BIOHAZARD

Lecture / First Semester

NCM 118
4. Pathological Waste including waste
biopsy materials, human tissues, organs and
body parts and anatomical parts from
autopsy, surgeries, and procedures.

5. Sharp Waste including used syringes,

scalpels, broken glass that is contaminated
 Biohazard are any biological substances with blood or potentially infectious material,
that pose a threat to the health of living and IV tubing with needle attached.
organisms. By now you know that biohazards
can include certain bacteria, viruses, and
medical waste. BIOHAZARD

 Bacteria that are harmful to humans, and

 Medical Wastes are any waste materials
therefore considered a biohazard include:
generated at hospitals and healthcare or
staphylococcus, pseudomonas, salmonella,
medical research facilities.
E. coli, and methicillin resistant
staphylococcus aureus (MRSA), to name a
 Biohazard is a biological substances that
few.
poses a threat to the health of living
organisms, primarily humans. This could
 Viruses of significant concern include human
include a sample of microorganisms, virus or
immunodeficiency virus (HIV), Hepatitis B
toxin that can adversely affect human
(HBV), and Hepatitis C (HCV).
health. A biohazard could also be a
substance harmful to other living beings.
 Everyone should use caution when handling
human blood and body fluids. If you find
 Biohazards are defined as any biological or
yourself in a situation that requires to handle
chemical substance that is dangerous to
such substances, reaching out to a
humans, animals, or the environment. This
professional bioremediation specialist is the
could include body fluids, human tissue,
best way to protect yourself and prevent
blood, and recombinant DNA
infection.

EXAMPLES
OTHER EXAMPLES OF BIOHAZARDOUS
1. Human blood and blood products WASTES

1. Infectious waste such as: blood and blood

2. Human Body Fluids including semen,
products, contaminates personal protective
vaginal secretions, amniotic fluid, and
equipment (PPE), IV tubing, blood
pleural fluid.
transfusion bags and suction canisters
cultures, stocks, or any laboratory agent
3. Microbiological Waste including
that may be contaminated with an
discarded specimen cultures, discarded live
infectious disease (often defined as
and attenuated viruses, and disposable
microbiological waste).
culture dishes.
2. Any type of waste produced in the room of BIOHAZARD
a patient diagnosed with a communicable
 Medical waste management is serious
disease.
business because it keeps medical
personnel and patients safe from infectious
3. Empty vials from vaccine use.
disease. If one person is infected, it can
spread quickly among neighborhoods.
4. Animal waste or waste resulting from
veterinary procedures.  Biohazard waste containers control disease
spread. A biohazard kit is sometimes called
5. Pathological waste including waste a biohazard body fluid spill kit because it is
materials from a biopsy procedure. often used to handle liquid biohazards like
blood. Cleaning up a liquid presents a
6. Sharps waste including needles, scalpels higher risk than a solid because of the way a
and broken glass vials. liquid behaves.

7. Recombinant DNA and RNA (per National

Institutes of Health Guidelines and LEVELS OF BIOHAZARDS
developed for safe operating procedures at BIOHAZARD LEVEL 1 (Minimal Hazards)
universities and labs around the country). Bacteria and viruses such as E. coli,
canine hepatitis, varicella, non-infectious
8. Laboratory items (otherwise known as bacteria and cell cultures are considered level
microbiological waste) including cultures, 1. The level of protection required in handling
items contaminated with an infectious includes gloves and masks.
disease, used petri dishes.
BIOHAZARD LEVEL 2 (Minimal Hazards)
9. Liquid medical waste such as clinical Level 2 includes bacteria and viruses that
specimen liquids or bodily fluids or bloods can cause mild disease in humans such as
that may contain an infectious agent. measles, mumps, salmonella, dengue fever,
HIV, Lyme disease, hepatitis A, B and C and
10. Gloves, surgical masks, swabs or gauze that some strains of influenza A. Diagnostic work and
is soaked, saturated or dried and able to clinical specimen work can be completed at
flake with blood, bodily fluids or other this level.
infectious material.
BIOHAZARD LEVEL 3 (Moderate Hazards)
NOTE Level 3 biohazards are those that can
cause fatal or severe illness in humans such as
Each of the above, if even suspected of SARS-CoV-2, Influenza A H5N1, Venezuelan
harboring viral, parasitic, or bacterial infection, equine encephalitis, typhus, tuberculosis,
should be appropriately segregated and anthrax, yellow fever and malaria.
handled with the utmost care. Microorganisms
within these waste streams have the potential to BIOHAZARD LEVEL 4 (Serious Hazards)
affect health and wellness. They thrive in Level 4 biohazards cause fatal or severe
hospital environments, as well as outpatient illness in humans that have no available
clinics, physicians’ offices, and yes, even your treatment or vaccine. These viruses include
local dental office! Ebola virus, Lassa fever virus, Crimean-Congo
hemorrhagic fever, Marburg virus and Bolivian
hemorrhagic fever.
 DISPOSAL OF BIOHAZARDS

