Critical Care Nursing Introductory Complex Care Topics Criteria for admission into a complex care unit Commonly encountered critical care situations Critical care pharmacology and drug calculations Composure of the interdisciplinary team Communicating in a critical care settingCritical CareNursing Pharmacology * Cardiovascular drugs Neurological drugs Pulmonary drugs Drugs for cardiopulmonary arrestCritical Care Diagnostics* Acid base balance and arterial blood gases (ABGs) CT scans, PET scans, x-rays EchocardiogramsCardiovascularSystem Critical CareArrhythmias High-grade atrioventricular block Third-degree atrioventricular heart block Symptomatic ventricular arrhythmias Symptomatic bradycardic Ventricular tachycardiaEKG Interpretation * Common wave patterns Conditions associated with patternsCardiomyopathies* Forms of cardiomyopathies Critical nursing care planning forcardiomyopathiesCarditis Endocarditis pathophysiology, potential causes and complications, clinical manifestations, diagnostics, and treatment Pericarditis pathophysiology, potential causes and complications, clinical manifestations, diagnostics, and treatment Myocarditispathophysiology, potential causes and complications, clinical manifestations, diagnostics, and treatmentMyocardial Infarction (MI) Pathophysiology, risks factors, and clinical manifestations of acute myocardial infarction Diagnostic markers: cardiac enzymes and EKG findings MI treatment algorithm: pharmaceutical management and treatment priorities Cardiac catheterization: angiography, and other options Critical nursing care planning foracute myocardial infarction:assessment, diagnoses, interventions, and outcomesValvular Disorders Aortic stenosispathophysiology, potential causes and complications, clinical manifestations, diagnostics, and treatment Aorticregurgitation (insufficiency)pathophysiology, potential causes and complications, clinical manifestations, diagnostics, and treatment Mitral valve stenosispathophysiology, potential causes and complications, clinical manifestations, diagnostics, and treatment Mitral valve regurgitation (insufficiency)pathophysiology, potential causes and complications, clinical manifestations, diagnostics, and treatment Critical nursing care planning forvalvular disorders:assessment, diagnoses, interventions, and outcomesGastrointestinalCritical CareGastrointestinal Emergencies Stress ulcer prophylaxis Nursing management of GI emergenciesGastrointestinalBleeds Upper GI bleeds Critical nursing care planning for GI bleedsAcute Pancreatitis Pathophysiology, common causes, and complications associated with acute pancreatitis Local complications:pancreatic pseudocyst and abscess Systemic complications: acute respiratory distress syndrome (ARDS), shock, and disseminated intravascular coagulation (DIC) Diagnostics: laboratory values and imaging tests for the pancreas Primary componentsof treatment: pain control, fluid and electrolyte replacement, pancreatic rest, and nutritional support Critical nursing care planning for acute pancreatitisMusculoskeletal Critical CareMusculoskeletalEmergencies* Fractures Vertebral and spinal trauma Critical care nursing management of musculoskeletalemergenciesPulmonary/Respiratory Critical CareVentilators Evidence-based nursing on ventilator care practices Types of ventilators and non-invasive ventilation Oxygenation monitoring Ventilator-associated pneumonia Nursing care for patients on ventilatorsRespiratory Failure Acute respiratory failure (ARF) Adult respiratory distress syndrome (ARDS) Nursing interventions: prone positioning Nursing care for patients with respiratory issuesCOPD Asthma: pathophysiology, etiology, patient presentation, diagnostics, treatment, and nursing management Emphysema: pathophysiology, etiology, patient presentation, diagnostics, treatment, and nursing management Chronic bronchitis: pathophysiology, etiology, patient presentation, diagnostics, treatment, and nursing managementPlural Effusion Pathophysiology and etiology of plural effusion Patient presentation of plural effusion Treatment approach for plural effusion Nursing management of plural effusion in critical carePulmonary Embolism Pathophysiology and etiology of pulmonary embolisms Patient presentation of pulmonary embolism Treatment approach for pulmonary embolism Critical nursing care planning forpulmonary embolism:assessment, diagnoses, interventions, and outcomesSevere Hemothorax