Nurse Bob's MICU/CCU Survival Guide
Critical Care Concepts
General Nursing Requirements of the Intensive Care Patient
critical care patient will be left without
a nurse in attendance.
Rationale: Critically ill patients may have life-threatening changes in their condition; remove an invasive line or self-extubate quickly.
nurse will be responsible for
the entire care of his/her patient, and acts to coordinate care with
health team professionals.
Rationale: The caregiver, by assuming full responsibility for monitoring the patient's condition and care, can detect changes promptly.
will be arranged according
to unit need/safe coverage by mutual agreement between each nurse and
coworkers. The nurse must give a full report to another staff nurse
leaving for a break. The second nurse assumes responsibility for the
and interacts with family/other health team members in the principle
Rationale: When many people are involved in the care, a principle caregiver reduces the assumption that someone else did or did not complete a task, and helps to maximize resources.
staff nurse will report any
changes in his/her patient's condition directly to the physician. The
nurse may be utilized to report the information, e.g., on nights. The
will ensure a physician is aware of all lab reports. The staff nurse
the charge nurse informed of changes in the patient's condition. The
nurse will be notified if the staff nurse needs any direction regarding
procedure, policy or physician interaction.
Rationale: The staff nurse is the one person who has current and detailed information on the patient's condition.
5. All critical care
patients will have continual ECG monitoring.
Rationale: A critically ill patient requires intensive monitoring
6. Alarms must be left on
the ECG and
arterial lines at all times. Appropriate
limits will be selected at the nurse’s discretion according to
Rationale: To ensure rapid detection of heart rate or BP changes. To reduce risk associated with leaving alarm disabled.
7. An ECG strip
will be obtained and analyzed according to
institutional policy. Generally, this is
every four hours and as needed for patients with a cardiac disorder. The ECG strips are analyzed, rhythm
identified and taped to the back of the flow sheet.
Changes are reported to the physician.
Rationale: Heart rate and rhythm are keys to determining the hemodynamic stability of an intensive care patient.
8. For a stable,
non-acute patient without invasive monitoring
vital signs will be done at the staff nurse's discretion, at least
Rationale: To ensure regular vital sign monitoring
9. Temperatures will be
measured on all patients at least q4h by
axilla route. Patients having abnormal temperatures (< 36 or
will have temperature measured by a core method (rectally, tympanic,
artery, esophageal, foley).
Rationale: Temperature changes may indicate infection or other disease states. Core represents a much more accurate value.
patients admitted for
neurological problems will have hourly neurological assessments
performed. All patients will have a
assessment evaluated and recorded on the flow sheet at least once per
using the Glasgow Coma Scale.
Rationale: To quickly reference previous, function if deterioration occurs. This will provide a clear understanding of the patient's neurological status and avoid uncertainty over assessments at shift change. Unconscious patients will have neurological assessments done q.1-4h. At the nurse's discretion.
turning of all critically ill
patients every two hours around the clock is done unless
skin assessment recorded as part of the every four-hour assessment. If turning is contraindicated, pressure
points will be relieved q2h. If pressure relieve is not possible,
will be documented.
Rationale: This is to relieve pressure points and allow for skin perfusion as well as provide reference for comparison of skin care.
intensive care patients will
have chest PT q4h and PRN unless contraindicated. The frequency will be
recorded on the flow sheet documented in progress note.
Rationale: Immobility increases the risk for the retention of secretions and reduced ventilation.
critical care patients will
have range of motion exercises q4h unless contraindicated (i.e.
blockers). This will be recorded on the flow sheet treatment section
Rationale: To reduce possible contracture formation, disuse atrophy, "frozen joints", and to promote venous return.
care will be done every
shift and as needed PRN for all patients.
Rationale: To promote hygiene and comfort.
Critical Care patients will
mouth care done every four hours with inspection for oral skin sores.
will be brushed every shift and as needed.
Rationale: Intubation increases risk for developing mouth ulcers and/or infections.
Critical Care nurse may
restrain patients at his/her discretion. Provided documentation done
to hospital policies and procedures.
Rationale: To ensure life-supporting tubes or lines are not disconnected.
restraints will be secured to
allow rapid lowering of bedside.
Rationale: For rapid access in a crisis.
18. Any patient
who expires, that falls into the
classification of a coroner's case, or who is going to have a autopsy
all lines/airways/tubes left in place unless the coroner confirms that
Rationale: Correct tube placement is occasionally evaluated at post mortem.
All routine dressing
changes, I.V. tubing changes and catheter changes will
done on night shift. The Flow sheet will be updated with
date change, and the procedure documented in the clinical record.
Rationale: To maintain consistency among all nurses.
daily baths will be done
on night shift. This will include total skin care, fingernails
and hair washing q. weekly and prn
Rationale: The night shift is quieter and less hectic
dressings unless otherwise
indicated will be changed daily..
Rationale: To remove bacterial contaminates and replace with an aseptic dressing
hose and SCD’s
will be removed for thirty minutes once per
Rationale: To promote venous return and reduce thrombus formation and to permit circulation and inspection of the limb.
care will be spaced out
to allow periods of rest.
Rationale: Sensory overload predisposes the patient to disorientation.
patients who have not had a
bowel movement will be checked for impaction q.3. days
and the flow sheet updated.