Due to the risks associated with cleaning up and

disposing of biohazardous materials, people
handling the waste must know the correct
procedures, have easy access to the necessary
PPE, cleaning and containment products.

One of the major biohazards is blood and body

fluids. Helix Solutions has developed Bodily Fluid
Spill Kits that make it easy and safe to clean up
spills and dispose of the biohazard. The hospital-
grade packs are used for cleaning a spill and
disinfecting the site using Chlor-Clean. Once the
spill has been cleaned all equipment, PPE and
spill residues are contained in one bag for
disposal. The patented Chlor-Clean technology
is also available as Detergent Sanitiser Tablets
and dry Chlor-Clean (Biohazard) disinfectant
wipes.

BIOHAZARDOUS WASTES DISPOSAL

PROCEDURES

 Solid biohazardous waste should be sterilized

otherwise rendered noninfectious prior to
disposal in a dumpster. This must be done by
autoclaving or other methods approved by
Environmental Health and Safety.

 Liquid biohazardous waste must be treated

using an appropriate chemical disinfection
method prior to discharge to the sewer
system. For most research activities,
chemical treatment with sodium
hypochlorite (bleach) to a final
concentration of 500 – 100 mg/L free
chlorine is an effective disinfectant per CDC
guidelines. If you have any questions
regarding an appropriate disinfection
method, contact Emergency Health and
Services to verify it is approved by
applicable regulations.
 NCM 118
EMERGENCY MANAGEMENT PRIORITY EMERGENCY MEASURES FOR ALL
 Care given to patients with urgent and PATIENTS
critical needs.  Make safety the first priority.
 This includes whatever the patient or family  Preplan to ensure security and a safe
considers it to be. environment.
 Most common situations are life-threatening  Closely observe patient and family members
conditions (cardiac dysrhythmias, acute in the event that they respond to stress with
coronary syndrome, acute heart physical violence.
failure, pulmonary edema, and stroke).
 Assess the patient and family for
LIFE-THREATENING COMMON SITUATIONS psychological function.
 A cardiac dysrhythmia (also called
arrhythmia) is an abnormal or irregular Emergency Unit is open 24 hours so anybody
heartbeat. An abnormal heart rate means can just go in and out.
that your heart rate is either too fast
(typically over 100 beats per minute) or too  Patient and family – focused intervention
slow (typically below 60 beats per minute).  Relieve anxiety and provide a sense of
 Acute coronary syndrome (ACS) refers to a security.
group of conditions that include ST-elevation  Allow family to stay with patient, if
myocardial infarction (STEMI), non-ST possible, to alleviate anxiety.
elevation myocardial infarction (NSTEMI),
 Provide explanations and information.
and unstable angina. It is a type of coronary
 Provide additional interventions
heart disease (CHD), which is responsible for
one-third of total deaths in people older depending upon the stage of crisis.
than 35.
ISSUES IN EMERGENCY NURSING CARE
SCOPE AND PRACTICE Demanding because of the diversity of
 Nurse has special training, education, conditions and situations that present unique
experience and expertise in assessing and challenges.
identifying health care problems in crisis  Include legal issues, occupational health
situations. and safety risks, and the challenge of
 Interventions are accomplished providing holistic care in the context of a
interdependently in consultation with or fast-paced, technology-driven
under direction of a physician.
environment in which serious illness and
 Works as a team.
death are encountered on a daily basis.
EMERGENCY NURSING 1. Documentation of Consent and Privacy
 Care given to patients with urgent and 2. Limiting Exposure to Health Risks
critical needs. 3. Violence in the Emergency Department
 Includes whatever the patient or family 4. Providing Holistic Care
considers it to be.  Patient-focused interventions
 Most common situations are life-threatening  Family-focused interventions
conditions.  Anxiety and Denial
 Remorse and Guilt
  Anger THE CONTINUUM OF CARE
 Grief 1. Discharge Planning
 Caring for Emergency Personnel 2. Community and Transitional Services
3. Special Consideration (Geriatric, Obesity)
HEALTH RISK IN EMERGENCY
 A health risk is something that increases your PRINCIPLES OF EMERGENCY NURSING
chance of developing a disease.  Avoid unnecessary handling except to
 Health risks in emergencies can arise from a remove the victim from additional danger.
disaster’s effect on the physical, biological,  Give first aid to the injured part.
and social environment including  Observe and keep a medical record of the
contamination or destruction of water, casualty’s initial condition until he reaches
sanitation and waste management systems
the hospital.
and shelter.
 Epidemiological studies have identified
PRINCIPLES IN EMERGENCY MANAGEMENT