Pathophysiology, common causes, and clinical manifestations of severe hemothorax Major risks and complications: hemorrhage, cardiopulmonary arrest, and hypovolemic shock Diagnostics: laboratory values andimaging tests Treatment of hemothorax: pharmacology and collaborative care Critical nursing care planning forhemothorax:assessment, diagnoses, interventions, and outcomesRespiratory Syndromes Acute respiratory distress syndrome (ARDS) Systemic inflammatory respiratorysyndrome (SIRS) Multi-systemic organ dysfunction syndrome (MODS) Pathophysiology and progression of ARDS, SIRS, and MODS Diagnostics: laboratory values andimaging tests Treatment of hemothorax: pharmacology and collaborative care Critical nursing care planning:assessment, potential nursing diagnoses, interventions, and outcomesMultisystem/MultiorganCritical CareShockin Critical Care Determinants of tissue perfusion Pathophysiology of shock states: sepsis to septic shock and hypovolemic shock Common causes of shock and forms of shock Pharmaceuticals for shock states Fluid and volume replacement Critical nursing care planning: assessment, diagnoses, interventions, and outcomesDKA and HHSin Critical Care Pathophysiology of diabetic ketoacidosis and hyperglycemic hyperosmolar shock Comparing clinical manifestations of DKA and HHS Fluid volume replacement, insulin titration, and potassium Critical nursing care planning for DKA and HHS:assessment, diagnoses, interventions, and outcomesTrauma Care Principles of trauma management ABCDE: airway, breathing, circulation, disability, exposure Primary survey and resuscitation Secondary survey Pharmacology in trauma management The nurses role in trauma careBurns in Critical Care Emergencyassessment of burns Pharmaceutical treatment and diagnostics Critical care nursing management of MVAsMotor Vehicle Accidents (MVAs) Emergency assessment and triage Pharmaceutical treatment and diagnostics Critical care nursing management of MVAsNeurologicalCritical CareAssessment of the NeurologicalSystemin Critical Care Neurological assessment in the critical care setting Glasgow coma scale Cranial nerve assessment Reflexes assessmentAutonomic Dysreflexia (AD) Pathophysiology and etiology Early recognition Clinical manifestations Treatment of AD The importance of teaching awareness to patients with SCI Critical nursing care planning forADSpinal Cord Injury (SPI) Risk factors linked to SPI Presentation of severe SPI Potential complications of vertebraldamage Treatment options Pharmaceutical management Critical care nursing management of SPIStroke Ischemic and hemorrhagic strokes Pharmaceutical treatment Critical nursing care planning forstrokeTraumatic Brain Injury Critical Care Scalp lacerations Skull fractures: Basilar and depression Concussions and contusions Hematoma: subdural (acute, subacute, chronic), epidural, subarachnoid, and intraparenchymal hematoma Complications: DI, SIADH, cerebral salt wasting, sympathetic storming, cardiovascular and pulmonary complications, cerebral aneurysm, cerebral hemorrhage, seizuresIncreased ICP for Critical Care Neurological indicators of increased intracranial pressure Cushings triadSpinal Cord Injury for Critical Care Neurological indicators of spinal cord injury Primary survey and cervical spine precautions Potential short-term complications of SCIUrogenitalCritical CareAcute Kidney Injury Prerenal injury pathophysiology, potential causes and complications, clinical manifestations, diagnostics, and treatment Intrarenal injury pathophysiology, potential causes and complications, clinical manifestations, diagnostics, and treatment Postrenal injury pathophysiology, potential causes and complications, clinical manifestations, diagnostics, and treatment Critical care nursing management of AKIDialysis for Critical Care Indications for dialysis (acute and chronic) Major forms of dialysisLiver Injury in Critical Care Common causes of liver injury Fulminant liverdisease and chronic hepatic failure Diagnostics value and imaging for the liver Cirrhosis, hepatoencephalopathy, and ascites Critical care nursing management of liver injuryUrogenitalEmergencies * Urinary retention Benign prostate hypertrophyResources for Nursing Students on Critical Care American College of Emergency Physicians (2011). ED Facility Level Coding Guidelines. Retrieved from http://www.acep.org/Content.aspx?id=30428 The AACN Synergy Model for Patient Care. The American Association