Rationale: To monitor bowel function
will be explained to
patients; person, place and time being
stated to the patient. Sensory
stimulation, ie., radios, tape recorders, will be provided for
indicated during the day.
Rationale: It is not known how much an unconscious patient can hear or comprehend. Sensory deprivation leads to disorientation. Anxiety decreases with an awareness of one's surroundings. Maintain a normal sleep/wake pattern.
and emotional support
needs for the family and patient will be provided
the nurse/physician/social work/pastoral care/palliative care, as
Rationale: The critical nature of the patient's illness places tremendous strain on the patient and family unit.
28. The environment will
be maintained in a mechanically safe
through: dry floors, good repair of
furniture, proper placement of machines and equipment, cleanliness,
from clutter, and good repair of equipment.
Rationale: To reduce risks to patients, visitors, or staff.
Isolation technique will be
followed as per infection control manual.
Rationale: To minimize cross infection to patients, visitors, and staff.
signs, such as, "isolation",
"can hear", or "neuromuscular blocking agent in use" will
be posted when indicated
Rationale: To communicate important information
31. Sharps and glass will
be disposed of into point of use sharps
Rationale: To protect health care workers from injury/contamination.
containers of body fluids
(i.e. suction canisters or chest drainage sets) must be disposed in the
approiate biohazard bag or box.
Rationale: To reduce risk of contamination to health care workers during handling.
will: be grounded, have 3-prong plugs,
be used away from water or wet floors, be protected from spillage of
be inspected by Biomedical Department.
Any equipment that malfunctions or appears damaged will be
Rationale: Particularly with patients having access catheters into the heart, electrical shocks could pose serious risk for harm.
will be affixed to: all
medications, intravenous bags and bottles, all wound or bladder
irrigations, multidose vials, multiple
hemodynamic transducers and monitors (identifying waves and pressures).
Rationale: To reduce risk for errors.
medications will be reviewed
by the Critical Care physicians (upon admission to Unit.) and either
or stopped. Nursing staff will ensure this
has been done prior to carrying out any medication, treatment or
orders. Each treatment/medication must
be listed when reordered (e.g., "Renew all preoperative meds" is NOT
Rationale: To ensure optimal management.
orders may only be
carried out when written by the patients
Ventilatory changes will only be done upon
Rationale: To maintain optimal and consistent respiratory management
37. All orders written other than by the Critical Care physicians will be brought to the attention of the Critical Care physician by the nurse prior to being carried out. Rationale: To ensure all therapy is consistent with goals for the patient's management
MAY NOT be kept
at the bedside. If use is not immediate after withdrawal from the
cabinet, wastage as per narcotic protocol will be
Rationale: To maintain narcotic control.
negotiated between the nurse and family, with consideration
unit activity and institutional policy. All exceptions should
be reported nurse to nurse.
Rationale: It is important to communicate information to oncoming nurse to avoid discrepancies.
number of visitors will be
limited to 2 at a time; however,
the nurse may use discretion based on
condition and room activity
Rationale: To promote privacy for other patients in the bay and to accommodate space limitations.
nurse/physician will notify
families of significant deteriorations in the patient's condition.
Rationale: The family has the right to determine when they wish to attend their family member.
42. Support will be given
to family’s that would like children
visit. Special preparation of the
children MUST BE done.
Rationale: Research has shown that allowing children to participate in the grieving process can have a positive impact on subsequent adjustment to family tragedy. Improper preparation can have a negative and lasting impact.
handout will be given to one member of each patient's family. Indicate on Nursing Note the date and family
member who received the booklet.
Rationale: To reduce the anxiety associated with visiting in the critical care unit. To provide information regarding resources available to families.
patients in Critical Care Unit, will be
weighed daily and on admission and
the flow sheet. per week. For new hospital
record weight on nursing admission database also.
Rationale: To accurately measure Body Surface Area, for calculating hemodynamic indexed values, to identify drug dosages, to assess nutritional requirements, to assess adequacy of nutritional status, and to evaluate fluid balance.
patients in the critical care
unit will have a minimum IV access of two Heparin Locks.
Rationale: To ensure rapid resuscitation with IV drugs or fluid if needed. Critical care patients are at sufficient risk to warrant access. When a patient's illness has become chronic but stable, they may not have an immediate need for an IV, and staff may be unable to secure a peripheral site. If despite reasonable attempts by a skilled individual a peripheral IV cannot be secured, the risk associated with a central line insertion may be deemed greater than the benefit of having an IV access. Appropriate documentation must be included in the clinical record to justify this decision.
change of shift reports will
include a review of all physician orders, lab results, medication
administration record, and joint review of neuron
Rationale: To ensure communication between shifts and reduce potential for medication or treatment errors. Neuro status is jointly reviewed to ensure that both incoming and out going shifts are clear on interpretation of findings to be able to promptly detect a change in patient condition.
staff working at a bedside
where an acute trauma or actively bleeding patient is being managed
protective goggles, masks and gloves.
Protective gear is also required anytime risk of splash from
exists e.g. suctioning.
Rationale: Current literature shows that it is during periods of acute crisis when health care workers are at the highest risk for disease transmission. This has also been shown to be the time when health care workers are least compliant with universal precautions.Masks, goggles and gloves in high risk situations are a requirement as per Hospital Universal Precautions Policies.
Reference: AACN Standards for Critical Care Nurses.
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