emergency departments (EDs) as high-risk
1. Prevention
settings for violence against health-care
2. Protection
workers. The 24-h unrestricted “open-door”
policy, volume of patients, acuity of illness, 3. Mitigation
and political focus all make ED staff 4. Response
vulnerable for violence. 5. Recovery
 The 24 hour unrestricted “open door” policy,
volume of patients, acuity of illness, and Remember CFAC when assessing the stool
political focus all make ED staff vulnerable Color, Frequency, Amount, Consistency Check
for violence. for hydration by assessing the tongue, lips if
cracked, skin turgor, etc.
PATIENT – FOCUSED INTERVENTION
Patient-focused interventions are those that TRIAGE
recognize the role of patients as active  From the French word “trier” meaning “to
participants in the process of securing sort”.
appropriate, effective, safe and responsive  Patients are sorted into groups according to
healthcare. Patients/citizens can contribute to severity of their health problems and
quality improvement at both an individual and immediacy with which problems must be
a collective level. treated.
 Differs from disaster triage in that patients
REMORSE AND GUILT who are most critically receive the most
To put it simply, remorse says, “Forgive me for resources, regardless of potential outcome.
hurting you," while guilt or regret says, “Stop  The preliminary assessment of patients or
making me feel guilty for hurting you.” "Regret casualties in order to determine the urgency
often seems flat, emotionless, and is more of their need for treatment and the nature of
focused on moving on and getting the treatment required.
“punishment” over with," Fjelstad says. Category 1 – immediate
Category 2 – urgent
PRINCIPLES OF EMERGENCY CARE
Category 3 – non-urgent
 By definition, emergency care is care that
must be rendered without delay. BASIC TRIAGE SYSTEM
 Treatment should always be guided by the Emergent – highest priority.
3Ps: Urgent – those who have serious health
1. Preserve Life problems but not immediately life-threatening.
2. Prevent Further Injury Non urgent – those who have episodic illnesses.
3. Promote Recovery
 NURSE TRIAGE  Maintaining a safe environment.
 Formal process of early assessment of  Reassessment of patients in the waiting
patients attending an accident and area.
emergency (A&E) department by a trained  Liaison to families of patients.
nurse, to ensure that they receive
appropriate attention in a suitable location, MANAGEMENT OF PATIENTS WITH INTRA-
with the requisite degree of urgency. ABDOMINAL INJURIES
 Triage is defined as prioritizing or sorting the (BLUNT TRAUMA AND PENETRATING INJURIES)
patients for the care and treatment.  Blunt trauma or penetrating injuries.
 Triage of patients involves looking for signs  Abdominal trauma can cause massive life-
and serious illness or injury. These emergency threatening blood loss into abdominal
signs are ABCD – Airway, Breathing, cavity.
Circulation/Consciousness, and  Assessment
Dehydration.  Obtain history
 Perform abdominal assessment and
5 LEVEL TRIAGE SYSTEM assess other body systems for injuries that
 Used for both emergencies and routine frequently accompany abdominal
health care. injuries.
 Assist the nurse to precisely determine the  Assess for referred pain that may
needs of the patient and the urgency for indicate spleen, liver, or intraperitoneal
treatment. injury.
 Emergency Severity Index  Perform lab studies, CT scan, abdominal
- Level 1 (most urgent) to Level 5 (least ultrasound (FAST) and diagnostic
urgent). peritoneal lavage.
- Assignment based on both acuity and  Assess stab would via sonography.
the anticipated resource needs.  Ensure airway, breathing and
 Canadian Triage and Acuity Scale circulation.
- Includes time parameters which  Immobilize cervical spine.
patients are reassessed by either the  Continually monitor the patient.
nurse or provider.  Document all wound.
- 5 Levels  If viscera are protruding, cover with a
5 LEVELS sterile, moist saline dressing.
Resuscitation Continuous nursing  Hold oral fluids.
surveillance  NG to aspirate stomach contents.
Emergent At least every 15  Provide tetanus and antibiotic
minutes prophylaxis.
Urgent At least every 30  Provide rapid transport to surgery if
minutes indicated.
Less Urgent At least every 60
minutes MULTIPLE TRAUMA
Non-urgent At least every 120 (VEHICULAR ACCIDENT)
minutes
Priorities of Care for the Patient with Multiple
NURSES RESPONSIBILITIES Trauma
 Collection of crucial baseline data.  Use a team approach.
 Asking questions relevant to the patient’s  Determine the extent of injuries and establish
condition. priority of treatment.
 Provision of basic first aid.  Assume cervical spine injury.
 Responsible for and monitors the waiting  Assign highest priority to injuries interfering
rea. with vital psychological function.
Priorities in the Management of the Patient with
Multiple Injuries

