IBEROAMERICAN JOURNAL OF MEDICINE 03 (2020) 183-187

Journal homepage: www.iberoamericanjm.tk

Review

Critical Care Nursing

Siniša Franjića,*
a
Faculty of Law, International University of Brcko District, Brcko, Bosnia and Herzegovina

ARTICLE INFO ABSTRACT

Article history: Everyday routine jobs, as well as suddenly specific situations, as well as severe
Received 11 March 2020 medical conditions of a nurse, can be considerably psychophysically exhausted. It is
Received in revised form 17 March therefore important for nurses to find a model to deal effectively with stress and
2020 the severity of working conditions. Higher levels of education and lifelong learning
contribute to finding new strategies that facilitate work in the intensive care unit.
Accepted 18 March 2020
Qualities that give importance to nurse's are communication skills, emotional
stability, empathy, flexibility, interpersonal skills, physical endurance, respect,
Keywords: knowledge and many others. The role of a nurse is to establish a balance between
Critical Care technique and humanity, or to bring humanity in the care of a patient, because no
Patient one device will replace the caring and sympathy of the nurse.
Nurse
© 2020 The Authors. Published by Iberoamerican Journal of Medicine. This is an open access
article under the CC BY license (http://creativecommons. org/licenses/by/4.0/).

specialists in pulmonary medicine, cardiology, nephrology,

1. INTRODUCTION anesthesiology, surgery, or critical care, the ability to
provide critical care depends on the basic principles of
Critical care is unique among the specialties of medicine internal medicine and surgery. Critical care might be
[1]. While other specialties narrow the focus of interest to a considered not so much a specialty as a “philosophy”of
single body system or a particular therapy, critical care is patient care.
directed toward patients with a wide spectrum of illnesses. Care of the critically ill patient has evolved into a
These have the common denominators of marked discipline that requires specialized training and skills [2].
exacerbation of an existing disease, severe acute new The physician in the ICU (intensive care unit) depends on
problems, or severe complications from disease or nursing for accurate charting and assessment of the patients
treatment. The range of illnesses seen in a critically ill during the times when he or she is not at the bedside and
population necessitates well-rounded and thorough for the provision of the full spectrum of nursing care,
knowledge of the manifestations and mechanisms of including psychological and social support and the
disease. Assessing the severity of the patient’s problem administration of ordered therapies.
demands a simultaneously global and focused approach, Complex mechanical ventilation devices need appropriate
depends on accumulation of accurate data, and requires monitoring and adjustment. This expertise and other
integration of these data. Although practitioners of critical functions are provided by a professional team of
care medicine—sometimes called intensivists—are often respiratory therapy practitioners. The wide spectrum of the
pharmacopeia used in the ICU is greatly enhanced by the

* Corresponding author.
E-mail address: [email protected]
© 2020 The Authors. Published by Iberoamerican Journal of Medicine. This is an open access article under the CC BY license (http://creativecommons.
org/licenses/by/4.0/).
http://doi.org/10.5281/zenodo.3713334
184 IBEROAMERICAN JOURNAL OF MEDICINE 03 (2020) 183-187

