Critical Care Nursing - Confidentiality and dignity

- Delivery of specialized care to - The right to die with dignity

critically ill patient - Right of those seeking care
- To be considered critical, an illness and the providers
or injury must acutely impair one or
more vital organ systems to such a - The World Federation of Critical
degree that there is a high Care Nurses (WWCCN) considered
probability of life-threatening the rights of critically ill patients and
deterioration (Perring and McLeod, also agreed to the statements of
2018) patient’s rights from the ICN

Professional Regulation Commission - Goals of Critical Care Nursing

Board of Nursing (PRC-BON) (CCNAPI,2014)
- Committed to providing need-driven, - To promote optimal delivery of
effective, and efficient specialty safe and quality care
nursing care services of a high - To care for the critically ill patients
standard and at the international with a holistic approach
level within the obtainable resources - To use relevant and up-to-date
- PRC - BON working group in knowledge
developing the Nursing Specialty - To provide palliative care to
Framework was formed in the 1996 critically ill patients

Critical Care Nurses Association of the Levels of Care (CCNAPI,2014)

Philippines, Inc. (CCNAPI)
- Provide a clear and updated Level 1
statement regarding the scopes of - Should be capable of providing
practice and standards of critical immediate resuscitation for the
care nursing critically ill and short-term
- 11 Core Competencies for Entry cardio-respiratory support
Level for Safe and Quality Nursing because the patient is at risk of
Care deterioration
- A significant role in monitoring and
The Rights of the Critically Ill Patient preventing complications in “at-risk”
- The International Council of medical and surgical patients
Nurses (ICN) views health care as - Capable of providing mechanical
the rights of every individual ventilation and simple invasive
regardless of financial, political, cardiovascular monitoring
geographical, racial, and religious - Has a formal organization of
considerations. medical staff and at least one
registered nurse
- These rights include: - Patient ratio 1:1 for all critically ill
- The right to accept or refuse patients
treatment or nourishment
- Informed consent
Level 2 - Special department of the hospital or
- Capable of providing a high healthcare facility that provides
standard of general critical care intensive care medicine
for patients who are stepping - Caters to patients with severe or
down from higher levels of care or life-threatening illnesses and
requiring single organ injuries, which require constant
support/support postoperatively care, and close supervision from
- Capable of providing sustainable life support equipment and
support for mechanical ventilation, medication in order to ensure
renal replacement therapy, invasive normal bodily functions.
hemodynamic monitoring, and - Staffed by highly trained physicians,
equipment for critically ill patients of nurses, respiratory therapists, and
various specialties such as other members of the healthcare
medicine, surgery, trauma, team who specialize in caring for
neurosurgery, and vascular surgery. critically ill patients
- Has a designated medical director
with appropriate intensive care Categorization of CCU
qualification and a duty specialist
available exclusively to the unit at By Age Group
all times - Neonatal
- Patient ratio 1:1 for all critically ill - Pediatric
patients - Adult

Level 3 By Specialty
- It is a tertiary referral unit, capable of - Medical
managing all aspects of critical - Surgical
care medicine - Respiratory
- Has a medical director with - Neurosurgical
specialist critical/intensive care - Cardio-thoracic
qualification and a duty specialist - Trauma
available exclusively to the unit - Cardiac
and medical staff with an
appropriate level of experience By Specialty Operation
always present in the unit - Open System
- Patient ratio 1:1 for all critically ill - The admitting and other
patients attending doctors make
decisions without
consulting or
Critical Care Environment communicating with a
Critical Care Specialist.
CRITICAL CARE UNIT (CCU) - Closed System
- Also known as Intensive Care Unit - Patient care is provided by a
(ICU) or Intensive Treatment Unit dedicated ICU team that
(ITU)
 includes a critical care Nurse practitioner, Clinical nurse
physician. specialist, Nurse researcher

