT and
OPD.
 Easily approachable
 Away from general hospital traffic.
 Restricted entry
3rd or 4th floor
SIZE:
DECISION MAKING  Depends on the type of services provided
The planning committee will take the following  In super specialty hospital 10% of the total
decisions: beds
o Critical care need of the hospital  In general hospital 2% of hospital beds
o Type and size of the ICU  Optimum size is 14 beds, minimum 4 beds
o Appointment of ICU in charge  If no. of beds required is more than 14, TWO
o Appointment of ICU in Matron ICUs be opened. Ideal ICU is 10 bedded.
o Planning, designing and physical facilities.
o Guidelines, policies, and procedure in ICU
functioning.
PRE-REQUISITE
o Training of Nursing and Medical Staff
o Procurement of beds and equipments
o Developing protocols for monitoring and life
support
o Training of supporting staff
o Commissioning and opening
LAYOUT DESIGNING:
 Circular placement of beds with Central
Nursing Station
 Rectangular with Central Monitoring Sytem
 Semi circular with monitoring station at the
front
 The lay out design depends on the availability
of space
 High intensity spot light connected to
generator
 Wall panels and call button near the end
 Sufficient electric sockets for plugging
 Wall suction tubes and piped oxygen supply
 Small wash basin
 No extension wire to be used to avoid tripping
& overheat because of many wires in the ICU
 Equipments with CV stabilizer /UPS
BASIC EQUIPMENTS NEEDED IN THE ICU

 Defibrillator
 Ventilator
 Pulse oximeter
 Cardiac monitor (movable/stationary)
 Infusion pump
 HD Machine
 Fluids stand
 Monitor and minor procedure trolley
 BOP
 Dialysis machine
NURSING STATION
 central monitoring system
 counter, case records and essential drugs
 complete visibility of all patients
 two way communication / paging / intercom
system
BED SPACE:
 Sufficient space is required for each bed for
free movements and keeping ventilator,
monitoring system and other equipments. ISOLATION AREA
 Required for each bed 100-120 sq ft in open The working area is equal to total bed area and
ICU separated by clean corridor from patient area. This
 140-180 sq ft in cubicle area has the 14 sq yards area comprises of:
 Minimum 15 sq ft of clear area in bed space  Washing, utility area
 Head wall space 1-2 ft  Securable cabinets for staff room
 Cubicle must have glass partitions or  Clean supply room
transparent curtains for clear observation  Work room w/ separate sink
from monitoring station.  Toilet, dirty utility
 X-ray viewing, special examination/ procedure
BED HEAD FIXTURES AND CALL BELL SYSTEM  24 hours lab, radiology and pharmacy
ANCILLARY AREA
 Offices spaces and record room
 Staff lounges, toilets
 Telephone facility
 Staff rest room
 Janitor’s room
 ICU matron’s office
MEDICAL ENVIRONMENT
 Air Condition:
 ICU must be air conditioned
 25-27’C
 40-50% humidity
 Large windows
 Plenty of sunlight
STAFF REQUIRED PER SHIFT
 Ventilation:  Ideally 1:1 ratio during day and 1:2 during
 6/8 air changes per hour night
 Filters less than 10 microns  Broadly 4-5 nurses per bed including reliever
 Positive pressure flow from patient  One ANS for administration
area to outside PER
 Lighting: SHIFT
 Varying degree of illuminations for MEDICAL
patient area, working area STAFF:
CONSULTANT ICU 1
 Intensity 1-30 lumens as per needed one Physician
 Provision of dimmer lights per 5 beds
 Noise: SENIOR RESIDENT 2
 Noise free JUNIOR RESIDENT 2
 Soft & light music TECHNICAL
RESPIRATORY THERAPIST 1
 TV & clock in each cubicle STAFF:
 Noise absorbable materials PHYSIOTHERAPIST 1
 Walls reflection free, light color ICU TECHNICIAN 1
 Floor mosaic LAB TECHNICIAN 1
OT ASSISTANT 1
SAFETY OFFICER 1
ANCILLARY
RECEPTIONIST 1
STAFF:
WARD BOYS 4
STRETCHER BEARER 2
SAFAIWALA 2
TYPES OF ICU
 Traditional Specialties  Surgical, Medical,
Pediatric
 Organ System  Cardiac, Neuro, Renal,
Respiratory
 Clinical Syndrome  Burn, Trauma, Stroke
 Clientele  Neonatal, Pedia, Gyne
ADMISSION AND TREATMENT POLICY
 ICU is a place for potentially salvageable 3. Cleaning and maintenance of equipments.
critically ill patient in need of constant 4. Checking and replacement of essential drugs.
monitoring, life support and requiring 5. Proper maintenance of records.
specialized treatment and trained nursing 6. Daily round of physician and I/c ICU combined
care to take decision for change in treatment.
 LEVEL OF ICU CARE
 LEVEL 1  Monitoring; Observation; DISCHARGE POLICY
Short Term Ventilation 1. Decision to discharge is taken in consultation
 LEVEL 2  Monitoring; Observation; with in- charge parent unit.
Long Term Ventilation (Intensive Care) 2. Patients who have recovered, stable and does
 LEVEL 3  Intensive Care; Invasive not require artificial ventilation can be shifted
Procedures; Haemo-Dialysis; Constant to intermediate care or high dependency area.
Support 3. Patient who are not progressing and chances
of recovery is remote to be discharged for
ADMISSION CRITERIA allotting bed to patient having fair chance of
 There should be fixed admission criteria for recovery when demand is acute.
admission 4. When there is no demand, patient is kept in
 Priority to be given to the patients, who have ICU till death.
fair chance of reversible condition or chances
of improvement QUALITY ASSURANCE IN ICU
1. To maintain high standard by hygiene and
cleanliness.
2. To prevent hospital acquired infection.
3. Proper treatment and disposal of BMW.
4. Daily maintenance/ checking of vital
equipments.
5. Priority on patient comfort and home feeling.
6. Exit interview of patients and relatives to
increase the standard and quality of care.
INTENSIVE CORONARY CARE UNIT

