NCM 118 CRITICAL CARE NURSING (DRAFT NOTES)

INTRODUCTION confront problems proactively and to assist patients

achieve and maintain an optimum level of functioning
Professional Regulation Commission – Board of
or a peaceful death.
Nursing (PRC – BON)
In other words, this nursing philosophy of the CCNAPI is
- is committed to provide need-driven, effective
accomplished by looking after critically ill patient in an
and efficient specialty nursing care services of
environment with specially trained nurses, appropriate
high standard and at international level within
equipment, adequate medical supplies and other
the obtainable resources.
members of the health care personnel.
- To respond to this mission and commitment, a
PRC-BON Working Group in Developing the
Nursing Specialty Framework was formed in the
THE RIGHT OF THE CRITICALLY ILL PATIENT
1996 to take on the task of setting the process-
based framework and guidelines for specialty International Council of nurses (ICN)
nursing services.
- The Working Group members are clinical nurse - Views health care as the rights of every
practitioners, nurse educators and nurse individual regardless of financial political,
managers. geographical, racial and religious consideration.
- This right includes the right to choose or
Critical Care Nurses Association of the Philippines, Inc decline care, including the right to accept or
(CCNAPI) refuse treatment or nourishment; informed
consent; confidentiality and dignity, including
- responsible for the promotion of man’s health
the right to die with dignity. It involves both the
and welfare for national development. It desires
right of those seeking care and the providers⁵.
to support the professional and personal growth
and development of initial core nurses. The World Federation of Critical Care Nurses (WFCCN)
- CCNAPI has organized itself into a national has considered the rights of the critically ill patients,
association committed to the ideals of service to WFCCN has agreed that the statement of the patient’s
the people, equality, justice and social progress. right from the ICN covers the requirement for position
statement on the rights of the critically ill patients.
Philosophy of Critical Care Nursing

The Critical Care Units

GOALS OF CRITICAL CARE NURSING INCLUDE THE
- Each patient is viewed as a unique individual
FOLLOWING:
with dignity and worth.
- The critically ill patient should receive comfort • To promote optimal delivery of safe and
and provided privacy in a highly technological quality care to the critically ill patients and
environment. their families by providing highly individualized
- In collaboration with other health care team care so that the physiological dysfunction as
members, critical care nurses provide high level well as the psychological stress in the ICU are
of patient care which includes patient and under control;
family education, health promotion and • To care for the critically ill patients with a
rehabilitation. holistic approach, considering the patient’s
- To achieve this holistic care process, biological, psychological, cultural and spiritual
participation by the patient and his/her family is dimensions regardless of diagnosis or clinical
always emphasized. setting;
Critical care nurses are able to continuously monitor • To use relevant and up-to-date knowledge,
and observe patients for physiological changes to caring attitude and clinical skills, supported by
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NCM 118 CRITICAL CARE NURSING (DRAFT NOTES)
appropriate technology for the prevention, early equipment for critically ill patients of various
detection and treatment of complications to specialties such as medicine, surgery, trauma,
facilitate recovery. neurosurgery, vascular surgery;
• To provide palliative care to the critically ill ❖ Has a designated medical director with
patients in situations where their health status appropriate intensive care qualification and a
is progressing to unavoidable death, and to help duty specialist available exclusively to the unit at
the patients and families go through their all times;
painful sufferings. ❖ The nurse in-charge and a significant number of
nursing staff in the unit have critical care
On the whole, critical care nursing should be patient-
certification; and
centered, safe, effective, and efficient. The nursing
❖ A nurse: patient ratio is 1:1 for all critically ill
interventions are expected to be delivered in a timely
patients.
and equitable manner.
Level 3