Critical Care Nurses Competencies of Critical Care Nurses

- Registered nurses, who are
trained and qualified to practice - Clinical Inquiry
critical care nursing. - Should be engaged in the
- A critical care nurse is a licensed ongoing process of
professional nurse who is questioning and evaluating
responsible for ensuring that practice and providing
acutely and critically ill patients and informed practice.
their families receive optimal care. - Clinical Judgement
- Clinical reasoning which
Roles of Critical Care Nurses includes clinical
decision-making, critical
Care provider thinking, and a global grasp
A. Direct patient care of the situation, coupled with
- Detects and interprets indicators nursing skills acquired
that signify the varying conditions of through a process of
the critically ill with the assistance of integrating formal and
advanced technology and experiential knowledge
knowledge - Caring Practices
- Plans and initiates the nursing - Nursing activities that create
process to its full capacity in a a compassionate, supportive,
need-driven and proactive manner and therapeutic environment
- Acts promptly and judiciously to for patients and staff, with the
prevent or halt deterioration of aim of promoting comfort and
patients’ condition when conditions preventing unnecessary
warrant, and Coordinates with suffering
other healthcare providers in the - Advocacy and Moral Judgment
provision of optimal care to achieve - respecting and supporting
the best possible outcomes. the basic rights and beliefs of
the critically ill patient
B. Indirect patient care – Care of the - Systems Thinking
Family - managing the existing
- Understands family needs and environmental and system
provides information to allay fears resources for the benefit of
and anxieties patients and their families
- Assists family to cope with the - Facilitator of Learning
life-threatening situation and/or - creatively modify or develop
patient’s impending death. patient/family educational
programs and integrate
- Staff Nurse, Nurse-educator, family/patient education
Nurse-manager, Case manager,
 - Response to Diversity
- sensitivity to recognize, Rapid Response Team (RRT)
appreciate, and incorporate
diversity into the provision of - Also known as the Medical
care Emergency Team
- Collaboration - A team of nurses and other health
- working with others in a way care professionals who bring critical
that promotes each person’s care expertise to the bedside.
contribution toward achieving - The teams may or may not include
optimal and realistic physicians.
patient/family goals. - The key goal is to act before
“failure to rescue” occurs and a
Working in Critical Care Environments patient has suffered a cardiac or
respiratory arrest.
Communication
- Optimal patient care is not possible Ethical Dilemma
without skilled communication, and - A situation that gives rise to
errors are frequent in situations conflicting moral claims, resulting
where communication between in disagreements about the choice
healthcare providers and patients of action.
and their families is impaired.
- Use of SBAR and/or DATAS
communication tool
- Use of CUS method and/or the Two- RESPONSES TO ALTERED
challenge Rule to resolve concerns VENTILATORY FUNCTION

Collaboration ANATOMY AND PHYSIOLOGY

- Collaboration is a process, not a
single event, and it requires that Respiratory System
members of the healthcare team
develop a pattern of sharing - Larynx
knowledge and responsibility for - Located at the top of the
patient care. This ultimately affects trachea
patient outcomes. - Houses vocal cord
- Transition point between the
Building the Team upper and lower airways
- Nurses have an important role on - The larynx is composed of
the multidisciplinary team in helping nine (9) cartilage
the team to recognize that the segments. Largest: Thyroid
overall goal is related to the patient’s cartilage
values and quality of life preferences
as well as assisting in the
establishment of the daily patient
goals and the treatment plan
- Epiglottis - Lungs and Lobes
- A flap of tissue that closes - The right lung is larger and
over the top of the larynx has three lobes (upper,
when the patient swallows middle, and lower lobes)
- This is to AVOID - The left lung is smaller and
ASPIRATION has only two lobes (upper
- If there is a contraction of and lower lobes because of
the intra-abdominal the space limitation imposed
muscle, there will be an by the heart)
increase of intra-abdominal
and intrathoracic pressure. CIRCULATION
- An abrupt increase can
reduce venous return or - CIRCULATION
blood flow. - VALSALVA - (Deoxygenated blood)
MANEUVER ENTERS the lungs from the
PULMONARY ARTERY of
- Lower Airway the right ventricle
- Trachea, Bronchi, Lungs - Flows through the main
- Begins: Trachea pulmonary arteries into the
- Division starts at CARINA smaller vessels of the pleural
(the point where the trachea cavities
divides) - MAIN BRONCHI, through
- Mainstem Bronchi: (RIGHT - the arterioles
shorter, wider, more - Capillary networks in the
vertical) alveoli
- Lobar Bronchi
- Tertiary bronchi - GAS EXCHANGE: (oxygen &
- Terminal Bronchioles carbon dioxide diffusion in the
(smallest airway alveoli)
WITHOUT alveoli) - Takes place in the alveoli.
- Respiratory - Pulmonary capillaries
Bronchioles - Oxygenated blood flows
- Alveolar Ducts through progressively
- Alveoli larger vessels
(endpoint of - Enters the main pulmonary
your veins
respiratory - Left atrium
tract; it is
where gas - PULMONARY CIRCULATION
exchange - Right and left pulmonary
takes place arteries carry deoxygenated
blood
 - These arteries divide to form through which gas
distal branches called exchange occurs.
arterioles
- Which terminates as a - TYPE II CELLS →
concentrated capillary produce surfactant, a
network in the alveoli and (lipoprotein) lipid type
alveolar sac, where gas substance that coats
exchange occurs. the alveoli
- Venules (end branch of - (Decreases surface
pulmonary veins) collect tension - to protect
oxygenated blood from the alveoli)
capillaries - (Surfactant: allows
alveoli to expand
Respiratory System uniformly; during
exhalation, it
- Pleura prevents alveolar
- Each lung is wrapped in a prolapse)
lining called the visceral
pleura - Bony Thorax
- All areas of the thoracic - Clavicles
cavity that come in contact - Sternum
with the lungs are lined with - Scapula
parietal pleura. - 12 set of ribs
- This allows the layers to slide - 12 thoracic vertebrae
smoothly (to avoid friction
causing injury) over each - Ribs
other as the chest expands - Made of bone and cartilage
and contracts and allows the chest to
- The parietal pleura also expand and contract during
contains nerve endings that each breath.
transmit pain signals when - All ribs are attached to
inflammation occurs (e.g. vertebrae.
pneumonia: pain upon - The first seven ribs also are
inspiration) attached directly to the
sternum.
- Alveoli - The eighth, ninth, and tenth
- the gas exchange units of ribs are attached to the ribs
the lungs (300 million alveoli above them
- typical adult) - The eleventh and twelfth
- Alveoli consist of TYPE I and ribs are called floating ribs
TYPE II epithelial cells:
- TYPE I CELLS →
form the alveolar wall,
ACCESSORY INSPIRATORY MUSCLES - Pulmonary Perfusion -
Blood flow from the right
Primary muscle used in breathing: side of the heart, through
DIAPHRAGM the pulmonary circulation,
and into the left side of the
- AT REST heart
- Inspiratory muscles relax. - Diffusion - Gas movement
- Atmospheric pressure is from an area of greater to
maintained in the lesser concentration
tracheobronchial tree. through a semipermeable
- No air movement occurs. membrane

- INHALATION - Several pressures are involved in

- Inspiratory muscles the process of respiration:
contract. 1. AIRWAY PRESSURE →
- The diaphragm descends. pressure in the conducting
- Negative alveolar pressure airways
is maintained. 2. INTRAPLEURAL
- Air moves into the lungs. PRESSURE → pressure in
the narrow space between
- EXHALATION the visceral and parietal
- Inspiratory muscles relax, pleurae
causing the lungs to recoil to 3. INTRA ALVEOLAR
their resting size and PRESSURE → is the
position. pressure inside the alveoli
- The diaphragm ascends. 4. INTRATHORACIC
- Positive alveolar pressure PRESSURE → pressure
is maintained. within the entire thoracic
- Air moves out of the lungs. cavity

RESPIRATION - OXYGEN TO TISSUE - Internal

respiration occurs only through
Effective respiration requires gas exchange diffusion, when the red blood cells
in the lungs (external respiration) and in (RBCs) release oxygen and absorb
the tissues (internal respiration). carbon dioxide

- OXYGEN TO LUNGS - Three VENTILATION AND PERFUSION

external respiration processes are
needed to maintain adequate Ineffective gas exchange causes three
oxygenation and acid base balance: outcomes:

- Ventilation - Gas
distribution into and out of
the pulmonary airways
1. SHUNTING Respiratory Distress
- Reduced causes Syndrome)
unoxygenated blood to
move from the right side of OXYGEN TRANSPORT
the heart to the left side of - Most oxygen collected in the lungs
the heart and into systemic binds with hemoglobin to form
circulation. oxyhemoglobin.
- Shunting may result from a - The portion of oxygen that dissolves
physical defect that allows in plasma can be measured as the
unoxygenated blood to partial pressure of arterial oxygen
bypass fully functioning (Pao2) in blood
alveoli. - Internal respiration occurs by
- airway obstruction prevents cellular diffusion when RBCs release
oxygen from reaching an oxygen and absorb the carbon
adequately perfused area of dioxide produced by cellular
the lung. metabolism.
- Common causes of shunting
include acute respiratory ACID-BASE BALANCE
distress syndrome (ARDS), Carbon dioxide is 20 times more soluble
atelectasis, pneumonia, than oxygen, it dissolves in the blood,
and pulmonary edema where most of it forms bicarbonate (a
base) and smaller amounts form carbonic
2. DEAD-SPACE VENTILATION acid
- reduced perfusion to a lung
unit - Acid-Base Controller
- alveoli don’t have adequate - The lungs control
blood supply for gas bicarbonate levels by
exchange to occur converting BICARBONATE
- Not all air that enters the to CARBON DIOXIDE AND
airway would reach the WATER for excretion. In
alveoli. response to signals from the
- The part of tidal volume that MEDULLA
does not participate in - In metabolic alkalosis,
alveoli gas exchange is which results from excess
called dead-space bicarbonate retention, This
ventilation. increases carbonic acid
levels.
3. SILENT UNIT - In metabolic acidosis, the
- combination of shunting and lungs increase the rate and
dead space ventilation depth of ventilation to exhale
- little or no ventilation and excess CO2, thereby
perfusion are present reducing carbonic acid
- Cases of pneumothorax and levels.
severe ARDS (Acute
 - Inadequately functioning sickle cell anemia, heart
lungs can produce acid base disease, or chronic illness,
imbalances, For example, such as asthma or
hypoventilation results in emphysema.
carbon dioxide retention, - Determine whether the
causing respiratory patient lives with anyone
acidosis. who has infectious disease,
- hyperventilation leads to such as TB or influenza.
increased exhalation of - Lifestyle Patterns
carbon dioxide and causes - Ask about the px’s
respiratory alkalosis. workplace
- Also ask about the px’s
RESPIRATORY ASSESSMENT home, community and
other environmental
- HISTORY factors
- Build your patient’s health - Ask about the px’s sex
history by asking short, open habits and drug use
ended questions. - Current Health Status
- Respiratory disorders may - Begin by asking why your
be caused or exacerbated patient is seeking care
by obesity, smoking, and because many respiratory
workplace conditions so be disorders are chronic.
sure to ask about these - Ask how the patient’s latest
conditions. acute episode compares with
- Previous health status previous episodes
- Look at the patient’s health (compared to previous
history, being especially episodes) and what relief
watchful for: measures are helpful and
- A smoking habit unhelpful.
- Exposure to
secondhand smoke COMMON CHRONIC COMPLAINTS
- Allergies - Dyspnea
- Previous surgeries - Is commonly seen in patient
- Respiratory diseases with pulmonary or cardiac
such as pneumonia compromise
and tuberculosis (TB) - Assess your patient’s
- Ask about current shortness of breath, to rate
immunizations, such as a his usual level of dyspnea
FLU SHOT or by asking him from a scale
PNEUMOCOCCAL of 0 to 10
VACCINE. - Then ask him to rate his
- Family History current level of dyspnea.
- Ask the patient if he has a Other scales grade
family history of cancer, dyspnea as it relates to
 activity, such as climbing a - Sputum Production
set of stairs or walking a city - A pulmonary illness often
block. results in the production of
- Grading dyspnea: sputum.
- Grade 0: not - Also ask these questions:
troubled by - color and consistency
breathlessness - Has it changed
except with strenuous recently (if chronic)?
exercise If so, how?
- Grade 1: troubled by - Do you cough up
shortness of breath blood? If so, how
when hurrying on a much and how often?
level path or walking - AMOUNT and COLOR of the
up a slight hill sputum produced in 24h
- Grade 2: walks more
slowly on a level - The color of the sputum
path (because of provides information about
breathlessness) than the infection
people of the same - YELLOW, GREEN,
age or has to stop to BROWN – signifies
breathe when walking bacterial infection
on a level path at his - YELLOW may occur
own pace (more eosinophils)
- Grade 3: stops to ALLERGY rather
breathe after walking than INFECTION
about 100 yards (91 - RUST COLORED
m) on a level path (yellow sputum mixed
- Grade 4: too with blood) – may
breathless to leave signify tuberculosis
the house or - MUCOID, VISCID or
breathless when BLOOD STREAKED
dressing or – often sign of a
undressing VIRAL INFECTION
- ORTHOPNEA - Persistent
- Refers to shortness of SLIGHTLY BLOOD
breath when lying STREAKED –
down present in patient with
- COUGH CARCINOMA
- frequent respiratory - Large amount of
symptom with CLOTTED BLOOD –
varying significance present in patient with
PULMONARY
INFARCT
 - Chest pain for your nursing assessment.
- Chest pain due to a Don't assume the obvious.
respiratory problem - If you don't have time to go
- It may also be the result of through each step of the
indigestion. nursing process, make sure
- Less common causes of pain you gather enough data to
include rib or vertebral answer vital questions
fractures caused by - The FOUR STEPS for conducting a
coughing or osteoporosis. physical examination of the
respiratory system are: (IPPA)
- Sleep Disturbance 1. INSPECTION
- may be related to 2. PALPATION
obstructive sleep apnea or 3. PERCUSSION
another sleep disorder 4. AUSCULTATION

