Critical Care Concepts

General Nursing Requirements of the Intensive Care

Patient
The following are some general requirements for nursing
care of the intensive care patients.
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.