ENVIRONMENTAL EMERGENCIES
(HEAT STROKE, FROSTBITE, HYPOTHERMIA)

HEAT STROKE
 A failure of heat regulating mechanisms.
 Types
 Exertional: occurs in healthy individuals
during exertion in extreme heat and
humidity.
 Hyperthermia: the result of inadequate
heat loss.
 Elderly, very young, ill, or debilitated—and
persons on some medications—are at high
risk.
 Can cause death.
 Manifestations:
 CNS dysfunction
 Elevated temperature
 Hot dry skin
 Anhydrosis
 Tachypnea
 Hypotension
 Tachycardia

Management of Patients with Heat Stroke

 Use ABCs and reduce temperature to 39° C
as quickly as possible.
 Cooling methods:
 Cool sheets
 Towels, or sponging with cool water
 Apply ice to neck, groin, chest, and
axillae
 Cooling blankets
  Iced lavage of the stomach or colon potential cardiac dysrhythmias and
 Immersion in cold water bath electrolyte disturbances.
 Monitor temperature, VS, ECG, CVP, LOC,
urine output. POISONING
 Use IVs to replace fluid losses (CHEMICAL/CORROSIVE SUBSTANCES AND
- Hyperthermia may recur in 3 to 4 hours; FOOD)
avoid hypothermia. Management of Patients with Poisoning
FROSTBITE  Poison is any substance that when ingested,
 Trauma from freezing temperature and inhaled, absorbed, applied to the skin, or
actual freezing of fluid in the intracellular produced within the body in relativity small
and intercellular spaces. amounts injures the body by its chemical
 Manifestations: hard, cold, and insensitive to action.
touch; may appear white or mottled; and  Treatment goals:
may turn red and painful as rewarmed.  Remove or inactivate the poison before
 The extent of injury is not always initially it is absorbed.
known.  Provide supportive care in maintaining
 Controlled but rapid rewarming; 37° to 40° C vital organ systems.
circulating bath for 30- to 40-minute  Administer specific antidotes.
intervals.  Implement treatment to hasten the
 Administer analgesics for pain. elimination of the poison.
 Do not massage or handle; if feet are
involved, do not allow patient to walk. Most Common Antidotes
The most commonly used include activated
HYPOTHERMIA charcoal, acetylcysteine, naloxone, sodium
 Internal core temperate is 35° C or less. bicarbonate, atropine, flumazenil, therapeutic
 Elderly, infants, persons with concurrent antibodies and various vitamins. Most antidotes
illness, the homeless, and trauma victims are are of low toxicity, but serious adverse effects
at risk. can result from excessive use, as well as frim
 Alcohol ingestion increases susceptibility. inadequate doses.
 Hypothermia may be seen with frostbite;
treatment of hypothermia takes Assessment of Patient with Ingested Poisons
precedence.  Use ABCs.
 Physiologic changes in all organ systems.  Monitor VS, LOC, ECG, and UO.
 Monitor continuously.  Assess laboratory specimens.
 Determine what, when, and how much
Management of Patients with Hypothermia substance was ingested.
 Use ABCs, remove wet clothing, and  Assess signs and symptoms of poisoning and
rewarm. tissue damage.
 Rewarming  Assess health history.
 Active core rewarming  Determine age and weight.
Cardiopulmonary bypass, warm fluid
administration, warm humidified Management of Patients with Ingested Poisons
oxygen, and warm peritoneal lavage.  Measures to remove the toxin or decrease its
 Passive external rewarming absorption
Warm blankets and over-the-bed  Use of emetics.
heaters.  Gastric lavage.
 Cold blood returning from the extremities  Activated charcoal.
has high levels of lactic acid and can cause  Cathartic when appropriate.
  Administration of specific antagonist as
early as possible.
 Other measures may include diuresis,