assistance of our colleagues in pharmacy. Many institutions healthcare expenditure coupled with temporary or
find it useful to have pharmacists with advanced training permanent demand excess leads to an imbalance between
participate in rounding to help practitioners in the available resources and expenditure. This imbalance has
appropriate pharmacologic management of the critically ill. led to providers seeking to ‘contain costs’ in a wide variety
Additionally, technicians with experience in monitoring of disciplines in medicine. In the UK, the use of the R word
equipment may help in obtaining physiologic data and (Rationing) in conjunction with healthcare is politically
maintaining the associated equipment. Without these and sociologically problematical, conjuring up images of
additional healthcare professionals, optimal ICU the post-war period of austerity and conflicting with the
management would not be possible. concept of free access from cradle to the grave healthcare.
It is, however, self-evident that those resources are not
infinite. Coupling this fact with rising expectations
2. CRITICAL CARE amongst patients and increasing costs in critical care leads
to a conflict between expressed needs and our ability to
One of the most important responsibilities that nurses have meet them. The ensuing balancing act may have untoward
is to make correct and safe decisions in a variety of client- consequences; a systematic review of rationing of critical
care situations [3]. The decisions made by nurses affect the care beds in the UK has shown that people die that
health status, recovery time, and even the survival or death otherwise might have lived. For the most part, choosing
of a client. For example, the critical care nurse must decide between competing patients is often a matter of logistics as
when to give certain medications on the basis of changes in alternative arrangements can often be made.
the client’s condition. The emergency department nurse Notwithstanding that, at the bedrock of rationing and
must decide which clients to treat first by assessing the discussion thereof is the question that is health or life itself
extent of their injuries. The hospital staff nurse must decide so special that we should improves its quality or longevity
what prn medication to give for which set of symptoms. at any cost? This chapter examines the ethical and
The home health nurse must decide when to call the economic principles behind rationing in critical care.
physician about a change in a client’s condition.
The process by which these decisions are made involves
the use of critical thinking. Critical thinking is based on 3. NURSE
reason and reflection, knowledge, and instinct derived from
experience. It has also been defined as “the art of thinking Critical care nurses care for patients who are critically ill
about thinking.” It is both an attitude about and an [6]. They have a great deal of one-on-one contact with the
approach to solving problems. Critical thinking helps patients and are often the main source of information for
nurses make decisions about problems for which there are the family members. They are responsible for constantly
no simple solutions. Often nurses have to make these monitoring the patient’s condition, as well as recognizing
decisions with less than complete information. any subtle changes. These nurses use a great amount of
The first objective is, of course, to provide exemplary care technology within their practice, and function as integral
[4]. The intensivist must develop and trust in his or her members of the multidisciplinary health care team. Critical
clinical skills. An effective approach to solving clinical care nurses must possess the ability to collaborate with
dilemmas in the ICU must involve the development of a other members of the health care team such as physicians,
clinical hypothesis; the dictum ‘don’t just do something, case managers, therapists, and, especially, other nurses.
stand there’ is an invaluable lesson in developing and They are responsible for all care given to the patient, from
guiding therapy. Frequently, the level of illness in the ICU medication administration to tracheotomy and other
can be overwhelming and there is an urge to act quickly, ventilator care, as well as constant monitoring of the
but not necessarily in a directed fashion. This may serve patient for any alterations in status. Responsibilities include
only to further confuse interpretation of the underlying monitoring, assessment, vital sign monitoring, ventilatory
pathophysiologic state. The six steps below are a useful management, medication administration, intravenous
tool for guiding physician behavior in the ICU: insertion and infusion, central line care, Swan–Ganz
 Develop and trust one’s clinical skills. catheters, and maintenance of a running record of the
 Formulate clinical hypotheses and test them. patient’s status. They must be prepared at all times to
 Liberate patients from interventions so that perform cardiopulmonary resuscitation and other life-
treatments do not outnumber diagnoses. saving techniques.
 Define therapeutic goals and seek the least RN (registered nurse) preparation and advanced cardiac life
intervention in achieving each goal. support certification are required. A Bachelor of Science in
 First, do no harm. Nursing and critical care nurse certification are preferred,
 Organize the critical care team. and may be required depending on the institution. Most
In the USA, 40% of health expenditure is spent in the last institutions require at least 1 to 2 years of medical–surgical
month of the patient’s life, which amounts to ~1.5% of the experience, although some hospitals are offering extended
GDP of the USA [5]. At the pinnacle of high tech medicine preceptorships to selected new graduates. Previous critical
is the critical care unit. It is hardly news that a limitation of care experience is desired. In addition to prior experience,
 IBEROAMERICAN JOURNAL OF MEDICINE 03 (2020) 183-187 185

