Nurse Bob's MICU/CCU Survival Guide
Critical Care Concepts
General Nursing Requirements
of the Intensive Care
Patient
1. No
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.
2. Each
nurse will be responsible for
the entire care of his/her patient, and acts to coordinate care with
other
health team professionals.
Rationale: The caregiver, by
assuming full
responsibility for monitoring the patient's condition and care, can
detect
changes promptly.
3. Breaks
will be arranged according
to unit need/safe coverage by mutual agreement between each nurse and
his/her
coworkers. The nurse must give a full report to another staff nurse
prior to
leaving for a break. The second nurse assumes responsibility for the
patient
and interacts with family/other health team members in the principle
nurse's
absence.
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.
4. The
staff nurse will report any
changes in his/her patient's condition directly to the physician. The
charge
nurse may be utilized to report the information, e.g., on nights. The
nurse
will ensure a physician is aware of all lab reports. The staff nurse
will keep
the charge nurse informed of changes in the patient's condition. The
charge
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
institutional policy.
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
equipment,
vital signs will be done at the staff nurse's discretion, at least
every hour.
Rationale: To ensure regular vital
sign monitoring
9. Temperatures will be
measured on all patients at least q4h by
other than
axilla route. Patients having abnormal temperatures (< 36 or
>37.5 C)
will have temperature measured by a core method (rectally, tympanic,
pulmonary
artery, esophageal, foley).
Rationale: Temperature changes may
indicate infection or
other disease states. Core represents a
much more accurate value.
10. All
patients admitted for
neurological problems will have hourly neurological assessments
performed. All patients will have a
neurological
assessment evaluated and recorded on the flow sheet at least once per
shift,
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.
11. The
turning of all critically ill
patients every two hours around the clock is done unless
contraindicated, with
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,
rationale
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.
12. All
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.
13. All
critical care patients will
have range of motion exercises q4h unless contraindicated (i.e.
neuromuscular
blockers). This will be recorded on the flow sheet treatment section
and in
clinical record.
Rationale: To reduce possible
contracture formation,
disuse atrophy, "frozen joints", and to promote venous return.
14. Perineal
care will be done every
shift and as needed PRN for all patients.
Rationale: To
promote hygiene and comfort.
15. All
Critical Care patients will
have
mouth care done every four hours with inspection for oral skin sores.
Teeth
will be brushed every shift and as needed.
Rationale: Intubation increases
risk for developing
mouth ulcers and/or infections.
16. The
Critical Care nurse may
restrain patients at his/her discretion. Provided documentation done
according
to hospital policies and procedures.
Rationale: To ensure
life-supporting tubes or lines are
not disconnected.
17. All
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
must have
all lines/airways/tubes left in place unless the coroner confirms that
they may
be removed.
Rationale: Correct tube placement
is occasionally
evaluated at post mortem.
20.
All routine dressing
changes, I.V. tubing changes and catheter changes will
be
done on night shift. The Flow sheet will be updated with
the new
date change, and the procedure documented in the clinical record.
Rationale: To
maintain consistency among all nurses.
21. Routine
daily baths will be done
on night shift. This will include total skin care, fingernails
and hair washing q. weekly and prn
dressing
changes.
Rationale: The night shift is
quieter and less hectic
22. All
dressings unless otherwise
indicated will be changed daily..
Rationale: To remove bacterial
contaminates and replace
with an aseptic dressing
23. TED
hose and SCD’s
will be removed for thirty minutes once per
shift.
Rationale:
To promote venous return and reduce thrombus formation and to permit
circulation and inspection of the limb.
24. Nursing
care will be spaced out
to allow periods of rest.
Rationale: Sensory overload
predisposes the patient to
disorientation.
25. All
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
26. Procedures
will be explained to
patients; person, place and time being
repeatedly
stated to the patient. Sensory
stimulation, ie., radios, tape recorders, will be provided for
patients as
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.
27. Information
and emotional support
needs for the family and patient will be provided
by
the nurse/physician/social work/pastoral care/palliative care, as
required.
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
condition
through: dry floors, good repair of
furniture, proper placement of machines and equipment, cleanliness,
freedom
from clutter, and good repair of equipment.
Rationale: To
reduce risks to patients, visitors, or
staff.
29.
Isolation technique will be
followed as per infection control manual.
Rationale: To
minimize cross infection to patients,
visitors, and staff.
30. Safety
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
containers.
Rationale: To
protect health care workers from
injury/contamination.
32. Any
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.
33. All
electrical equipment
will: be grounded, have 3-prong plugs,
be used away from water or wet floors, be protected from spillage of
liquids,
be inspected by Biomedical Department.
Any equipment that malfunctions or appears damaged will be
reported to
Biomedical Dept.
Rationale: Particularly with
patients having access
catheters into the heart, electrical shocks could pose serious risk for
harm.
34. Labels
will be affixed to: all
bedside
medications, intravenous bags and bottles, all wound or bladder
irrigations, multidose vials, multiple
drainage bags/bottles,
hemodynamic transducers and monitors (identifying waves and pressures).
Rationale: To
reduce risk for errors.
35. All
medications will be reviewed
by the Critical Care physicians (upon admission to Unit.) and either
reordered
or stopped. Nursing staff will ensure this
has been done prior to carrying out any medication, treatment or
investigative
orders. Each treatment/medication must
be listed when reordered (e.g., "Renew all preoperative meds" is NOT
acceptable.)
Rationale: To
ensure optimal management.
36. Respiratory
orders may only be
carried out when written by the patients
physician.
Ventilatory changes will only be done upon
receipt of
written order.
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
38. Narcotics
MAY NOT be kept
at the bedside. If use is not immediate after withdrawal from the
narcotic
cabinet, wastage as per narcotic protocol will be
carried out.
Rationale: To
maintain narcotic control.
39. Visiting
is
negotiated between the nurse and family, with consideration
given to
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.
40. The
number of visitors will be
limited to 2 at a time; however,
the nurse may use discretion based on
patient
condition and room activity
Rationale: To promote privacy for
other patients in the
bay and to accommodate space limitations.
41. The
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
to
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.
43. A
visitors
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.
44. All
patients in Critical Care Unit, will be
weighed daily and on admission and
recorded on
the flow sheet. per week. For new hospital
admission,
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.
45. All
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.
46. All
change of shift reports will
include a review of all physician orders, lab results, medication
administration record, and joint review of neuron
status.
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.
47. All
staff working at a bedside
where an acute trauma or actively bleeding patient is being managed
will wear
protective goggles, masks and gloves.
Protective gear is also required anytime risk of splash from
body fluids
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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