Critical care design and facilities

CRITICAL CARE NURSING

1Prof. Dr. Ram Sharan Mehta, MSND, CON, BPKIHS

CRITICAL Crucial Crisis Emergency Serious Requiring immediate action Thorough and constant observation Total dependent (Oxford Dictionary)

2Prof. Dr. R S Mehta, BPKIHS

DEFINITIONS

CRITICAL CARE : CRITICAL CARE IS A TERM USED TO DESCRIBE AS THE CARE OF PATIENTS WHO ARE EXTREMELY ILL AND WHOSE CLINICAL CONDITION IS UNSTABLE OR POTENTIALLY UNSTABLE.

CRITICAL CARE UNIT :IT IS DEFINED AS THE UNIT IN WHICH COMPREHENSIVE CARE OF A CRITICALLY ILL PATIENT WHICH IS DEEMED TO RECOVERABLE STAGE IS CARRIED OUT.

CRITICAL CARE NURSING :IT REFERS TO THOSE COMPREHENSIVE, SPECIALIZED AND INDIVIDUALIZED NURSING CARE SERVICES WHICH ARE RENDERED TO PATIENTS WITH LIFE THREATENING CONDITIONS AND THEIR FAMILIES.

Critical Care Technology ECG monitoring Arterial Lines Oxygen Saturation Ventilation Intracranial Pressure Monitoring

Temperature Pulmonary Artery Catheter IABP Extensive use of pharmaceuticals

Prof. Dr. R S Mehta, BPKIHS

Prof. Dr. R S Mehta, BPKIHS 7

Historical Background

World War II Shock wards

established for resuscitation

Transfusion practices in early stages

After World war-II, nursing shortage forced grouping of postoperative patients in recovery areas

Polio epidemic 1950’s: use of

mechanical ventilation (“iron lung”) for treatment of polio

Development of respiratory intensive care units

At the same time, general ICU’s developed for sick and postoperative patients

History Continued Collaboration between nurses and

physicians 1950’s & 1960’s – CV Disease most

common diagnosis 1960’s – 30-40% mortality rate for MI 1965 – 1st specialized ICU – The

Coronary Care Unit Emergence of Specialized ICU’s

Prof. Dr. R S Mehta, BPKIHS

ICU’s also treat the dying Isaac Asimov:

“Life is pleasant. Death is peaceful. It is the transition that is difficult”

Isaac Asimov: Professor of Biochemistry Boston 12

An Ideal ICU

Multidisciplinary & Collaborative approach to ICU care Medical & nursing directors : co-responsibility for ICU management• a team approach : doctors, nurses, R/T, pharmacist• use of standard, protocol, guideline consistent approach to all issues• dedication to coordination and communication

for all aspects of ICU management• emphasis on research, education, ethical

issues, patient advocacy14Prof. Dr. R S Mehta, BPKIHS

CLASSIFICATION OF CRITICAL CARE PATIENTS

Level O : normal ward care Level 1: at risk of deteriorating , support

from critical care team Level 2 : more observation or

intervention, single failing organ or post operative care

Level 3; advanced respiratory support or basic respiratory support ,multiorgan failure 15Prof. Dr. R S Mehta, BPKIHS

Types of ICU General Medical Intensive Care Unit(MICU) Surgical Intensive Care Unit Medical Surgical Intensive Care Unit(MSICU)

Specialized Neonatal Intensive Care Unit(NICU) Special Care Nursery(SCN) Paediatric Intensive Care Unit(PICU) Coronary Care Unit(CCU) Cardiac Surgery Intensive Care Unit(CSICU) Neuro Surgery Intensive Care Unit(NSICU) Burn Intensive Care Unit(BICU) Trauma Intensive Care Unit

DESIGN OF ICU

ORGANIZATION OF ICU DESIGN OF ICU : 1. Should be at a geographically distinct area

within the hospital, with controlled access.2. There should be a single entry and exit.

However, it is required to have emergency exit points in case of emergency and disaster.

3. There should not be any through traffic of goods or hospital staff. Supply and professional traffic should be separated from public/visitor traffic. 18Prof. Dr. R S Mehta, BPKIHS

4. Safe, easy, fast transport of a critically sick pt should be a priority in planning its location. Therefore, the ICU should be located in close proximity or ER, OT, trauma ward etc.

5. Corridors, lifts and ramps should be spacious enough to provide easy movement of bed/trolley of a critically sick patient.

6. Close, easy proximity is also desirable to diagnostic facilities, blood bank, pharmacy etc.

BED STRENGTH:1. It is recommended that total bed strength in ICU

should be between 8-12 and not less than 6 or not more than 24 in any case.

2. 3-5 beds per 100 hospital beds for a Level III ICU or 2 to 20% of the total no of hospital beds.

3. 1 isolation bed for every ICU beds.

BED AND ITS SPACE:1. 150-200 sq.ft per open bed with 8 ft in between

beds.2. 225-250 sq.ft per bed if in a single room.3. Beds should be adjustable, no head board, with

side rails and wheels.4. Keep bed 2 ft away from head wall.

ACCESSORIES:1. 3 O2 outlets, 3 suction outlets (gastric, tracheal

and underwater seal), 2 compressed air outlets and 16 power outlets per bed.

2. Storage by each bedside.3. Hand rinse solution by each bedside.4. Equipment shelf at the head end.5. Hooks and devices to hang infusions/ blood

bags, extended from the ceiling with a sliding rail to position.

6. Infusion pumps to be mounted on stand or poles.7. Level II ICUs may require multi channel invasive

monitors. 21Prof. Dr. R S Mehta, BPKIHS

8. ventilators, infusion pumps, portable X ray unit, fluid and bed warmers, portable light, defibrillators, anaesthesia machines and difficult airway management equipments are necessary.

STAFFING :1. Medical Staff – the best senior medical staff to

be appointed as an Intensive Care Director or Intensivist. Less preferred are other specialists from anaesthesia / medicine who has clinical commitment elsewhere. Junior staff are intensive care trainers and trainees on deputation from other disciplines.

2. Nursing staff – The major teaching tertiary care ICU requires trained nurses in critical care. 22

The no of nurses ideally required for such unit is 1:1 ratio, however it might not be possible to have such members in our set up. So 1 nurse for 2 patients is acceptable. The no of trained nurses should also be worked out by the type of ICU, the workload and work statistics and type of patient load.

3.Allied Services – Respiratory services, Nutritionist, Physiotherapist, Biomedical engineer, technicians, computer programmer, clinical pharmacist, social worker / counsellor and other support staff, guards and grade IV workers.

Design Summary: For critically ill: unstable patients Level: I II III Bed strength: ideal 8-14 Each pt. > 100 sq. ft. ( 125-150

desirable) Additional space = 100% 10% isolation bed At least 2 barriers to enter ICU

Only one entry and exit, emergency exit Proper fire extinguisher At least 2 ft. away from head wall Central nursing station: all pt. visibleEnvironment requirements: Heating, ventilation, air-conditioning

system in ICU (HVAC system) Fully air-conditioned : 6 cycle/hr, 2 cycle

outside air Temperature = 16-25 oC

Light: high illumination, 150 foot candle (fc), overhead light = 20fc, floor light at night = 10fc

Noise control: Under 45 dBA in day, <40 in evening, <20 in night. (watch tick= 20 & normal conversation at 55)

Furniture: solid, non-porous, stain resistant.

Floor: easy to clean and non-slippery Wall= 4-5 ft. finished with tiles Ceiling: paint with soft color, no wire lines

Summary… Stressors in ICU:

- Patients and family stressors Staff stressors: Nurses role is to decrease stress:

examining feeling about death, listen attentively to needs, use touch therapy as applicable, family care, maintain privacy, allow cultural practices as possible.