many institutions require nurses to pass a critical care 5. ELDERLY

course, usually offered in the hospital, and to complete 4 to
6 weeks of orientation to the unit. Certification in critical The elderly are a highly heterogeneous group, and the
care or cardiac medicine is available from the American physical and medical heterogeneity increases with age [9].
Association of Critical Care Nursing Certification Individuals over 65 years of age—with or without chronic
Corporation. diseases—vary widely in their physical, behavioral, and
The nurse in ICU risks moral distress when she feels that cognitive functions. Any clinician can relate the “Tale of
her actions conflict with her commitment to compassionate Two Octogenarians” seen in practice on the same day: the
practice [7]. Her patients are dying and not being cared for end-stage patient afflicted with Alzheimer’s disease seen at
as dying. Often, the nurse at the bedside is compelled to the nursing home and the vigorous retiree seen after his
perform invasive and painful procedures that she fears may golf game for monitoring of his historically well-controlled
be futile: dressing changes, wound irrigation, debridement, hypertension.
venipunctures, gastric tube insertions, catheterizations, Physiologic rather than chronological age is a better
turning, positioning, and restraining patients. predictor of the health status of the elderly. An abrupt
Accommodating the demand for ongoing monitoring and decline in physical function or any organ system is almost
bedside interventions, nurses are compelled to deny certainly due to disease and not due to “normal
privacy, modesty, and visitors. The nurse wants to be true aging.”Therefore, symptoms in the geriatric population
to her responsibility to the patient and neither create should not be attributed automatically to old age, and it is
unnecessary suffering nor omit possible lifesaving important to look for potentially reversible causes of
treatment. Nurses cause suffering because we believe we symptoms. Moreover, treatable conditions should not be
are accomplishing a long-term good. Therefore, the expert undertreated for fear of side effects of medication.
ICU nurse must continually evaluate the effectiveness of Improvement or maintenance of functional status is the
interventions to achieve realistic goals of care. major goal of medical care in the geriatric population.
Functional disability occurs faster and takes longer to
correct in the elderly, necessitating early preventive
4. CHILD measures. Active efforts should be made to maintain
functional level even during intensive care. Even small
A critically ill child is a child who is in a clinical state changes in function can make large differences in the
which may result in respiratory, cardiac, neurological, quality of life. For example, regaining the ability to oppose
gastrointestinal, metabolic, renal and haematological the thumb to other fingers may enable a geriatric patient to
complications [8]. The immediate goal is prompt become independent in feeding. Prevention of iatrogenic
recognition and aggressive early treatment to prevent initial diseases is also important. For example, close attention
respiratory and circulatory insufficiency. should be paid to prevent the development of pressure
This requires rapid and systematic clinical assessment to ulcers. A pressure ulcer can develop in just few hours, and
detect physiological instability so that timely, prompt and the mortality rate of those who develop the lesions in the
effective resuscitation and stabilisation may occur before first 2 weeks of intensive care has been reported to be as
the onset of organ failure. To achieve the best possible high as 73%. Other iatrogenic problems in the ICU include
outcomes and enhance patient safety requires aspiration pneumonia, sepsis, GI bleeding, delirium, drug
interprofessional team working and collaboration, whereby toxicity and interactions, and renal insufficiency.
formal decision making and care interventions are Multiple concurrent illnesses, cognitive and sensory
informed by the knowledge and skills within each of the impairments, age-related changes in physiology and
professional roles. pharmacodynamics, increased vulnerability to delirium,
A powerful incentive for greater teamwork among and complications from immobility make management of
professionals is created when there is respect and acute illness in the elderly a clinical challenge for all
understanding of the role of each of the team members and physicians and other health care providers who care for
recognition of the unique contribution of each individual in patients in this age group.
a critical care situation. In a well - practised team, each
member knows in advance their role and regards the leader
as the person who coordinates, directs the assessment, and 6. PATIENTS
consults with other members regarding problem
identification and subsequent care or management Caring for critically ill patients can engage a range of legal,
planning. Therefore interprofessional working models ethical and practical challenges [10]. This is significant in
require that the level of equality of esteem and power in that over 110,000 patients are admitted to NHS critical care
formal decision making is balanced within the professional units every year. In England there are currently 3,730 adult