- Wheezing - Examine the back first

- If a px wheezes, ask these - Always compare one side with the
questions: other. Then examine the front of the
- When does chest using the same sequence.
wheezing occur?
- What makes you I. Inspection
wheeze?
- Do you wheeze Inspection of the patient involves checking
loudly enough for for the presence or absence of several
others to hear it? factors:
- What helps stop 1. Cyanosis (peripheral, central,
your wheezing? differential)
a. Peripheral Cyanosis -
PHYSICAL ASSESSMENT extremities or on the tip of
the nose and ears
- Emergency Respiratory b. Central Cyanosis -
Assessment apparent on tongue and lips,
- acute respiratory distress, low oxygen tension
immediately assess the 2. Labored breathing
ABCs – airway, breathing, 3. Anterior-posterior diameter of the
and circulation. ABSENT, chest
call for help and start 4. Chest deformities
cardiopulmonary 5. Patients posture
resuscitation. 6. Position of the trachea (should be
midline)
- Setting priorities a. Pleural effusion,
- patient is in respiratory hemothorax,
distress, establish priorities pneumothorax, tension
 pneumothorax → deviated - May be seen with meningitis
AWAY from the affected area or severe brain damage
b. Atelectasis, Fibrosis,
Tumors, Phrenic Nerve
Paralysis → PULL the
trachea towards the
AFFECTED SIDE
7. Respiratory Rate
8. Respiratory effort
9. Duration of inspiration versus the
duration of expiration
10. Thoracic expansion
11. Patient’s extremities

COMMON ABNORMALITIES

- Barrel chest
- result of overinflation of the
lungs, which increases the
anteroposterior diameter of
the thorax
- occurs with aging and is a
hallmark sign of
emphysema and COPD
- occurs as a result of COPD,
this is due to lungs that have
lost their elasticity.
- Pectus Carinatum (Pigeon chest)
- Sternum protrudes
- when there is a depression
in the lower portion of the
sternum
- May occur with rickets or
Marfan syndrome
- Thoracic kyphoscoliosis
- spine curves to one side
and the vertebrae are
rotated
- BIOT’S RESPIRATION
- Irregular pattern
characterized by varying
depth and rate of respirations
followed by periods of apnea.