TREATMENT POLICY
1. The requirements here are as that of ICU.
1. Responsibility lies with the in charge of unit
2. The patients here are conscious/
admitting the case.
semiconscious.
2. A vacant bed is allocated in original ward for
3. Require constant observation and monitoring.
patient return.
4. Should have acoustic and visual privacy.
3. No direct admission to ICU but transferred
5. There should be partitions/ cubicle for each
from unit.
patient.
4. Admission only on recommendation of ICU
director subjected to available of bed.
Vacuum – color yellow/black
5. 20% beds to be kept vacant for emergency
O2 supply – color green
admission
Respiratory therapist – supporting staff
6. Continuity of treatment is the per view of ICU
Increase ICP -> pupil constricted w/o light
in charge in consultation with unit in charge.
Cerebral hypoxia -> dilated pupils 5mm; no O2
going to the brain
POLICIES AND PROCEDURES
Observe the sclera -> if RED (minimal seizure attack)
1. Standard treatment protocol to be followed.
-What to do? NONE but have 2-3L/min of O2
2. Silence to be observed
3. All new admission/ discharge to be informed
to ICU in charge.
4. All admissions/ discharges to be registered
STAFF STANDING ORDER

1. Joint round at the time of shift change and
proper handing/ taking.
2. Instruction and maintenance of input- output
chart.

NCM 118 Notes Prelim

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What are the different levels of ICU care?

What are the different levels of ICU care?

What are the admission criteria for ICU?

What are the admission criteria for ICU?

CRITICAL CARE NURSING GUIDELINES, STANDARDS The expanding healthcare and nursing knowledge

AND COMPETENCIES together with new and evolving healthcare sites,

- To identify Critical Care Nursing Service characteristics

This process-based framework not only describes the

THE RIGHT OF THE CRITICALLY ILL PATIENT

PHILOSOPHY OF CRITICAL CARE NURSING

-To promote optimal delivery of safe and quality care to

ROLES OF THE CRITICAL CARE NURSES c. Adjusting intravenous analgesia / sedations;

d. Performing and interpreting ECGs;

The development of the Advanced Practice Nursing is

Acts in the best interests of the patient and

Outcome management has been introduced into the

Critical Care Nurses Association of the Philippines, Inc.

The challenging needs that the advanced critical care

Continuing Professional Education (CPE)

The updated educational component includes but not

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOME CRITERIA

5. Ensures that informed consents

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOME CRITERIA

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOME CRITERIA

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOME CRITERIA

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOME CRITERIA

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOME CRITERIA

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOME CRITERIA

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOME CRITERIA

3. Experienced staffs are available to

4. An agreed nursing care delivery 7. Identifies activities through which

1. The critical care nurse possesses The critical care nurse:

2. Experienced staff are available 7. Provides individualized and

3. A policy is available to evaluate 8. Documents interventions in

The implemented care is evaluated

1. Collects data for evaluation within

2. Compares the patient’s responses

3. Determines the causes of

4. Reviews and revises the plan of

5. Documents evaluation findings in

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOME CRITERIA

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOME CRITERIA

COMPETENCIES FOR CRITICAL CARE NURSES

Safe and Quality Nursing Care

Collaboration and Teamwork

Personal and Professional Development

Key Responsibility Areas Responsibilities / Tasks Competent Behavior Clusters

7. Demonstrating specific A. Pulmonary careThe critical care

J. Organ transplantation care

L. Prevention and Control of

M. Psychosocial and spiritual care

The critical care nurse:

The critical care nurse:

The critical care nurse:

The critical care nurse:a.

b. Conducts intensive care nursing

The critical care nurse:

The critical care nurse: