Critical Care Nursing Theory

Scope of Critical Care Nursing

Scope of Critical Care Nursing

- Critical care nursing is subspecialties of medical surgical nursing. The
reason of being of Nursing in any setting is the provision of holistic
nursing care.
- The adjective Critical is characterized by actual or potential crises for the
recipients of nursing care
- Critical is defined as pertaining to a crisis, involving danger or risk.
- Critical care practice areas began to develop in the late 1960s in response
to:a- Developments in medical science and technology
b- Related changes in community values and attitudes.
Definition:
- The American Nurses Association defined Nursing as:
- The diagnosis and treatment of human response to actual or potential
health problem.
- In 1984, the American Association of Critical Care Nurses (AACN)
defined Critical Care Nursing:
- Critical care Nursing is that specialty within nursing that deals
specifically with human responses to life- threatening problems
- Analysis of these definitions reveals several important concepts.
- The basis of the definition rests with the words human responses.

Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

Critical Care Nursing Theory

Scope of Critical Care Nursing

- Critical care nurses deal with

a- The total human being
b- His or her response to actual and potential health problems.
- This suggests that the critical care nurse is involved with prevention as well
as cure.
- Additionally, human response can take the form of :a- a physiological phenomenon.
b - a psychological phenomenon.
- Ex: a critical care nurse can teach patient methods to lower blood
cholesterol levels, which may prevent a life-threatening problem.
- Scope of critical care nursing practice
- A scope of practice statement provides a framework within which an
individual can provide a particular service.
- The AACNs Scope of Critical Care Nursing Practice statement provides a
definition and description of the practice of critical care nursing.
- The scope of critical care nursing practice is described as a dynamic
process with three components:
1- The critically ill patients and their significant social relationship.
2- The critical care nurse.
3- The environment where critical care nursing is practiced.
- Central to the scope are nurse-patient interactions.
- The goal of critical care nursing is :- To ensure effective interaction of these three requisite elements to affect
competent nursing practice and optimal patient outcomes

Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

Critical Care Nursing Theory

Scope of Critical Care Nursing

1- Critically ill patient:- Critical care patients share one or more of a number of defining
characteristics:
a- A significant health breakdown problem which is life threatening.
b- Biophysiological health breakdown problems of such acuity and / or
chronicity that they may lead to extraordinary dependence on health care
providers, and possibly technology for health maintenance or life support.
- The American Association of Critical Care Nurses (AACN) described the
critically ill patient as follows:
- The critically ill patient is characterized by the presence of actual and / or
potential (being at risk for developing) life- threatening health problems.
- The needs of these patients require continuous assessment (observation)
and intervention to restore health and prevent complications.
- As man is biopsychosocial being the concept of the critically ill patient
includes the family and / or significant others.
- The needs of the critically ill are considerable. These needs may be
categorized as physical or non-physical
1- Physical needs:- are equated with basic physiological or biological needs for ex, for air,
nutrition, and elimination.
2- Non-physical needs:- may include social, spiritual, and psychological needs. Social integrity
(self-esteem), information, and communications are also included.
- The comfort and support provided by social relationships can enhance
effective coping. Therefore the concept of the critically ill patient includes
the interaction and impact of the patients family and / or significant
others.

Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

Critical Care Nursing Theory

Scope of Critical Care Nursing

- The nature of critical care is such that physical needs are considered a
priority and are almost always met. However, the critical care environment
can actually obstruct the fulfillment of non-physical needs contributing to
the stressful nature of critical illness.
- Identity and social integrity can be very difficult to maintain when a
person is in a strange situation without their usual clothes, hair style, and
when work and conversation or discussion goes on around and over them
without including them as a person.
- The obstructed need for identity and social integrity may lead to the
development of a range of negative emotional or psychological status for
ex. Loss of self-esteem & confidence.
- Obstruction of these non-physical needs increases the stress experienced by
fragile, critically ill patients.
- Obviously the needs of the patients family and significant others must also
be considered and met as far as possible.
- If all the needs of the critically ill are to be met, both physical and nonphysical needs should be considered in planning holistic nursing care.
2-Critical Care Nurse:- The critical care nurse is a licensed professional, who is responsible for
ensuring that all critically ill patients receive optimal care.
- Nurses practicing in critical care areas have to make clinical judgments to
prevent clinical deterioration in their patients.
- Anticipation and early prevention of patient problems are central
requirements of critical care nursing practice, and these requirements
mandate highly developed skills of :1- Assessment.
2- Clinical judgment.
- The very essence of critical care nursing is anticipation and early
intervention in problems besetting the critically ill.
Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

Critical Care Nursing Theory

Scope of Critical Care Nursing

- Prediction of patient problems must be based on:1- A sound understanding of anatomy and physiology
2- Astute assessment skills.
- From the perspective of the Australian Society of Critical Care Nurses
(ASCCN),
- Critical care nursing practice is based on the following:
1- Individual professional accountability.
2- A thorough knowledge of biophysical and social sciences.
The application of this knowledge requires :a- Skills in clinical assessment
b- Appropriate nursing and technological intervention.
3- Recognition and appreciation of the holistic basis for nursing practice.
This includes recognizing:a- The individuals uniqueness, wholeness,
b- Significant social and environmental relationships.
- Acknowledgment of the interaction and collaborative roles of all members
of the health team
(Coordination of the care delivered by various health care providers).
- Since the clinical requirements of the critically ill are such that the team
caring for any single patient may consist of :- Various medical officers,
- A nurse,
- A pharmacist,
- A dietician,
- A physiotherapist,
- A radiographer,
- A social worker.
Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

Critical Care Nursing Theory

Scope of Critical Care Nursing

- The knowledge base, which underlines critical care nursing practice, is

highly specialized and it is constantly subject to revision and development
as a consequence of:a- Research activity
b-Technological innovation.
- Preparations for practice in critical care must emphasize the importance of
a holistic approach to nursing care. Such an approach is most likely to meet
the needs of the critically ill person.
3- Critical Care Environment:- Critical care nursing takes place in a specialized environments that are
designed and organized to give the best possible patient care in an area
where significant change in patient morbidity can occur rapidly, and often
does.
- The safety of both patients and staff in the CCU is a primary consideration
in designing the milieu in which critical care nursing is carried out.
- The critical care environment is viewed from three prospective:
1-The conditions and circumstances surrounding the direct interaction
between the critical care nurse and the critically ill patient.
- The environment must contain resources that constantly support this
interaction. E.g. emergency equipment and supplies.
2-The setting within which critically ill patient receive care. Here critical
care management and administrative structure ensure effective care
delivery through provision of:- Adequate human and financial resources,
- Quality control systems, and maintenance of standard of nursing care.
-Factors that influence the provision of care to the critically ill:-

Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

Critical Care Nursing Theory

Scope of Critical Care Nursing

- Legal,
- Regulatory,
- Social,
- Economic,
- Political factors.
- The presence and application of technology as a common component of
patient management is another key feature of critical care nursing practice.
- Critical care nurses are required to be competent in the use of a wide range
of technological devices, many of which are necessary for life support.

Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

Critical Care Nursing Theory

Scope of Critical Care Nursing

Stress
- Is defined as non-specific response of the body to any demands made upon
it.
Stressor:
- It is stress inducing demands (factor that disturbs the bodys equilibrium).
- The stressor could be physical or emotional, pleasant or unpleasant, leading
to a series of physiological responses, which then require the individual to
adapt. (G. A. S).
- General Adaptation Syndrome (G. A. S.) (Selyes theory) Comprises 3
stages:
1- Stage of alarm reaction:- Initial reaction, the defenses of the whole body mobilized and prepared to
action.
2- Stage of resistance:- Bodys adaptation takes place\ body attempts to cope.
3- Stage of exhaustion:- If exposure to the same stressor is prolonged, the adaptation energy is lost.
Coping:
- an attempt to gain mastery over conditions of threat
or
- efforts to manage environmental and internal demands and conflicts
which tax or exceed a persons resources.

Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

Critical Care Nursing Theory

Scope of Critical Care Nursing

Physiologic adaptation:
- There are a large number of physiologic responses of the human body to
stressors.
- The common adaptive mechanisms
1- The endocrine adaptive response.
2- The neurologic adaptive response.
3- The inflammatory adaptive response.
4- The immunologic adaptive response
Stress response indicators
- (Lab investigations, diagnostic procedures and the other indices of stress)
include:
- Blood and urine analysis to demonstrate change in hormonal levels and
hormonal breakdown products.
- Blood levels of catecholamines, corticoids, and adenocorticotrophic
(ACTH).
- Drop in eosinophils.
- Blood creatinine / creatinine ratio, and elevation of cholesterol and free
fatty acids.
- Immunoglobulin assays.
- Electro-encephalogram may be used to measure brain activity.
- Galvanic skin resistance which measures the electrical conductivity of the
skin. (To measure of sweat excretion, which rises in stress)
- Blood pressure and heart rate and other indices of stress that may be
observed by others or by the person himself. (both physical and behavioral
changes)
Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

Critical Care Nursing Theory

Scope of Critical Care Nursing

- (Increase respiratory rate, excessive sweating and thirst, sleep disturbance,

and anxiety).
Physiological stress responses of the critically ill patient:
- Blood volume is enlarged,
- Respiration become faster and deeper,
- Cardiac output becomes larger,
- Protein, fat, glycogen are converted to glucose for energy.
- So the alarm stage should be limited, if it sustained it leads to death.
- The body moves into stage of resistance, in which it attempts
to cope with the stressor.
- Secretion of adrenal cortical and medullary hormones returns to normal.
- If the body not returned to the normal state exhaustion will occur.
- Potassium depletion may be a major factor in exhaustion.
The symptoms of this stage include:1- Irregular pulse,
2- Hypotension,
3- Weakness,
4- ECG chances.
- The catecholamine release will cause hypermetabolism and
- Blood pressure and pulse rate and RR and alertness
- This can pose special problems for the persons who has pulmonary and
cardiovascular problems because he will be unable to meet the O2 needs,
or to handle the circulatory demands.
- Also the selective vasoconstriction of the vessels that serve vital body
parts. E.g. Kidney cause
- releasing of rennin to its supply and this will lead to
- Peripheral vasoconstriction.

Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

10

Critical Care Nursing Theory

Scope of Critical Care Nursing

- If stress reaction is very severe or prolonged permanent damage to

Kidney or lactic acidosis can result.
- Gluconeogenesis, from Protein and fat will cause Blood sugar, this is
very dangerous for diabetics.
- Also catecholamine stimulate the release of clotting factors, although these
effects are basically protective, they can cause blood viscosity and
predispose to stasis.
- Fluids must be given with great care to the severely stressed person.
(because of the increased intravascular volume) that cause (Fluid
overload, and urinary output).
Psychological stress responses of the critically ill patient:
A- Delirium.
B- Catastrophic reaction.
C- Euphoric response.
A- Delirium.
- Is abnormal mental condition
(clinical picture includes:
1- Reduced ability to focus, shift, and maintain attention
2- Disorganization of thinking or speech,
3- Illusions and hallucinations,
4- Disturbed sleep wake cycles,
5- Altered psychomotor activity
6- Disorientation
7- Memory impairment).

Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

11

Critical Care Nursing Theory

Scope of Critical Care Nursing

B- Catastrophic reaction.
- It is a passive response to severe anxiety.
1- Patient exhibits flat affect,
2- Hyperalterness,
3- Immobility,
4- Lack of spontaneity, with monosyllabic response to questioning
5- Passive cooperation with treatment.
C- Euphoric response.
1- The patient try to deny the seriousness of their illness
2- Patients are noted to be extremely active and his activities are contrary to
the therapeutic limitations).
Sources of stress in the critical care unit:
- In addition to the trauma, disease, surgery,the following factors are
considered to be stressful factors for the critically ill patient.
- Pain.
- Fear of death.
- Presence of tubes.
- Monitors.
- Ventilators.
- Lack of sleep.
- Immobility.
- Isolation.
- Admission to the I. C. U.
- Too much light (sensory overload).
- Extreme of temp.
- Noise.
- Separation from family and friends.
- Presence of very ill patient in the CCU.
- Nurses and doctors.
Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

12

Critical Care Nursing Theory

Scope of Critical Care Nursing

Coping patterns:
A- Problem-focused coping patterns,
B- Emotion-focused coping patterns,
A- Problem-focused coping patterns,
- Which directed to manage the problem by dealing with demands.
1- Try to maintain some control over the situation.
2- Try to change the situation.
3- Talk the problem over with some one who has been in the same type of
situation.
4- Draw on the past experience to help handle the situation.
B- Emotion-focused coping patterns,
- Which directed at lessening the emotional distress
1- Pray.
2- Work off tension with physical activity.
3- Go to sleep.
4- Seek comfort or help from family or friends.
1- Explanation and clarification:
- Explain his illness to him.
- Correct any misconceptions about disease and its consequences
- Provide orientation to the place, personnel, time,
- Explain every procedure before its performance.
2- Fostering optimism:
- Allow the patient to continue to use deny their emotional feelings as a
means of coping with stress at least to a certain point.
- Treat the patient with the conviction that recovery is fully anticipated.
- Emphasize survival and recovery rather than risks and dangers.

Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

13

Critical Care Nursing Theory

Scope of Critical Care Nursing

3- Reassurance:
- Provide reassurance by talking to the patient in the most encouraging
fashion possible.
- Act in a calm, positive, efficient manner.
- Inform the patient with any evidence of progress toward recovery.
- Avoid broad promises such as, Dont worry, everything will be all
right
4- Listening:
- Listen attentively and demonstrate genuine to assist the patient to ventilate
his feelings which decrease fears ,to recognize the sources of the problem,
and be able to deal with them.
5- Manipulating environment:
- Maintain a peaceful atmosphere which helps the patient to relax
and regain his emotional equilibrium.
- Provide rest periods for the patient during whom visitors or the staff does
not disturb time.
- Allow radio, television, and newspapers to prevent a feeling of isolation.
- Allow the patient to sit in a bedside chair (if the condition permits) is
usually a source of encouragement.
6- Anticipating emotional reactions:
- Explain that emotions experienced by patient are normal, common reaction
and anticipated response during this period.
7- Drug therapy:
- Administer tranquilizers during the first few days of hospitalization.
- Adjust the dosage so that the patient is not constantly drowsy or sleepy.

Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

14

Critical Care Nursing Theory

Scope of Critical Care Nursing

Delirium
Definition:- It is a reversible global impairment of cognitive process, usually of sudden
onset, .
Clinical manifestation:1- Disorientation,
2- Impaired short-term memory,
3- Altered sensory perceptions (hallucinations),
4- Abnormal thought processes,
5- Inappropriate behavior.
Incidence of delirium:- Delirium is probably more prevalent than generally recognized and is
difficult to diagnose in the critically ill patient.
- The incidence ranges from 30% to 70% in medical-surgical critical care
patients.
Causes of delirium:1- Metabolic
2- Intracranial
3- Endocrine
4- Organ failure
5- Respiratory
6- Alcohol withdrawal
7- Heavy metal poisoning.
8- Drug related
9- Additional causes

1- Metabolic

Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

15

Critical Care Nursing Theory

Scope of Critical Care Nursing

- Acid-base disturbance,
- Electrolyte imbalance,
- Hypoglycemia.
2- Intracranial
- Epidural hematoma,
- Subdural hematoma,
- Intracranial hemorrhage,
- Meningitis,
- Encephalitis,
- Cerebral abscess,
- Tumor.
3- Endocrine
- Hyperthyroidism
- Hypothyroidism,
- Addison's disease,
- Hyperparathyroidism,
- Cushing's syndrome
4- Organ failure
- Liver encephalopathy,
- Uremic encephalopathy,
- Septic shock.
5- Respiratory
- Hypoxemia
- Hypercarbia.
6- Alcohol withdrawal,
7- Heavy metal poisoning.
8- Drug

Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

16

Critical Care Nursing Theory

Scope of Critical Care Nursing

- Digitalis,
- Antibiotics,
- Steroids,
- Beta adrenergic blockers,
- Respiratory stimulant.
9- Additional causes
- Sleep deprivation,
- Sensory deprivation
- Sensory overload,
- Immobilization,
- Age over 60 years old.
The major categories to assess delirium :1- Acute onset of mental status changes or fluctuating course.
2- In-attention.
3- Disorganized thinking.
4- Altered level of consciousness, which include any level of consciousness
other than "alert" (vigilant, lethargic, stupor, coma).
Forms of delirium:A- Hyperactive delirium
B- Hypoactive delirium
C- Mixed delirium

A- Hyperactive delirium

Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

17

Critical Care Nursing Theory

Scope of Critical Care Nursing

The patient may

- Become violent;
- Be extremely restless .
- Remove invasive devices (intravenous lines, catheters, machines, and
dressings
- Try to get out of bed;
- Pick at things in the air;
- Call out of persons who are not there.
Sympathetic nervous system responses are evident :- Tachycardia,
- Dilatation of pupils,
- Diaphoresis,
- Facial flushing
B- Hypoactive delirium
The patient may:- Complain of extreme fatigue,
- Be slow to respond,
- Have hypersomnolence that can progress to
loss of consciousness.
At times the patient
- is absorbed in a dreamlike state,
mumble to them,
- Experience vivid hallucinations,
- Make inappropriate gestures.

C- Mixed delirium ( sundown's syndrome )

Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

18

Critical Care Nursing Theory

Scope of Critical Care Nursing

- It is a mixture of agitation and hypoactive behaviors that may vary

throughout the day.
- Symptoms and hallucinations seem to worsen during night, with more
lucid intervals during the day.
Management:
A- Prevention
- Preventive measures through correcting the underlying cause of delirium.
B- Non- pharmacologic strategies
1- Backmassage,
2- Music therapy,
3- Noise reduction in the environment,
4- Decreasing lights at night to promote sleep,
5- Clustering nursing care to provide some uninterrupted rest periods,
6- Speaking in calm, quit, and gentle voice.
C- Pharmacologic strategies:1- Sedatives for short-term use are prescribed for patients with hyperactive
delirium.
- Risperidone (Risperdal) is now preferred over Haloperidol in treatment
of delirium because it produces :- Less sedation
- Fewer anticholinergic effects
(e.g., dry mouth, constipation, urinary retention).

2- Narcotics can be administered when delirium is considered to be

secondary to pain,

Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

19

Critical Care Nursing Theory

Scope of Critical Care Nursing

- However, the following can exacerbate the delirium.

a- The paradoxical effects of depressed respiration
b- The paradoxical effects of cardiac output
3- Neuromuscular blocking agents sometimes used for severely agitated
patients who are on mechanical ventilation
a- To decrease in oxygen consumption,
b- To promote synchrony with the ventilator,
c- To increase tissue oxygenation.

Dr. Abdul-Monim Batiha

Assistant Professor Of Critical Care Nursing

20