Core Competencies Patient Care Medical Knowledge Professionalism & Ethics Interpersonal Communication Skills Practice-based Learning and

Improvement Systems-based Practice

Objective Parameters Model for ICU admissionVital Signs • Pulse < 40 or > 150 beats/minute• Systolic arterial pressure < 80 mm Hg or 20 mm Hg below the patient's

usual pressure • Mean arterial pressure < 60 mm Hg • Diastolic arterial pressure > 120 mm Hg • Respiratory rate > 35 breaths/minute

Laboratory Values (newly discovered)• Serum sodium < 110 mEq/L or > 170 mEq/L • Serum potassium < 2.0 mEq/L or > 7.0 mEq/L • PaO2 < 50 mm Hg pH < 7.1 or > 7.7 • Serum glucose > 800 mg/dl • Serum calcium > 15 mg/dl • Toxic level of drug or other chemical substance in a hemodynamically or

neurologically compromised patient 29Prof. Dr. R S Mehta, BPKIHS

Radiography/Ultrasonography/Tomography (newly discovered)

Cerebral vascular hemorrhage, contusion or subarachnoid hemorrhage with altered mental status or focal neurological signs

Ruptured viscera, bladder, liver, esophageal varices or uterus with hemodynamic instability

Dissecting aortic aneurysm

Electrocardiogram Myocardial infarction with complex arrhythmias,

hemodynamic instability or congestive heart failure Sustained ventricular tachycardia or ventricular fibrillation Complete heart block with hemodynamic instability

Physical Findings (acute onset) Unequal pupils in an unconscious patient Burns covering > 10% BSA Anuria Airway obstruction Coma Continuous seizures Cyanosis Cardiac tamponade

Functions of critical care nurse Help to restore life process: BLS/ALS Help to maintain life sustaining functions Manage crisis/ critical care situations Maintain standard: follow guidelines Maintain team spirit and IPR Ensure availability of all equipments Provide continue nursing services Maintain good rapport with family

Thank you

ICU & CCU Service of BPKIHS

Nursing Care and Protocols

Critical Care Considerations

F=Feeding/fluid A=Analgesics S=Sedation T=Thrombolytic agents H=Head elevation U=Ulcer – bed sore G=Glucose monitoring

Feeding and Fluids It includes Enteral feeding

oOro - gastric and Naso - gastric feeding oChurn dietoDairy and poultry products (Milk, egg,

youghort)oHigh protein liquid dietoMedications

Oral feedingoHospital dieto Bland dietoNormal dieto Liquid intake

Transparenteral dieto OliclinomelIncludes:-

• Amino acid solution with electrolyte (5.5%) volume 800 ml

• Amino acid 44 gram• Na acetate• Na glycerophosphate • KCl

MgCl2 Sodium Magnesium PO4

Acetate Chloride Glucose 20% solution with CaCl2

Overall volume of TPN = 2000 ml Osmolarity = 75 mOsm/L pH = 6 Amino acid = 44 gram Total calorie = 1,215 Kcal

Fluids IV fluids like NS, RL, 5% D, 10% D, DNS

Analgesics

Fentanylo It works 600 times more effectively than

Morphine and reduces the pain and increases the pain threshold

oUsed in moderate and severe paino In ICU 50 – 100 µg per Kgo Antidote Naloxone 0.05 mg/ Kg

Morphineo Reduces painoChiefly used in MIo 2-4 mg dissolved in 10 ml NSo Antidote: Naloxoneo Supplied by hospital.

Acetaminophen and NSAIDsoOften more effective than opioids in reducing

pain from pleural or pericardial rubs, a pain that responds poorly to opioids.

o particularly effective in reducing muscular and skeletal pain

o Tab form: 500mg OD

Sedatives

Benzodiazepines1. Midazolam

oShort acting sedatives and hypnoticsoIn intubated patientsoDose 0.01- 0.05 mg/Kg for several hours

Benzodiazepines…

2. Diazepam• Adult dose = 0.2 – 0.5 mg/ Kg• Not given in MI patients

Dissociative Anaesthesia Ketamine

Adult dose= 1 – 3 mg/kg IV

Propofolo Arousal is rapid 10- 15 minoUsed in neuro cases and those with

increased ICP, during tracheostomy procedure

Inotropes Dopamine Dobutamine Nor- adrenaline

Thrombolytic agents TEDS compressive stocking SCD (Systematic Compressive Device) LMWX Heparin flush

Head elevation Head is elevated to 30 degree.

Ulcer Two hourly position change Back care in each shift Oxygen therapy Each shift dressing of pressure sore Air mattresses

Glucose monitoring RBS as prescribed Insulin therapy Careful monitoring of signs of

Hypoglycemia(trembling, clammy skin, palpitations, anxiety, sweating, hunger, and irritability)

Infection control Hand washing before, during and after the procedure Sterility maintenance during procedures Use of disinfectants Weekly high wash Monthly culture test of health personnel, equipments

and infrastructures Regular inspection by infection control team Each shift CVP dressing

Specific equipments used in ICU and CCU

Ventilators Infusion pumps Cardiac monitors Defibrillator ABG machine ECG machine

Drugs used in CCU Aspirin Clopidogrel Nitroglycerine Atorvastatins LMWX Morphine

Sedation score in ICU is done by RASS

(Richmond Agitation Sedation Scale = RASS)

RASS(Richmond Agitation Sedation Scale) Number Characteristics Definition Intervention

+4 Combative Violent, immediate danger to staff

Restrain and sedate

+3 Very agitated Aggressive, pull or remove tubes

Restrain and sedate

+2 Agitated Frequent non purposeful movement, fights ventilator

Restrain and sedate

+1 Restless Anxious movement but not aggressive or vigorous

Sedate

0 Alert and calm

Number Characteristics Definition Intervention-1 Drowsy Not fully alert but has

sustained awakening, eye contact to voice (>10 sec)

Verbal stimulation

-2 Light sedation Briefly awakens, eye contact to voice (<10sec)

Verbal stimulation

-3 Moderate sedation

Moderate or eye opening to voice but no eye contact

Verbal stimulation

-4 Deep sedation No response to voice but movement or eye opening to physical stimuli

Physical stimulation

-5 No response No response to voice or physical stimuli

Physical stimulation

“It may seem a strange principle to enunciate (articulate) as the very first requirement in a Hospital that it should do the sick no harm.” [1859]

MONITORING IN CRITICAL CARE AREAS…

Airway monitoring Keep talking to your patient

Breathing check Don’t forget to auscultate your patient

Circulation monitoring When in doubt check bilateral limb BP and radio-femoral delay

Disability(neurological monitoring) Keep an eye when your patients walking

Expose and look for problems Keep an eye on all tubes and wires

Pain management is must

A• ACIDOSIS• AORTIC

DISSECTION• ALCOHOL• AIRWAY

B • BREATHING• BABY

C • CIRCULATION• COMPRESSION• COOLING

D• DISABILITY• DEFIBRILLATION• TRENDELENBURG

POSITION

E• EXPOSURE• EFFUSION• EMBOLISM• ECG

TAKE HOME POINTSAlways follow ABCDIdentify and work on EWS

Thank you…!!!

Guidelines for monitoring the patients in ICU: Discuss

Decrease anxiety & fear: reassure, sedation Assess: all physiological parameters Inspect & examine pt.: LOC, secretions etc. Vitals : TPR BP RR HR Pao2, paco2, urine output Weight gain Capillary refill: 3-5 sec Phy. Exam: head to toe & systematic ETT, Airway, subcutaneous emphysema, chest tube, Skin temp, gastric distention All relevant Laboratory reports: ABG, BUN, LFT etc.

Role of Nurses in ICU

67Prof. Dr. RS Mehta, BPKIHS

ICU nurses play a vital role in the patient’s care, including the following:

Taking regular blood tests Changing the patient’s treatment in line with test results Giving the patient the drugs and fluids that the doctors

have prescribed Recording a patient’s blood pressure, heart rate and

oxygen levels Clearing fluid and mucus from the patient’s chest using

a suction tube Turning the patient in his or her bed every few hours to

prevent sores on the skin

Contd… Cleaning the patient’s teeth and

moistening the mouth with a wet sponge Washing the patient in bed Changing the sheets Changing a patient’s surgical stockings,

which help circulation when he or she is inactive (lying still) for a long time

Putting drops in the patient’s eyes to make it easier to blink

Nurses role to patient with CVP Position the patient in Semi Fowler position. Removes clothing that could constrict the

neck or upper chest Provide adequate lightening to visualize

effectively the external jugular veins. Prevent the infection from the ports by

change dressing.

Contd… Label the date of insertion and change. Observe for complication such as

pneumothorax, hemothorax, hematoma, cardiac tamponade, air embolism and colonization of micro-organism.

Thank you…!!!

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