dialysis, or hemoperfusion.
BURNS (CHEMICAL BURNS)
Management of Patients with Carbon Monoxide
Management of Patients with
Poisoning
Chemical Burns
 Inhaled carbon monoxide binds to
 Severity of the injury depends upon the
hemoglobin as carboxyhemoglobin, which
mechanism of action of the substance, the
does not transport oxygen.
penetrating strength and concentration,
 Manifestations: CNS symptoms predominate
and the amount of skin exposed to the
 Skin color is not a reliable sign and pulse
agent.
oximetry is not valid.
 Immediately flush the skin with running water
 Treatment
from a shower, hose, or faucet.
 Get to fresh air immediately.
 Lye or white phosphorus must be
 Perform CPR as necessary.
brushed off the skin dry.
 Administer oxygen: 100% or oxygen
 Protect health care personnel from the
under hyperbaric pressure
substance.
 Monitor patient continuously.
 Determine the substance.
 Some substances may require prolonged
Management of Patients with Food Poisoning
flushing/irrigation.
 A sudden illness due to the ingestion of
 Follow-up care includes reexamination of
contaminated food or drink.
the area at 24 hours, 72 hours, and 7 days.
 Food poisoning, such as botulism or fish
poisoning, may result in respiratory paralysis
and death.
 ABCs and supportive measures.
 Determination of food poisoning: see Chart
71-12Treat fluid and electrolyte imbalances.
 Control nausea and vomiting.
 Provide clear liquid diet and progression of
diet after nausea and vomiting subside.

Antidotes
Acetylcysteine – for acetaminophen poisoning.
Activated Charcoal – for most poisons.
Atropine – for organophosphates and
carbamates.
Digoxin – immune fab for digoxin toxicity.
Dimercaprol – for arsenic, gold, or inorganic
mercury poisoning.
Flumazenil – for benzodiazepine overdose.
 CRITICAL CARE NURSING
Lecture / First Semester
NCM 118
Critical care is a term used to describe the care
SEVEN C'S OF CRITICAL CARE
of patients who are extremely ill and whose
clinical condition is unstable or potentially 1. Compassion (empathy, concern)
unstable. 2. Communication (with patient and family)
3. Consideration (to patients, relatives, and
CRITICAL CARE NURSING colleagues) and avoidance of conflict
4. Comfort (prevention of suffering)
 The care of seriously ill clients from point of
5. Carefulness (avoidance of injury)
injury or illness until discharge from intensive
care.
6. Consistency
7. Closure (ethics and withdrawal of care)
 Deals with human response to life
threatening problems trauma/major surgery.
 It refers to those comprehensive, CRITICAL CARE UNIT
specialized and individualized nursing care Medical care for people who have life-
services which are rendered to patients with threatening injuries or illnesses. It usually takes
life threatening conditions and their place in an ICU. A team of specially-trained
families. health care providers give you 24 hour care. This
includes using machines to constantly monitor
CRITICAL CARE NURSE the vital signs.
 Care for clients who are ill.
WHAT ARE THE CONDITIONS CONSIDERED AS
 Provide direct one to one care. CRITICAL
 Responsible for making life and death Patients with:
decisions.  ARF - Acute Renal Failure
 At high risk of injury or illness from possible  AMI - Acute Myocardial Infarction
exposure to infections.  Cardiac Tamponade
 Communication skills are of optimal  Severe Shock
importance.  Heart Block
 "Specialty dealing with human responses to  Traumatic Injuries
life-threatening problems".  Multiple Organ Failure and Organ
 Requires extensive knowledge and a Dysfunction
continual desire to learn.  Severe Burns

