ASSIGNMENT

ON
ACUTE, LONG & CRITICAL CARE

SUBMITTED TO: SUBMITTED BY:

Mr. Paul Dhinagran Purnima Sahay

Associate Professor M.Sc. Nursing 1st year

Medical Surgical Nursing Medical Surgical Nursing

VED NURSING COLLEGE (BAROLI) PANIPAT

INTRODUCTION: Acute care is a branch of secondary health care where a patient receives
active but short-term treatment for a severe injury or episode of illness, an urgent medical
condition, or during recovery from surgery.

Long-term care is a variety of services which help meet both the medical and non-medical needs
of people with a chronic illness or disability who cannot care for themselves for long periods.

Critical Care is a high quality, peer-reviewed, international clinical medical journal that aims to
improve the care of critically ill patients by acquiring, discussing, distributing, and promoting
evidence-based information relevant to intensivists.

Acute Illness:
An acute illness is a condition which produces a sings & symptoms soon after the exposure to
the cause.

Features of Acute/Critical Illness :

 Critical illness is focused & well defined.

 The onset of disease is rapid.

 The cause of illness is short and temporary.

 Outcome of illness is fairly predictable.

 It requires prompt actions as the life may be at stake.

It usually ends with complete recovery or abrupt termination in death. Acute illness may become
chronicles.

Principles of Critical Care :

The guiding principles involved in emergency care are as below:-

 Keen observation and quick assessment of the patients condition.

 Institution of life saving measures e.g. Care of Airway, Breathing and circulation i.e.
cardio-pulmonary re-suspiration may be needed.
 Prevent crowding around the casualty.
 Control bleeding if any and prevent further blood lose.
 Place the patient in dorsal position if not contraindicated & head turn to one side.
 Avoid unnecessary handling.
  Be swift, don’t panic, keep the situation under control.
 Be resourceful for the use of available resources.
 Keep casualty warm and comfortable.
 Be comforting & inspire confidence in victim relatives.
 Maintain adequate record of observation & treatment given to the patient.
 In case of community emergency, give first aid to all injuries, than arrange for safe
transportation to nearby hospital for medical/surgical interventions.
 Carry out a rapid initial and ongoing physical examination
 Start cardiac monitoring
 Establish a patent airway and provide adequate ventilation employing resuscitation
measures when necessary, protecting the cervical spine first and assessing chest injuries
with subsequently airway obstruction.
 Evaluate and restore a cardiac output by controlling hemorrhage and its consequences,
preventing and treating shock and maintaining or restoring affecting circulation.
 Determine patients ability to follow command and evaluate motor skills and pupillary
size and reactivity.
 Protect and clean wounds apply sterile dressing.
 Identify allergies and medical history that is significant.
 Document a medical record of the patient’s vital signs, blood pressure, neurological
status and intake and output to guide decision making.

SCOPE OF CRITICAL CARE NURSING-

 Emergency department overcrowding is growing and severe problem requires crisis
intervention national wide.
 The patient population presenting emergency department span the age and continum from
neonates to geriatrics.
 Is a speciality area of his profession like no other. To provide quality care nurse must
possess general and specific knowledge about health care to provide care for all ages
people.
 Critical nurse must be ready to treat a wide variety of illness and injuries situations.

Conditions which require Critical care/Emergency care:-

 Unconsciousness & Comatoge patients.

  Any type of shock.
 Hemorrhage due to multiple trauma.
 Pain i.e. Chest pain due to Myocardial Infections i.e. Abdominal Pain.
 Poisoning i.e. Food Poisoning, Gas Poisoning, Drugs and Chemical Poisoning.
 Excessive heat & cold injuries.
 Carebrovascular Accident/ Stroke.
 Burns and multiple gross injuries.
 Insects and snake bites.
NSG Process in Critical Care Settings:-

Component of NSG process in a critical setting are the same as those used in other clinical areas.
However many factors affect the orders of nsg assessment & interventions. In any emergency
care setting the NSG process is influenced by:-

 Limited time frame.

 Urgency of client condition.
 Need for urgent care to save the life.
 Skills for special care in ICUs.
 Need for urgent referral to OT or ICU
 Limited information due to communication difficulty or limited time.
 Lack of resources of emergency care settings.
 Often intervention occurs before complete assessment.
 We must follow standard protocols given by authority.

ICU MODEL CARE

FUL TIME INTENSIVIST MODEL – patient care is provided by intensivist.

CONSULTANT INTENVIST MODEL- an intensivist consults for another physician to

coordinate or assist in critical care, but does not have primary responsibility for care.

MULTIPLE CONSULTANT MODEL- multiple specialists are involved in the patient care
but none is designated especially as the consultant intensivist.

SINGLE PHYSICIAN MODEL- primary physician provides all ICU care.

A Good ICU
 Well organized, trust, coordinated care
 Full time intensivist daily round
 Protocol and policies
 Bedside nurses (master degree)
 No intern
 A team- doctor, nurses, pharmacists.
 Led by full time intensivists.
 Critical care trained, available in a timely fashion, no competing clinical responsibilities
during duty.
 Closed units, if resources allow.

Classification of Critical Care Patients

LEVEL 0- normal ward care

LEVEL 1- at risk of deteriorating support from critical care term.

LEVEL 2- more observation or intervention, single failing organ or post operative care.

LEVEL 3- advanced respiratory support or basic respiratory support, multiorgan failure.

Types of Critical Care Units

1. GENERAL UNITS- includes:
 Medical intensive care unit(MICU)
 Surgical intensive care unit (SICU)
 Medical surgical intensive care unit(MSICU)

2. SPECIAL UNITS- includes

 Respiratory intensive care unit (RICU)
 Geriatric intensive care unit (GICU)
 Neonatal intensive care unit (NICU)
 Burn intensive care unit(BICU)
 Shock trauma intensive care unit (STICU)
 pediatric intensive care unit (PICU)
 psychiatric intensive care unit(PICU)
 coronary intensive care unit(CICU)
 trauma neuro critical care unit(TNCC)
 cardiac surgery intensive care unit(CSICU)
 cardiovascular intensive care unit(CVICU)
 medical intensive care unit(MICU)
 overnight intensive recovery(OIR)
 neurotrauma intensive care unit(NTICU)
  neuro intensive care unit(NICU)

Required Classification for Nurses in Critical Care Department BLS-

basic life support

ACLS- advanced care life support

TNCC- trauma nurse care curriculum

PALS- paediatric advanced life support

ENPC- emergency nurse pediatric course

CEN – certified emergency nurse

ABLS- advanced burn life support

NRP- neonatal resuscitation provider

CCRN- critical care registered nurse

1. EMERGENCY MEDICAL SERVICES

Early detection- members of public or another agency find the incident and understand the
problem.

Early Reporting- the first persons on scene make a call to the emergency medical services and
provide details to enable a response to be mounted.

Early Response- the first professional rescurer along with nurse arrive on scene as quickly as
possible, enabling care to begin.

Good on scene Care- emergency medical service provies appropriate and timely intervention to
treat the patient at scene of the the incident.

Care In Transit- emergency medical services including nursing service load the patient into
suitable transport and continue to provide appropriate medical care and nursing care throughtout
the journey.

Transfer to definitive care- patient is handed over to an appropriate care setting, such as the
emergency department at hospital in to the care of physicians.
PRINCIPLES OF MEDICAL CRITICAL CARE
Triage :- When there are large number of patients, who need emergency care a system called
triage is used for identifying people at greatest risk. Patients are classified as per danger of
emergency i.e. needs Triage Categories:-

1. Emergent:- Life threatening emergency. Patient may die without immediate

interventions. Airway obstruction, Acute Respiration failure/Distress, Cardiac arrest,
severe chest pain with dysphea, open chest wound, shock etc. Pt may need ICU care to
save life.

2. Urgent Emergency:- These patients need emergency care with in ½ to 1 hrs i.e. intra
peritoneal bleeding, severe dehydration i.e. Cholera, Severe diarrhea etc.

3. Non-urgent:- These cases are not life threatening. Interventions may be delayed
beyond few hours i.e. soft tissue injury, minor injuries i.e. cuts, abrasion etc.

Assessment & Priority management:- Initial assessment should be done within 60

seconds and set the priority.

 Equipments:- Emergency Tray, Resuscitation bag, BP apparatus & recording articles.

Emergency Interventions in Specific Critical Ill Condition:-

  Unconsciousness:- Definitions: Hypoxia of the cerebral cortex causes unconsciousness.
It is a condition in which disturbance in sensory perceptions to a great extent that his
awareness and responsiveness to stimuli are altered or lost. It is one of the dangerous
signs of any disease. It’s onset is usually sudden.

Etiology:- There are so many causes of altered consciousness i.e.

 Cerebral edema, Brain stem hemorrhage, Brain Tumor, Cerebral Tumor, Brain Abscess, Cerebral
Abscess, Cerebral hemorrhage, Diseases of other organs i.e. Liver, Heart, Lungs, endocrine
glands, Kidney, Cerebral Infections, Epidural, Subdural hematomas, Poisons, Drugs, Alcohol,
Fluids, Electrolyte, Acid base imbalances e.g. Encephalitis, Scizhres, Infections, Severe
Nutritional Deficiencies, Hypoglycemia, Ischemia, Anoxia, Syncope, Temperature regulation
disorders.

NSG Assessment & Clinical Findings:

Guides to patient Assessment:

Glasgow Coma Scale: It is an objective evaluation of LOC, motor, verbal response. A

standardized system for assessing the degree of neurologic impairment in the critical ill patients:

 A score of 15 indicates a client is awake, oriented

 The lowest score 3 is deep coma. A score of seven or below is considered coma.

Glasgow Coma Scale:

Subscale Response Score

Best Eye Opening (E) Spontaneous 4

To Voice 3

To Pain 2

None 1

Best Verbal Response (V) Oriented 5

Confused Conversation 4

Inappropriate words 3

In comprehensive words 2

None 1
Best Motor Response (M) Obeys Commands 6

Localize to pain 5

Flexion Withdrawal 4

Abnormal 3

Extensions 2

Flacid 1

TOTAL 15

Additional Assessment:
 Vital Signs i.e. Pulse Rate, Blood Pressure, Respiratory Pattern & Temperature

 Signs of increase 1 CP

 Pupillary reactions & Eye movements

 Level of consciousness at any period of interval.

 Check for deep tendon reflex.

 Bekinski’s reflex, etc.

Levels of Unconsciousness:
1. Fainting:- It is a momentary loss of consciousness. Patient usually responses
spontaneously.

2. Somolent:- In this state patient feels sleepy or drowsy.

3. Stupor:- Patient responds only to external stimuli i.e. Pin Prick, Loud Noise etc.

Coma:-> It is a stage of unconsciousness in which patient is unaware of himself, his environment. The
patient may responds to deep painful stimuli, but in deep coma there is no arousal.

Laboratory Investigations and Diagnostic Tests:

 Lumber Puncture
  X-Ray of skull & Spine

 C.T. Scanning

 MRI

 Brain Scan

 Cerebral Angiography

 Electroemelphelography

NSG Diagnosis: NSG diagnosis for a patient with a condition of unconsciousness may include:
 Ineffective airway clearance

 Risk for aspiration

 Ineffective breathing pattern

 Risk for injury

 Altered tissue perfusion to brain

 Altered nutrition

 Potential altered body temperature

 Risk for skin integrity

 Urinary retention

 Bowel Incontinence

 Constipation

 Risk for disuse syndrome

 Sexual dysfunctions

 Impaired verbal-communication

 Impaired swallowing

 Self care deficit

Planning with Expected outcome:-

 Adequate respiratory functions will be maintained

  Cerebral perfusion will be improved

 Client will remain free from injury due to neuro sensory deficit

 Fluids, electrolytes imbalance & nutritional status will be maintained

 Complications will be recognized & treated promptly

 Normal body temp. will be maintained

 Adequate bowel, bladder elimination will be maintained

 Client’s skin integrity will be maintained

 Ability to communicate will be improved

 Maximum independence in self care activities will be attained

 Sensory perception will be improved

 Optimal cognitive functioning will be attained

Interventions:-
1. ASSESS AND INTERVEN- it is a systemic approach to effectively establishing and
treating health priority. It includes
 PRIMARY SURVEY- follows the A B C D
A- Airway
B- Breathing
C- Circulation
D- Disability
 SECONDARY SURVEY- follow the E F G H I
E- Exposure to environment
F- Full set of vital sign
G- Give comfort measure
H- History collection
I- Inspect the posterior surface
Recent advance in secondary survey in medical emergency care. The mnemomic A M P L E
which assists the nurse in remembering to ask about the following

A- Allergy
M- medication history

P- past health history

L- last meal
 E- events or environment preceding illness or injuries.

ISSUES IN EMERGENCY NURSING CARE

Emergency nursing is demanding because of diversity of conditions and situations that present
unique challenges. These include legal issues and safety risk of Emergency department staff.
These are-
1. Docementation of consent and privacy-
 Consent to examine and treat the patient is part of emergency department record.
 Patient must consent to invasive procedure unless he or she is unconscious or critical
conditions and unable to make decisions.
 Patient is unconscious and brought to emergency department without family or friends it
should be documented.
 Patient’s condition, instituted treatment and time at which they performed must be
documented.
 A patient may also request extra privacy by limiting access to his or her room and by
choosing not to receive calls, mails, flowers, other gifts and certain visitors. These
practice related to the federally mandated privacy policy stipulated in health insurance
portability and accountability act (HIPPA).