of Critical Care Nurses. Retrieved from http://www.aacn.org/wd/certifications/content/synmodel.pcms?menu=#Nurse American Thoracic Society. (1998). Research priorities in respiratory nursing. American Journal of Respiratory and Critical Care Medicine, 158(6), 2006-2015.Retrieved from http://www.atsjournals.org/doi/full/10.1164/ajrccm.158.6.ats798#.UmDT397n_IU Baker, S. N., & Weant, K. (2012). Management of acute agitation in the emergency department. Advanced Emergency Nursing Journal, 34(4), 306-318. Retrieved from http://www.nursingcenter.com/lnc/CEArticle?an=01261775-201211000-00004&Journal_ID=646631&Issue_ID=1454646 Cvijanovich, N. Z.,Cook, L. J., Mann, N. C.,& Dean,J. M.(2003). Population-based assessment of pediatric all-terrain vehicle injuries. Pediatrics, 108(3), 631-635. Retrieved from http://pediatrics.aappublications.org/content/108/3/631.abstract Deutschman, C. S., Ahrens, T.,Cairns, C. B., Sessler, C. N., & Parsons, P. E. (2012).Multisociety Task Force for Critical Care Research: Key issues and recommendations. American Journal of Critical Care, 21(1), 15-23. Retrieved from http://ajcc.aacnjournals.org/content/21/1/15.full Dittrich, K. (2007). Critical Care:ACLS update: A new role for medications. Nursing, 37(12), 56. Retrieved from http://www.nursingcenter.com/lnc/JournalArticle?Article_ID=757400&Journal_ID=54016&Issue_ID=757324 Maiocco, G. (2002). Posters give nursing staff consistent information.Critical Care Nurse, 22(2), 152. Retrieved from http://ccn.aacnjournals.org/content/22/2/152.full Vella,K.,Goldfrad, C.,Rowan,K.,Bion, J., & Black, N. (2012). Use of consensus development to establish national research priorities in critical care. BMCJournal,320, 976-981. Retrieved from http://www.bmj.com/content/320/7240/976?variant=full-textBasics Concepts of Critical Care NursingCritical Care Nursing Class Notes on Basic Concept Introductions

Introduction of Critical Care TopicsWelcome to Critical Care!Complex Care Intro Topics The complex care arena: interdisciplinary team composure,communication, and the work environment Critical care theory framework: theSynergy Model from the AACN and the nurses role in the care of the critically ill patient Admission criteria, what it means to be critical, and commonly encountered situations in the complex care unit Environmental factorsfor the patient: visiting, the effects of family, sleep, stressors, noise, light, temperature, communication, delirium risk Assessment of the critical care patients family and meeting the needs of the family membersLike other areas of nursing, critical care is driven by the nursing process. Thisframework includes assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.The Critical Care ArenaExamining the Arena of Critical Care Members of the interdisciplinary team (IDT) The Synergy Model from the AACN Elements that contribute to a health work environmentThe Critical Care Interdisciplinary Team (IDT) Physicians: Intensivists (critical care physician), Radiologist, Neurologist, Nephrologist, and other specialists Surgeons: trauma surgeons, thoracic surgeons, cardiovascular surgeons, and other specialists Other providers: Nurse Practitioner (NP), Physician Assistant (PA) Registered Nurse (RN) with special certifications in critical care and ACLS (advanced cardiovascular life saver) Respiratory Therapist (RT) Registered Dietitian (RD) Techs and aides: Certified Nursing Assistant (CNA), Patient Care Technician(PCT), Primary Care Technician, and Trauma Care Technicians Emergency transporters: paramedic, emergency medical technician (EMT) Non-medical team members: law enforcement officer (police and detectives) and patient advocates Supportive staff and administrators: patient transport technician and othersThe Synergy ModelWhat is the Synergy Model?The Synergy Model is framework that links practice to patient outcomes. Itsa patient-centered nursing practice model forcomplex care developed by the American Association of Critical-Care Nurses. The model outlines the components that are conducive to the complex care arena and environment. It matches the nurses competencies to the needs of the patient by assigning the sickest patients to the most experienced nurse as they probably have the most competencies (Grudge Match Nurses: how come you talk about EBP but cant place a foley?)and evaluates the relationship between clinical practice and outcomes. The focus is on patient-derived outcomes, including functional change, behavioral change, trust, satisfaction, comfort, and quality of life. The model also addresses nurse-derived outcomes: the nurses actions are evaluated. The broad emphasisis over physiological changes, absence of complications, provided care, and treatment.Components of the Synergy Model for Critical Care Resiliency Vulnerability Complexity Resource availability Participation in care Participation in decision-making PredictabilityAdmissions Criteria for Critical CareWhat It Means to be CriticalThe American Association of Critical Care Nurses defines admission criteria to be for those who are at high risk for actual or potential life-threatening health problems (2005). A critical illness or injury is an acute impairment of one or more vital organ systems in which the patients survival is jeopardized (Department of Health and Human Services). Critically ill patients have complex physiologic and hemodynamic perturbationsCommon Situations for Critical Care Admissions Trauma perpetrations: MVA, contusions, abrasions, fractures, hemorrhage Cardiovascular perpetrations: myocardial infarction Neurological perpetrations: stroke Neurological findings: altered level of consciousness Pulmonary findings: altered breathing patterns, dyspnea, low oxygen saturation, use of accessory muscles Cardiovascular findings: hypotension or hypertension, bradycardia or tachycardia Integumentary findings: mottled skinNutritional Needs The role of nutrition for the critically ill patient is vital to the recovery process Fever from serious illness increases the metabolic demands of the body Serious burns require increased caloric and protein needs to healThe Critical Care EnvironmentVisiting in Critical CareEvidence based practice states that the ICU should have open-visiting hours. Open-visiting hours is not synonymous with 24-hour visiting. As the nurse is the patients advocate, its important toanalyze the effects that visitors have on the patient. While some visitors can help the patient relax, others can bring undue stress. Educate family members and caregivers on the effect they are having on the patient; for example, does the patients pulse and blood pressure sky-rocketwhen they visit? Or does the patient show physiological signs of comfort in theirpresence? Its also important to bear in mind that caregivers areextremely prepositioned to burnout, so remind them to go home and get some rest, eat well, and take time for themselves. Family members that are willing to learn and able to communicate tend to have the best effects on the patients outcome.The Role of theFamily Keep in mind that the family members serves a pivotal role in critical care. Remember that the family is also in crisis anddisequilibrium. The nurse must assess the family unit anddetermine who-is-who within the family structure.Assessing the Family Determine the family structure,and function Inquire about the spiritual and cultural needs of the family Determine how the family copes with stress Communicate effectively and consistently with the family: listen, use vocabulary that matches their level Consider what factors may promote the familys comfort Provide for visitation and personalize the environmentPersonalizing theComplex Care Unit Enable the patient and family to personalize the setting as much as possible within the framework of hospital policies. For instance, it may help to allow them to bring in a favorite pillow, pajamas, or to place family photographs in the room. Also recognize the importance of maintaininga relaxing environment thats conducive t to recovery. Give them a sense of privacy while still being able to monitor them.Poor communication leads to increased rates of errorsTheCritical Care Working EnvironmentThe Importance of a HealthyCritical Care Environment A healthy work environment is inherent to the success of a critical care unit. It affectsstaff and patientsafety. The work environment also influencespatient outcomes. Retention of competent nursing staff and other members of the interdisciplinary health care team are dependent upon the work environment. Therefore, its important for the nurse to understand what elements are conducive to a healthy work environment and what potential sources of stress exist. The AACN has developed guidelines to create and maintain a healthy work environment, and the benefits affect everyone involved.Ubiquitous Sources of Staff Stress