Note: The main function of the 3rd ventricle is to produce,

CRITICAL ILL CLIENT secrete, and convey CSF.
 At high risk for actual or potential life-
threatening health problems. ECONOMIC IMPACT OF ICU (1994)
 More ill.  < 10% of hospital beds.
 Requires more intensive and careful nursing  30% of acute care hospital cost
care.  > 20% of hospital budget
 1 % of GNP expended for ICU Care.

With aging of the population

 Demand for critical care service will
increase.
 COMMON DRUG USED IN EMERGENCIES Continuation of the Historical Background
Adrenaline Atropine  Collaboration between nurses and
Xylocard Calcium physicians.
Gluconate  1950's and 1960's - Cardiovascular Disease
Midazolam Diazepam
most common diagnosis.
Pam Epinephrine
 1960's – 30 to 40% mortality rate for
Mannitol Hydrocortisone
Myocardial Infarction.
Magnesium Heparin
Sulfate  1965 - 1st specialized ICU - The Coronary
Morphine Naloxone Care Unit.
Fentanyl Lorazepam  Emergence of Specialized ICU's.
Propofol Digoxin
Propranolol Aspirin AMERICAN ASSOCIATION OF CRITICAL CARE
NURSES (AACN)
DUTIES OF CRITICAL CARE NURSE  1969
 The duties of a critical care nurse may  Educational support
include assisting physicians during  Certification
procedures, checking patients vital signs,  Largest professional specialty nursing
taking blood samples, managing ventilation organization
and life support equipment and ordering  Scholarships
diagnostic tests.  Research
 Critical care is medical care for people who  Publishes journals
have life-threatening injuries and illnesses. It  Local chapters
usually takes place in an intensive care unit.  Political awareness
A team of specially trained health care  Provides standards of practice
providers gives you 24 hours care. This
includes using machines to constantly ICU BED
monitor vital signs.  ICU Bed (7 function) with electrically
 Critical care nurses have been specially operated back rest tilting 0-35°,
trained to handle these emergency care Trendelenburg Tilting 0-20°, Reverse
situations. They provide both important Trendelenburg Tilting 0-20°, Mattress Vase
medical care and monitoring, as well as Tilting to the right up to 40°.
support to patients and their families. Critical  All functions controlled with Power Device.
care nurses work in a very high stress Four easy lifting guardrails (2 on each side),
environment in a dynamic and highly which are safe and reliable, and can be
important role. fixed upward or downward.
 Easy to operate built-in Control Panel on
HISTORICAL BACKGROUND both sides of guard rails.
 Foot step control panel under the bed
World War II frame. Removable and Interchangeable
 Shock wards established for resuscitation. high quality engineering plastic head panel
 Transfusion practices in early stages. and foot panel. Head panel and foot panel
 After World War II, nursing shortage forced equipped with safety lock and roller
groupings of postoperative patients in bumpers.
recovery areas.  Provision for I.V Rod on both sides of the bed.