❖ Is a tertiary referral unit, capable of managing

LEVELS OF CARE PROVISION
all aspects of critical care medicine (This does
Level 1 not only include the management of patients
requiring advanced respiratory support but also
❖ Should be capable of providing immediate patients with multi-organ failure);
resuscitation for the critically ill and short term ❖ Has a medical director with specialist critical /
cardio-respiratory support because the patients intensive care qualification and a duty specialist
are at risk of deterioration; available exclusively to the unit and medical
❖ Has a major role in monitoring and preventing staff with an appropriate level of experience
complications in “at risk” medical and surgical present in the unit at all times;
patients; ❖ A nurse in-charge and the majority of nursing
❖ Must be capable of providing mechanical staff have intensive care certification; and
ventilation and simple invasive cardiovascular ❖ A nurse: patient ratio is at least 1:1 for all
monitoring; patients at all times.
❖ Has a formal organization of medical staff and at
least one registered nurse. CATEGORIES OF CRITICAL CARE UNIT
❖ A certain number of nurses including the nurse
The Critical Care Unit can be categorized according to
in-charge of the unit should possess post-
patients’ age group or medical specialties.
registration qualification in critical care or in the
related clinical specialties; and A. Age Group
❖ Has a nurse: patient ratio of 1:1 for all critically
• Neonatal • Pediatric •
ill patients.
Adult
Level 2
B. Specialty
❖ Should be capable of providing a high standard
In the existing environment, majority of the Critical Care
of general critical care for patients who are
Units in the Philippines provide service for patients of
stepping down from higher levels of care or
various specialties. They are labelled as General ICUs. In
requiring single organ support/support post-
certain hospitals, the critical care unit / service is
operatively;
dedicated to the following specific groups:
❖ Capable of providing sustainable support for
mechanical ventilation, renal replacement • Medical
therapy, invasive hemodynamic monitoring and • Surgical
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NCM 118 CRITICAL CARE NURSING (DRAFT NOTES)

• Cardio-thoracic They possess the standard critical care nursing

• Cardiac competencies in assuming specialized and expanded
• Respiratory roles in caring for the critically ill patients and their
• Neurosurgical family.
• Trauma

SYSTEM OPERATION OF CRITICAL CARE UNITS CRITICAL CARE NURSE QUALIFICATION

A. Open System - a licensed professional nurse who is responsible
The admitting and other attending doctors dictate for ensuring that all critically ill patients and
management, change management or perform their families receive optimal care.
procedures without consultation or communication - In the Advanced Practice Nursing level, the
with a Critical Care Specialist. A Critical Care Specialist advanced practice nurses in the critical care,
may be available for advice or be consulted to provide must earn an advanced degree either at the
interventional skills (optional). No designated person master’s or doctorate level in nursing.
who assumes the “gatekeeper” role.

B. Closed System ROLES OF THE CRITICAL CARE NURSES

Management is coordinated by a qualified Critical Care In response to the changes and expansions within and
Specialist. The critical / intensive care specialist has outside the healthcare environment, critical care nurses
clinical and administrative responsibility. There is a have broadened their roles in the practice levels.
multi-disciplinary team of specially trained critical care Competencies of critical care nurses are honed and
staff. The “intensivist” is the final common pathway for developed to achieve their roles in practice,
all medical decision-making including the decision to management / leadership and research.
admit or discharge patients.

Irrespective of the ICU “System” Operations, i.e. open

system or closed system, or a mixture of the two, there PRACTITIONER ROLE
should be a designated group of registered nurses
The critical care nurses execute their practice roles 24-
under unique management to provide highly
hours a day to provide high quality care to the critically
specialized care to the critically ill patients. The nurse in-
ill patient.
charge and the majority of nursing staff in each unit
should have the relevant qualification in the specialty of 1. Care Provider
the respective Unit. a. Direct patient care
• Detects and interprets indicators that
signify the varying conditions of the
SCOPE OF CRITICAL CARE NURSING critically ill with the assistance of
advanced technology and knowledge;
The scope of critical care nursing is defined by the
• Plans and initiates nursing process to its
dynamic interactions of the critically ill patient/family,
full capacity in a need driven and
the critical care nurse and the critical care environment
proactive manner;
to bring about optimal patient outcomes through
• Acts promptly and judiciously to
nursing proficiency in an environment conducive to the
prevent or halt deterioration of
provision of this highly specialized care.
patients’ condition when conditions
Critical Care Nurses are registered nurses, who are warrant, and
trained and qualified to practice critical care nursing.

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NCM 118 CRITICAL CARE NURSING (DRAFT NOTES)

• Co-ordinates with other healthcare • Participates in the training and coaching

providers in the provision of optimal of novice healthcare team members to
care to achieve the best possible achieve cohesiveness in the delivery of
outcomes. patient care.
b. Indirect patient care – Care of the Family 4. Patient Advocate
• Understands family needs and provide
Typically, the critical care nurse may be in the best
information to allay fears and anxieties
position to act as the liaison between patient and family
and
and other team members and departments because
• Assists family to cope with the life-
they are the healthcare professionals with the most
threatening situation and/or patient’s
interpersonal contact with the patients. To perform this
impending death.
function adequately, the nurse must be knowledgeable
2. Extended roles as critical care nurses
about the involved in all aspects of the patient’s care
Critical care nurses have roles beyond their professional and have a positive working relationship with other
boundary. With proper training and in accordance with team members. The critical care nurses are expected to:
established guidelines, algorithms, and protocols that
• Acts in the best interests of the patient
are continuously reviewed and updated, critical care
and
nurses also perform procedures and therapies that are
• Monitors and safeguards the quality of
otherwise done by doctors. Such procedures and
care which the patient receives.
therapies are:

• Sampling and analyzing arterial blood

gases; MANAGEMENT AND LEADERSHIP ROLE
• Weaning patients off ventilators;
The critical care nurse in her management and
• Adjusting intravenous analgesia /
leadership role will be able to assume the following
sedations.
responsibilities:
• Performing and interpreting ECGs;
• Titrating intravenous and central line 1. Performance of management and leadership
medicated infusion and nutrition skills in providing safe and quality care;
support; 2. Accountability for safe critical care nursing
• Initiating defibrillation to patient with practice;
ventricular fibrillation or lethal 3. Delivery of effective health programs and
ventricular tachycardia; services to critically-ill patients in the acute
• Removal of pacer wire, femoral sheaths setting;
and chest tubes, and 4. Management of the critical care nursing unit or
• Other procedures deemed necessary in acute care setting;
their respective institutions under a 5. Taking the lead and supervision of nursing
clinical protocol. support staff, and
6. Utilization of appropriate mechanism for
3. Educator collaboration, networking, linkage –building and
referrals.
As an educator, the critical care nurse must be able to:

• Provides health education to patient

and family to promote understanding ROLE IN RESEARCH
and acceptance of the disease process
The critical care nurse’s role in research will entail the
thus facilitate recovery and
following responsibilities:
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NCM 118 CRITICAL CARE NURSING (DRAFT NOTES)
1. Engage self in nursing or other health – related be certified by the PRC- Board of Nursing as a Clinical
research with or under the supervision of an Nurse Specialist.
experienced researcher;
The critical care nurse specialist is responsible for
2. Utilization of guidelines in the evaluation of research building up nursing competencies in the ICU entity. He /
study or report She contributes to continuous improvement in critical
care nursing through staff and clients education and
3. Application of the research process in improving
uphold quality nursing guidelines on patient care
patient care infusing concepts of quality improvement in
through clinical research and refinement of ICU
partnership with other team-players.
Standards.
ADVANCED PRACTICE LEVEL
B. Acute Care Nurse Practitioner
The development of the Advanced Practice Nursing is
Acute Care Nurse Practitioner (ACNP) in the critical care
the future direction in the Philippines and to be bench
unit takes lead in developing evidence-based practices
marked with other countries. For now, a thorough study
to meet changing clinical needs and facilitates patient
of Advanced Practice in critical care is being undertaken
care processes across professional and organizational
to align with the PRC- BON initiative on specialization
boundaries. The qualification of Acute Care Nurse
framework.
Practitioner (ACNP) includes: should have the
The current global healthcare environment demands recommended number of post registration (licensed
critical care nurses to have advanced knowledge and experience)
skills to provide the highest possible level of care to the
nursing experience which are spent in the critical field,
critically ill patients. CCNAPI supports the following
exhibiting in –depth professional knowledge and skills.
descriptions of advanced practice roles.
An Acute Care Nurse Practitioner (ACNP) is a holder of:
a) clinical master’s degree in a clinical nursing specialty
(Medical-Surgical) such as Critical Care Nursing or b)
EXPANDED ROLES master’s degree in nursing or related discipline such as
A. Nurse Specialist / Clinical Nurse Specialist management together with recognized critical care
training qualifications. The Acute Care Nurse
The education and preparation of the critical care nurse Practitioner executes the nursing team leader’s
practitioner is provided by the respective hospitals. responsibilities as designated in the position of
CCNAPI recommends that a graduate study or a Advanced Nurse Practitioner
master’s degree program should support the
development of critical care nursing specialization goes C. Outcome Specialist
beyond the basic baccalaureate nursing degree. Outcome management has been introduced into the
Advanced educational preparation refers to the critical healthcare system to ensure achievement of quality and
care nursing educational program run by the university cost-effectiveness in the delivery of patient care. Some
offering Advanced Nursing Studies or other recognized critical care units have adopted clinical pathways (e.g.,
advanced critical care program offered in the Philippines Critical Pathways, Protocols, Algorithms and Orders) in
and overseas. the management of specific diseases such as Acute
A registered nurse who is a nursing degree holder, Myocardial Infarction and Cardio-thoracic Surgeries.
should have more than 3 years of uninterrupted practice Qualified nurse experts are involved in the development
experience in the critical care field. He/she can function and implementation of patient outcomes management.
as a critical care nurse specialist when he/she has CHALLENGES OF CRITICAL CARE NURSES
attained advanced education and expertise in caring
patients with critical problems. He/she is also eligible to The challenging needs that the advanced critical care
practitioner will face from the critical care nursing
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NCM 118 CRITICAL CARE NURSING (DRAFT NOTES)
service and its environments demand for them to Critical Care Nurses Association of the Philippines, Inc.
consider the following objectives: recommends that all practicing CCN shall continuously
update their knowledge, skills and behavior through
A. To develop, foster and maintain a level of knowledge
active participation in Critical Care Nursing Education or
about the norms, values, beliefs, patterns of illness,
its related field.
health and care needs of the people;
The following are categorization of critical care nursing
B. To analyze and evaluate critical care nurses specialty
education:
skills and their evolving roles;
1. Post Graduate Courses
C. To review current studies and researches and to
examine contextual issues that will enable evaluation Post graduate courses are part of higher education
and synthesis of new knowledge, traditional techniques, taken after a Bachelor’s Degree that are accredited from
religious and cultural influences to be applied in nursing the Commission on Higher Education (CHED) or the
practice, particularly evidence- based nursing practice, Professional Regulation Commission—Board of Nursing
and (PRC-BON).

D. To exercise professional judgments expected of them It is recommended that this course has been reviewed,
in the critical care clinical setting. evaluated and endorsed to the accrediting body by the
Critical Care Nurses Association of the Philippines, Inc.

Likewise it is further recommended that the World

TRAINING OF NURSES FOR CRITICAL CARE SERVICES
Federation of Critical Care Nurses policy statement of
The institution / hospital should provide training education shall be used as a framework for designing a
opportunities to ensure staff competencies. This will critical care nursing program. (Please see Declaration of
enable the nurses working in the critical care units to Madrid, 2005 Annex I)
cope with the complexities and demands of the
2. Certification Course
changing needs of the critically ill patients. The following
training activities should be supported by the higher Certification courses provides recognition and
level of management to maintain a high standard of designation earned by a professional nurse after
care: completing with satisfaction the requirements of the
course and has earned qualification to perform a job or
ORIENTATION PROGRAM / PRECEPTORSHIP AND
task.
MENTORING PROGRAM
The certification courses should be recognized and
New recruits to the critical care units shall attend an
accredited by the Professional Regulation Commission—
orientation program and be given opportunities to work
Board of Nursing (PRC-BON) or other authorized
under senior staff supervision. Experienced staff in the
accrediting body.
unit should be readily available for consultation.
This shall include but not limited to the following:
IN-SERVICE TRAINING PROGRAM
• Advanced Cardiac Life Support
a. Unit / hospital based training courses / workshop /
• Pediatric Advanced Cardiac Life Support
seminar at hospital level
• Newborn Resuscitation
b. In-the-job training and bedside supervision • Continuous Renal Replacement Certification
• Advanced Intravenous therapy
CRITICAL CARE NURSING PROGRAM (POST GRADUATE
• Stroke Nursing
SPECIALTY PROGRAM)