ina Critical Care Setting Technology: state-of-the-art technology also requires state-of-the-art education to train those responsible for using complex equipment Poor communication: communication has a direct impact on patient safety and the tone of the work environment Unstandardized practice: inconsistency leaves gaps in the continuum of careThe Six Standards of a Healthy Work Environment from the AACN 1. Skilled communication2. True collaboration: True collaboration is necessary to take truly quality care. This may involves several disciplines.3. Effective decision making: Must understand how the hospital culture works. Must know whats going on with the patient to answer questions succinctly through critical values. After implementing an intervention, it must be evaluated to determine if it was effective or ineffective and then plan for the next step. This also includes the ability to anticipate the providers actions. This involves an thorough understanding of the patients history, diagnosis, treatments, and other aspects4. Appropriate staffing5. Meaningful recognition6. Authentic leadership (Vollers, Roberts, Dambaugh, & Brenner, 2009)Emphasized Principles in the ACCNs Health Work Environment Standards Recognition is a central element Nurse-to-patient ratio An adequate mix of skillsSummarized from the AACNs Healthy Work Environment Standards and an Empowering Nurse Advancement System, 2009 Communication in Critical Care:The most vital outcome of skilled and effective communication between the Critical Care Nurse and the healthcare provider is patient safetyCommunication in a Critical Care Setting Skilled communication is the lifeblood of the critical care setting(Vollers, Roberts, Dambaugh, & Brenner, 2009)\ It involves multidisciplinary unity and collaboration of nurses, healthcare providers, and other medical professionals, along withadministrative leaders, the chief executive officer, and supporting staff Communication in the critical care setting has a direct impact on patient outcomes The importance of the Critical Nurses communication skills are ranked in the samecategory as clinical skills Its imperative for the communication between the provider and nurses to remain strong The most vital outcome of skilled and effective communication between the Critical Care Nurse and the provider is patient safety Communication can come in the form of face-to-face methods such as giving and receiving report, staff meetings, and technological communication methods such as email, phone calls, the Intranet (the internal network of the facility thats available only to employees, and possibly volunteers, and students), and the content of the facilitys websiteClinical Nurse Advancement System (CNAS)The Clinical Nurse Advancement System (CNAS) is practiced in many hospitals. Its composed primarily of staff nurses that represent each unit,the system functions todevelop specificjob descriptions and responsibilitiesfor nurses and governs the advancement process. This system keeps nurses accountable and allows them to advance from the clinician Ilevel up to IV, based upon performance, competence, experience, and knowledge with an emphasis placed on education and certification. Some CNASssupport nursing grand rounds, a presentation conducted by staff nurses to help attendees learn new content pertaining to a focused topic. This also assists nurses in developing their public presentation skills and generates further discussion regarding presented topic, allowing for vital input from patients, family members, and staff. CNASs promotes multidisciplinary unity and collaboration throughthe enhancement ofcommunication skills, encourages clinicians to be involved in research through article publication, further education, and present new information at regional and national conferences. Members of the CNAS may also serve on other interdisciplinary committees such as anticoagulation, ethics, infection control, pharmacy, and safety/quality improvement(Vollers, Roberts, Dambaugh, & Brenner, 2009)AACN StandardsThe Six Standards of the American Association of Critical-Care Nurses1. Assessment2. Diagnosis3. Outcomes identification4. Planning5. Implementation6. EvaluationStandard # 1: Assessment Assessment: data is collected from a holistic perspective Allpotentiallyvaluable sources are used to collect data, including the patient, family, and other team members through the use of