Polio Epidemic MULTIDISCIPLINARY AND COLLABORATIVE

 1950's: use of mechanical ventilation ("iron APPROACH TO ICU CARE
lung") for treatment of polio.  Medical and nursing directors:
 Development of Respiratory ICU.  Co-responsibility for ICU management.
 At the same time, general ICU's developed  A team approach:
for sick and postoperative patients.  Doctors, nurses, respiratory therapist,
pharmacists.
 Use of standard, protocol, guideline none is designated especially as the
 Consistent approach to all issues. consultant intensivist.
 Dedication to coordination and
communication for all aspects of ICU  Single Physician Model:
management: Primary physicians provide all ICU care.
 Emphasis on research education,
ethical issues, patient advocacy. A GOOD ICU
Well organized, trusted, coordinated care
CRITICAL CARE PRACTICE PATTERN  Full - time intensivist: daily round.
 Open Units  Protocol and policies well defined.
 Closed Units  Bedside nurses (trained in ICU.
 Transitional Units  No intern duty.
 A team of doctors, nurses, respiratory
1. Open Units therapist, pharmacists etc.
Definition: Any attending physician with
hospital admitting privileges can be the CLASSIFICATION OF CRITICAL CARE UNITS
physician of record and direct ICU care. (All
other physicians are consultants). LEVEL I
 Provides monitoring, observation, and short
Disadvantages: term ventilation. Nurse patient ratio is 1:33
 Lack of cohesive plan and the medical staff are not present in the
 Inconsistent night coverage unit all the time.
 Duplication of services
LEVEL II
2. Closed Units  Provides monitoring, observation, and long
Definition: An intensivist is the physician of term ventilation with resident doctors. The
record for ICU patients. (Other physicians nurse patient ratio is 1:2 and junior medical
are consultants). All orders and staff is available in the unit all the time and
procedures carried out by ICU Staff. consultant medical staff is available if
needed.
Advantages:
 Improved efficiency LEVEL III
 Standardized protocol; for care  Provides all aspects of intensive care
including invasive hemodynamic monitoring
Disadvantages: and dialysis. Nurse patient ratio is 1:1
 Potential to lock out private physician
 Increase physician conflict CLASSIFICATION OF CRITICAL CARE
PATIENTS
ICU Model Care  Level 1: at risk of deteriorating, support from
 Full-Time Intensivist Model:
critical care team.
Patient care is provided by an intensivist.  Level 2: more observation or intervention,
single failing organ or postoperative care.
 Level 3: advanced respiratory support or
 Consultant Intensivist Model:
basic respiratory support, multi-organ failure.
An intensivist consults for another
physician to coordinate or assist in TYPES OF ICU
critical care, but does not have primary General
responsibility for care.  Medical Intensive Care Unit (MICU).
 Surgical Intensive Care Unit.
 Multiple Consultant Model:  Medical Surgical Intensive Care Unit
Multiple specialists are involved in the (MSICU)
patient care, (especially Respiratory
Therapist doctors for ventilators), but
Specialized CRISIS INTERVENTION AND STRESS REDUCTION:
 Neonatal Intensive Care Unit (NICU). Partnerships are formulated during a crisis.
 Special Care Unit (SCN). Bends between nurses, patients, and families
 Pediatric Intensive Care Unit (PICU). are stronger during hospitalization. As patient
 Coronary Care Unit (CCU). advocates, their grieving pattern and provide
 Nurse Surgery Intensive Care Unit (NSICU). avenues for positive coping.
 Burn Intensive Care Unit (BICU).
 Trauma Intensive Care Unit. PRIME RESPONSIBILITIES OF A CRITICAL
CARE NURSE
PRINCIPLES OF CRITICAL CARE NURSING  Continuous monitoring
ANTICIPATION:  Keep ready emergency trolley/crash cart
The first principle in critical care is anticipation.  Efficient individual care
One has to recognize the high risk patients and  Counseling and information to family
anticipate the requirements, complications,  Application of policies and procedures
and be prepared to meet any emergency. Unit  Proper records of all activities
is properly organized in which all necessary  Maintain infection control principles
equipment and supplies are mandatory for  Keep update with advance information
smooth running of the unit.
QUICK REFERENCE PROTOCOL FOR MANAGING
EARLY DETECTION AND PROMPT ACTION: EMERGENCY IN ICU
The prognosis of the patient depends on the  Quickly review the patient identity, history
early detection of variation, prompt, and physical exam
