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Critical Care Nursing. Debbie L. Dempel. History of Critical Care & ICU’s. 1930’s – Introduction of Recovery Rooms WWII & Korean War – Concepts of triage and specialty nursing Late 1950’s – beginning of Critical Care Units Early Technology. History Continued.

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critical care nursing

Critical Care Nursing

Debbie L. Dempel

history of critical care icu s
History of Critical Care & ICU’s
  • 1930’s – Introduction of Recovery Rooms
  • WWII & Korean War – Concepts of triage and specialty nursing
  • Late 1950’s – beginning of Critical Care Units
  • Early Technology
history continued
History Continued
  • Collaboration between nurses and physicians
  • 1950’s & 1960’s – CV Disease most common diagnosis
  • 1960’s – 30-40% mortality rate for MI
  • 1965 – 1st specialized ICU – The Coronary Care Unit
  • Emergence of Specialized ICU’s
american association of critical care nurses aacn

Educational support


Largest professional specialty nursing organization



Publishes 2 journals

Local chapters

Political awareness

Provides standards of practice

American Association of Critical-Care Nurses - AACN
critical care now6
Nursing shortage

Half of patients in ICU’s >65

In US – critical care beds account for 8% of all hospital beds

20% of patients spends time in a critical care unit


Goal: provide high quality, holistic care

Critical Care Now
critical care technology
ECG monitoring

Arterial Lines

Oxygen Saturation


Intracranial Pressure Monitoring


Pulmonary Artery Catheter



Extensive use of pharmaceuticals

Critical Care Technology
the critical care nurse
The Critical Care Nurse
  • “Specialty dealing with human responses to life-threatening problems”
  • Requires Extensive Knowledge and a Continual Desire to Learn
  • Critical Care Certification by AACN
  • Requires:
    • Clinical hours working in an ICU
    • Successful completion of an exam
    • Requires continuing education and clinical hours for recertification
critical care clinical nurse specialist ccns
Critical Care Clinical Nurse Specialist (CCNS)
  • Advanced practice nurse
  • Licensed by the State
  • Five Roles of a CNS:
    • Patient & staff educator
    • Consultant
    • Administrator
    • Researcher
    • Expert practitioner
acute care nurse practitioner acnp
Acute Care Nurse Practitioner (ACNP)
  • Advanced practice nurse
  • Licensed by the State
  • Provides comprehensive care to select critically ill patients
the critical care patient
The Critical Care Patient
  • Physiologically Unstable
  • At Risk for Serious Complications
  • Require Intensive and Complicated Nursing Support and/or Advanced Technology
common problems of critical care patients nutrition
Common Problems of Critical Care Patients - Nutrition
  • Address it early
  • Goal: prevent or correct nutritional deficiencies
  • Parenteral
  • Enteral
common problems of critical care patients anxiety
Common Problems of Critical Care Patients - Anxiety
  • 70-80% of patients
  • Indicators – agitation, increased BP, increased HR, verbalization, restlessness
  • Treatment
common problems of critical care patients pain
Common Problems of Critical Care Patients - Pain
  • 70% reported moderate to severe pain
  • 5th vital sign
  • Leads to anxiety, agitation, increased myocardial oxygen consumption, delays wound healing
common problems of critical care patients impaired communication
Common Problems of Critical Care Patients – Impaired Communication
  • Patient on the ventilator
  • Use of medications
  • Nursing Interventions
common problems of critical care patients sensory perceptual problems
Common Problems of Critical Care Patients – Sensory-Perceptual Problems
  • “ICU Psychosis” – Really Delirium
  • 15-40% of patients
  • Alteration in mentation
  • Psychomotor behavior
  • Alterations in sleep
  • Predisposing factors
common problems of critical care patients sleep deprivation
Common Problems of Critical Care Patients – Sleep Deprivation
  • Poor sleep/wake cycles
  • Lack of REM sleep
  • Predisposes patients for delirium
  • Treatment
family need of the critical care patient
Family Need of the Critical Care Patient
  • Information – major source of anxiety and litigation
  • Reassurance – can reassure care is being given
  • Convenience – access to the patient
arterial lines
Arterial Lines
  • Catheter placed in an artery
  • Pressure from the artery is transmitted to a transducer by a column of fluid and converted in a pressure tracing
  • Transducer must be placed at the Phlebostatic Axis – 4th intercostal space
  • Radial artery is the most common site
arterial lines waveform
Arterial Lines - Waveform
  • Systole – aortic valve opens, blood ejected from LV, sharp rise in waveform
  • Dicrotic Notch – closure of the aortic valve, signifies the beginning of diastole
  • Diastole – lowest point recorded on the waveform
pulmonary artery catheter swan ganz catheter
Pulmonary Artery Catheter (Swan-Ganz Catheter)
  • Evaluate heart disease, shock states, compromised CO, and fluid status
  • Also used to evaluate a patient’s response to treatment
  • Catheter placed through a central vein to the right atrium, right ventricle, and into the pulmonary artery
pulmonary artery catheter swan ganz catheter25
Pulmonary Artery Catheter (Swan-Ganz Catheter)
  • Measures Intracardiac Pressures
  • Measures Cardiac Output
  • Able to Obtain Mixed Venous Blood Samples
pulmonary artery catheter swan ganz catheter26
Pulmonary Artery Catheter (Swan-Ganz Catheter)
  • Pulmonary Artery Port
  • Central Venous Port
  • Injectate Port
  • Thermister Connection
  • Balloon Inflation Valve
  • Volume within a cardiac chamber at the end of diastole
  • Pulmonary Capillary Wedge Pressure – estimates the left ventricular end-diastolic pressure, 6-12 mm Hg
  • Central Venous Pressure – right ventricular end-diastolic pressure, 2-8 mm Hg
  • Refers to the forces that oppose ventricular ejection
  • Systemic arterial pressure, resistance of the aortic valve, and mass and density of the blood
  • Systemic Vascular Resistance
cardiac output
Cardiac Output
  • Volume of blood pumped by the heart in 1 minute
  • Normal: 4-8 L/minute
  • Doesn’t take into account body size
  • More specific is Cardiac Index – size adjusted by Body Surface Index
intraaortic balloon pump iabp
Intraaortic Balloon Pump (IABP)
  • Balloon Catheter placed in the descending thoracic aortic arch
  • Balloon inflation timed to begin to inflate at the time the aortic valve closes – time of early diastole – dicrotic notch
  • Augments aortic pressure and forward flow
  • Increases coronary perfusion
  • When balloon deflates at end of diastole and aortic valve opens negative pressure pulls blood forward

A: Systole-balloon

Deflated, facilitates

Ejection of blood to


B: Early diastole –

Balloon begins to


C: Late diastole –

Balloon is totally

Inflated, augments

Aortic pressure &

Increases coronary


iabp goals
IABP - Goals
  • Support patients with inadequate CO
  • Support patients with inadequate BP
iabp common indications
IABP – Common Indications
  • Cardiogenic shock
  • Left ventricular failure
  • Cardiomyopathy
  • Bridge to transplant
iabp contraindications
IABP - Contraindications
  • Aortic aneurysm
  • Aortic dissection
  • Severe PVD
  • Aortic Valve Insufficiency