roles of doctor and nurse. Effective multidisciplinary team critical care beds, 405 paediatric and 1,368 neonatal
working is at the heart of providing high quality and safe intensive care cots with occupancy rates of 82 per cent,
care. 73.6 per cent and 70 per cent respectively. In fact, these
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figures are likely to underestimate the true prevalence, examination of adults and children, death investigation,
since critical care is not invariably administered in and some basic or introductory education on other areas of
intensive care or high-dependency units and the location of forensic science. The amount of education and training that
care will depend upon need. will be needed will depend on whether the LNC is being
Delivery of high-quality care to these vulnerable patients hired as an expert for the purpose of testifying or for the
can be compromised by ancillary factors such as resource purpose of screening criminal cases for potential forensic
constraints, which may impact negatively upon bed evidence.
availability and access to specialist staff. The legal Experience as a practicing Adult or Pediatric Sexual
framework that governs the care of critically ill patients is Assault Nurse Examiner will be extremely helpful but is
potentially extensive and incorporates the civil law (e.g. not absolutely necessary when considering a career as an
negligence actions), criminal law (physician-assisted LNC. Training as Sexual Assault Nurse should also not be
suicide and euthanasia), public law (judicial review) and the only medical forensic training that is used as the basis
European law (clinical research). All these aspects are for employment as a forensic LNC. In order to expand
underpinned by human rights and equality jurisprudence. one’s practice and competency as a forensic LNC outside
Additional areas of governance include the formal of cases that involve sexual assault reports or medical
complaints system and professional regulation. records, training in analysis of deoxyribonucleic acid
(DNA), toxicology, and interpretation of forensic evidence
is necessary. With generalized medical and forensic
7. LAW ASPECTS training, a forensic LNC can be involved in reviewing and
screening criminal cases such as murder, attempted
Although many legal issues may arise in the ICU as murder, assault, sexual assault, child abuse, vehicular
elsewhere in the hospital, a daily concern is obtaining murders and assaults, and DUI (Driving Under the
consent for the many procedures that are required [3]. In Influence).
order to be considered legally effective, consent to medical
treatment must meet three tests:
 It must be voluntary. 9. CONCLUSION
 The patient must be adequately informed.
 The obtaining of consent must be by someone Intensive medicine deals with the treatment of the most
with adequate capacity and authority. severe patients who are endangered by life and those who
It is important to note that physicians rely on family are currently stabilizing vital functions, but at any given
members as surrogate decision-makers for incapacitated time they can come to life-threatening conditions. Such
patients, even in the absence of a specific statute, advance patients require continuous monitoring, care and treatment.
directive, or court order. In addition, some patients may The person who is spending most time with a critical
lack relatives or friends to act as surrogate decision- patient is a nurse, stating that the role of a nurse in a health
makers. In such cases, physicians should seek guidance care unit in an intensive care unit is invaluable to the
from living wills or other forms of advance directive. recovery and emotional state of the patient. Work in the
Neither a patient nor a family member can demand medical intensive care unit requires not only a continuous presence
treatment that would be futile, and the physician is not with the patient, but also possesses special skills in the
obligated to provide such medical treatment. If the field of vital function monitoring, mechanical ventilation,
physician and patient or surrogate decision-maker have intravenous therapy, etc. Additional skills are needed in
irreconcilable differences, the physician may help provide intensive care units for children. Because of the complexity
alternate care opportunities. of procedures and methods of work in intensive care units
for children, nurses need to be additionally educated and
trained in order to master all the necessary skills which are
needed to provide care for pediatric patients.
8. FORENSICS
Forensic nurses generally work in roles that involve
evidence collection, documentation of medical forensic
evidence, expert or fact testimony, consultation, and
education of legal professionals [11]. A forensic nurse may
be hired by either the prosecution or defense in criminal
cases. When considering the role of a forensic legal nurse
consultant (LNC), there are some basic educational
considerations. As a clinical nurse, the specialties that will
best prepare a nurse for working on criminal cases are
critical care, trauma, or emergency nursing. Additional
foundational knowledge includes training in sexual assault
 IBEROAMERICAN JOURNAL OF MEDICINE 03 (2020) 183-187 187

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