2. Limiting exposure to high risk-

 Because of increasing number of infectious disease, HIV, hepatitis B & C health care
provider have risk after exposure to communicable diseases through blood, respiratory
droplets or other body fluids. This is further compounded in emergency department
because of common use of nursing procedures.
 Nurse in emergency department are usually fitted with personal high efficiency
particulate air (HIPA) filter mask to use when treating patients with airborne diseases.

3. Violence in emergency department-

Emergency department staff encounters many violent patients and some violent situation. Safety
is first priority so they assign security officers. If patient is a prisoner and under guard should
follow precautions like-
 Hand or ankle restraint is never released.
 A guard is always present in room.
 Patient is placed face down on stretcher to avoid injuries from head butting, spitting or
biting.
 Restraints are used on violent patient as needed.
  Medications are administrated as necessary to control violent behavior until definitive
treatment can be obtained.

4. Providing holistic care- patient and families experiencing sudden injury or illness are often
overwhelmed by anxiety because they have not had time to adopt to the crisis. So it is
essential to provide essential care.
 Patient focused interventions- clinician should act confidently to relieve anxiety and
promote a sense of security. The patient should be treated as if conscious, that is , patient
should be touched, called by name and given explanation of every procedure that is
performed. As patient regain consciousness nurse should orient the patient by stating his
or her name.
 Family focused interventions- all details are given to the family about the patient.
Family members allow to sit with patient when possible. Additional interventions are
based on assessment of stage of crisis that the family is experiencing.
 Anxiety and denial- family members are encouraged to recognize and talk about the
feelings of anxiety. Asking questions is encouraged. Honest answer given at level of the
family’s understanding. Must be provided. Family must be prepared for the reality of
what has happened and what may come.
 Remorse and guilt- expressions of remorse and guilt are common, with family members
accussing themselves of negligence or minor omissions. Family members are used to
verbalize their feelings to help them cope appropriately.
 Anger- it is way of expression of feeling which should be handled carefully.

RESEARCH STUDY:

Delirium screening in intensive care: A life saving opportunity

Author: E. Lamond. S. Murray. C.E. Gibson

Background
Delirium is described as ‘acute brain failure’ and constitutes a medical emergency which
presents a hazard for people cared for in intensive care units. The Scottish intensive care society
audit group recommend that all people cared for in intensive care units be screened for signs of
delirium so that treatment and management of complications can be implemented at an early
stage.

Clinical implication
There is inconsistent evidence about when and how the assessment of delirium is carried out by
nursing staff in the intensive care setting.
Aim:- This narrative review explores the pathophysiology and current practices of delirium
screening in intensive care. Consideration is given to the role of the nurse in detecting and
managing delirium and some barriers to routine daily delirium screening are critically debated.

Conclusion
It is argued that routine delirium screening is an essential element of safe, effective and person
centred nursing care which has potential to reduce morbidity and mortality.

1. Intubation-associated pneumonia: An integrative review

Author Ana Sabrina Sousa. Cândida Ferrito. José Artur Paiva

Abstract
Objective
This article aims to characterise intubation-associated pneumonia regarding its diagnosis, causes,
risk factors, consequences and incidence.

Research methodology

Integrative literature review using database Pubmed and B-on and webpages of organisations
dedicated to this area of study.

Setting

The research took place between May and July 2015. After selection of the articles, according to
established criteria, their quality was assessed and 17 documents were included.

Results

Evidence has demonstrated that intubation associated pneumonia has a multifactorial aetiology
and one of its main causes is micro-aspiration of gastric and oropharynx contents. Risk factors
can be internal or external. The diagnostic criteria are based on clinical, radiological and
microbiological data, established by several organisations, including the European Centres for
Disease Control and Prevention, which are, however, still not accurate. In recent years, there has
been a downward trend in the incidence in Europe. Nevertheless, it continues to have significant
economic impact, as well as affecting health and human lives.

Conclusions
Several European countries are committed to addressing this phenomenon through infection
control and microbial resistance programmes; however there is a much to be done in order to
minimise its effects. The lack of consensus in the literature regarding diagnosis criteria, risk
factors and incidence rates is a limitation of this study.

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8. http://www.intensivecriticalcarenursing.com/article/S0964-3397(17)30101-5/fulltext