interview, observation, analytical models, and problem-solving tools The assessment process is driven by current and anticipated needs Relevant assessment findingsare communicated to other team members and documentedStandard # 2: Diagnosis Assessment findings are used to develop and prioritize the most appropriate nursing diagnoses Diagnoses are validated through interactions with the patient, family, and other team members and are modified as needed Diagnosesare documentedStandard # 3: Outcomes Identification Identified outcomes take into consideration the patients unique situation and are derived from actual or potential diagnoses Outcomes are attainable, measurable, includea timeframe, and are modified as needed The identified outcomes are documentedStandard # 4: Planning A plan of care is made to achieve the desired outcomes with the collaboration of the patient and family. It is focused onrestoring health, promoting health, minimizing the risk of complications and providing for continuity of care.This plan establishes priorities, and takes into consideration the economic impact and resources available to deliver the care.The nurses skills and competencies must meet the patients needsStandard # 5: Implementation The plan of care is delivered through safe methods that involves the input of the patient and family Elements may also include health teaching, health promotion, and disease management All actions taken are documentedStandard # 6: Evaluation Evaluation performed in a systematic way usingongoing using evidence-based techniques and involves the collaboration of thepatient, family, healthcare providers,as appropriate Results are documented and adjustments are made as necessary to achieved the desired outcomesEmphasized Principles in the ACCNs Scope and Standards of Nursing Care Use of current best evidence Collaboration with the patient, family, healthcare provider, and other team members as appropriate Actions to minimize the risk of complications and deliver care in a safe and effective manner Documentation to record all actions takenSummarized from the AACNs Scope and Standards for Acute and Critical Care Nursing Practice, 2008 Resources for Nursing Students on Critical Care BasicsAmerican Association of Critical-Care Nurses (2008). AACN Scope and Standards for Acute and Critical Care Nursing Practice. Retrieved from http://www.aacn.org/wd/practice/docs/130300-standards_for_acute_and_critical_care_nursing.pdfAmerican Association of Critical-Care Nurses. The AACN Synergy Model for Patient Care.Retrieved from http://www.aacn.org/wd/certifications/content/synmodel.pcms?menu=#NurseAmerican Association of Critical-Care Nurses. The Synergy Model in Practice.Retrieved from http://www.aacn.org/wd/certifications/content/syninpract.pcms?menu=certificationBaker, S. N., & Weant, K. (2012). Management of acute agitation in the emergency department. Advanced Emergency Nursing Journal, 34(4), 306-318. Retrieved from http://www.nursingcenter.com/lnc/CEArticle?an=01261775-201211000-00004&Journal_ID=646631&Issue_ID=1454646Deutschman, C. S., Ahrens, T.,Cairns, C. B., Sessler, C. N., & Parsons, P. E. (2012).Multisociety Task Force for Critical Care Research: Key issues and recommendations. American Journal of Critical Care, 21(1), 15-23. Retrieved from http://ajcc.aacnjournals.org/content/21/1/15.fullFoster-Edwards, D. (1999). The Synergy Model: Linking patient needs to nurse competencies. Critical Care Nurse, 19(1). Retrieved from http://www.aacn.org/WD/Certifications/content/synpract2.contentKhalifezadeh, A., Safazadeh, S., & Mansour, B. A. (2011). Reviewing the effect of nursing interventions on delirious patients admitted to intensive care unit of neurosurgery ward in Al-Zahra Hospital, Isfahan University of Medical Sciences. Iranian Journal ofNursing and Midwifery Research, 16(1), 106-112. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3203289/Vollers, D., Roberts, C., Dambaugh, L., & Brenner, Z. R. (2009). AACNs Healthy Work Environment Standards and an Empowering Nurse Advancement System. Critical Care Nurse, 29(6), 20-27. Retrieved from http://ccn.aacnjournals.org/content/29/6/20.shortor access the full PDF document at http://www.aacn.org/WD/CETests/Media/C0962.pdfWenham, T., & Pittard, A. (2009).Intensive care unit environment. Continuing Education in Anaesthesia, Critical Care, & Pain, 9(6), 178. Retrieved from http://ceaccp.oxfordjournals.org/content/9/6/178.full