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NCM 118 CRITICAL CARE NURSING (DRAFT NOTES)
CONTINUING PROFESSIONAL EDUCATION (CPE) The following 11 Standards are intended to furnish
nurses with directions in providing quality care and
Continuing Professional Education Programs is a type of
excellence in Critical Care Nursing:
education that consist of updated knowledge and other
pertinent information that will help the Critical Care 1. The critical care nurse functions in accordance with
Nurse to attain broader understanding of critical care legislation, common laws, organizational regulations and
practice and its related field. The goal includes Critical by-laws, which affect nursing practice.
Care Nurses development of skill, behavior that will help
2. The critical care nurse provides care to meet
them view the critically ill person in a holistic dimension
individual patient needs on a 24-hour basis.
CCNAPI recommends that all practicing CCN shall ensure
3. The critical care nurse practices current critical care
they continuously update their knowledge, skills and
nursing competently.
behavior through active participation in related critical
care nursing education and must earn at least 20 credit 4. The critical care nurse delivers nursing care in a way
units per year. that can be ethically justified.
The updated educational component includes but not 5. The critical care nurse demonstrates accountability
limited to the following: for his/her professional judgment and actions.
• Advanced/Comprehensive Critical Assessment 6. The critical care nurse creates and maintains an
• Critical Care Practitioner environment which promotes safety and security of
• End-of-Life and Palliative Care patients, visitors and staff.

STANDARDS OF CRITICAL CARE NURSING PRACTICE 7. The critical care nurse masters the use of all essential
equipment, available services and supplies for
Critical care specialty addresses the management and
immediate care of patients.
support of patients with severe or life-threatening
illness. The goal of critical care nursing is to promote 8. The critical care nurse protects the patients from
optimal adaptation of critically ill patients and their developing environmental induced infection.
families by providing highly individualized care, so that
9. The critical care nurse utilizes the nursing process in
the critically ill patients adapt to their physiological
an explicit systematic manner to achieve the goals of
dysfunction as well as the psychological stress in the
care.
Critical Care Unit or Intensive Care Unit (ICU). To achieve
this, standards should be developed to serve as a guide 10. The critical care nurse carries out health education
for monitoring and enhancing the quality of intensive for promotion and maintenance of health.
care nursing practice.
11. The critical care nurse acts to enhance the
Care standards for critical care nursing provide professional development of self and others.
measures for determining the quality of care delivered,
and also serve as means for recognizing the
competencies of nurses in intensive care specialty. COMPETENCIES FOR CRITICAL CARE NURSES
Procedures standards for critical care nursing practice The competence of critical care nurses together with
provide a step-by-step guideline for nurses to carry out established nursing standards and the identified core
day-to-day nursing procedure in a most appropriate competencies for registered nurses will result to
manner. excellence in critical care nursing practice. This three-
pronged holistic framework ensures quality
performance through an adherence to nursing
standards, the demonstration of competencies, and the

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NCM 118 CRITICAL CARE NURSING (DRAFT NOTES)
integration of appropriate nursing model/s into the
health care delivery process.

To achieve safe and quality client-centered care, nurses

working in the critical care units are envisioned to adopt
not only the stated core competencies of registered
nurses but also the specific competencies stipulated in
the following eleven major key responsibility areas:

• Safe and Quality Nursing Care Management of

Resources Legal Responsibilities
• Ethico-Moral Responsibilities Collaboration and
Teamwork
• Personal and Professional Development
Communication
• Health Education Quality Improvement
Research
• Record Management