appropriate action to prevent or combat  Be with the patient, ask for help
complication. Monitoring of cardiac respiratory  Place the patient in a suitable position
function is of prime importance in assessment.  Attach the cardiac monitor and call for
crash cart
COLLABORATIVE PRACTICE:  Maintain ABC along with expert team
Critical care, which has originates as technical  Introduce IV, CV line
sub - specialized body of knowledge has  Administer medication as needed
evolved into a comprehensive discipline  Carry on investigations - ABG, ECG, Urea,
requiring a very specialized body of knowledge Creatinine, Blood Sugar, Cardiac enzymes
for the physicians and nurses working in the  Maintain fluid and electrolytes
critical care unit fosters a partnership for  Record right things at the right time rightly
decision making and ensures quality and
compassionate patient care. Collaborate CORE COMPETENCIES
practice is more and more warranted for critical  Patient Care
care more than in any other field.  Medical Knowledge
 Professionalism & Ethics
COMMUNICATION:  Interpersonal Communication Skills
Intra professional, inter departmental and inter  Practice - based Learning and
personal communication has a significant Improvement
importance in the smooth running of a unit.  Systems - based Practice
Collaborative practice of communication
model ADMISSION CRITERIA IN ICU
The ICU admission decision may be based on
PREVENTION OF INFECTION: Nosocomial several models utilizing prioritization, diagnosis,
infection costs a lot in the health care services. and diagnosis parameters models
Critically ill patients requiring intensive care at a
greater risk than other patients due to the A. Prioritization Model
immunocompromised state with the antibiotic This system defines those that will benefit most
usage and stress, invasive lines, mechanical from the ICU (Priority 1) to those that will not
ventilators, prolonged stay and severity of illness benefit at all (Priority 4) from ICU admission
and environment of the critical care unit itself.
Priority 1 b) Laboratory Values
These are critically ill, unstable patients in need  Serum sodium < 110 mEq/L or > 170
of intensive treatment and monitoring that mEq/L.
cannot be provided outside of the ICU. Usually,  Serum potassium < 2.0 mEq/L or 7.0
these treatments include ventilator support, mEq/L.
continuous vasoactive drug infusions. Examples  PaO2 < 50 mmHg pH 7.1 or < 7.1 or >
of these patients may include post - operative 7.7
or acute respiratory failure patients requiring  Serum glucose > 800 mg/dl.
mechanical ventilator support and shock or  Serum calcium > 15 mg/dl.
hemodynamically unstable patients receiving  Toxic level of drug or other chemical
invasive monitoring and/or vasoactive drugs. substance in a hemodynamically or
neurologically compromised
Priority 2 patient
These patients require intensive monitoring and
may potentially need immediate intervention. c) Radiography / Ultrasonography /
Examples include patients with chronic Tomography (newly discovered)
comorbid conditions who develop acute  Cerebral vascular hemorrhage,
severe medical or surgical illness. confusion or subarachnoid
Priority 3: hemorrhage with altered mental
These unstable patients are critically ill but have status or focal neurological signs.
a reduced likelihood of recovery because of  Ruptured viscera, bladder, liver,
underlying disease or nature of their acute esophageal varices or uterus with
illness. Examples include patients with hemodynamic irritability.
metastatic malignancy complicated by
infection, cardiac tamponade, or airway d) Electrocardiogram
obstruction.  Myocardial infarction with complex
arrhythmias, hemodynamic irritability
Priority 4 or congestive heart failure.
These are patients who are generally not  Sustained ventricular tachycardia or
appropriate for ICU admission. Admission of ventricular fibrillation.
these patients should be on an individual basis,  Complete heart block with
under unusual circumstances and at the hemodynamic irritability.
discretion of the ICU Director.

B. DIAGNOSIS MODEL
This model uses specific conditions or diseases
to determine appropriateness of ICU admission
(described in critically ill patient).

C. OBJECTIVE PARAMETERS MODEL

a) Vital Signs
 Pulse 40 > 150 beats/minute.
 Systolic arterial pressure < 80
mmHg or 20 mmHg below the
patient’s usual pressure.
 Mean arterial pressure < 60 mmHg.
 Diastolic arterial pressure > 120
mmHg.
 Respiratory rate > 35
breaths/minute.