Curriculum

for

Critical Care Nurse Training Program (CCNTP)

Critical Care Nurses Association of Nepal(CCNAN)

Kathmandu, Nepal2017

Contents

Topic Page Number1. Introduction 3

2. Goal 4

3. Objectives 4

4. Admission criteria 6

5. Duration of the course 7

6. Time allocation / rotation 7

7. CCNTP Training Site Requirements 8

8. CCNTP Instructors: Eligibility, Responsibility & Certification 10

9. Core Content 12

10. Leave 18

11. Final Assessment & Evaluation 18

12. Certification 19

13. Suggested Readings 20

14. Appendix 21

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INTRODUCTION

Critical Care Medicine is now recognized as a separate specialty around the world to provide quality service to critically ill patients in various Intensive Care Units (ICUs) and other areas of the hospital. Critical Care Medicine also supervises the organizational management, surge capacity building and proper resource allocation when there is increased need of ICU beds e.g. in event of epidemics or disasters. But because of the tremendous expense of Intensive Care Units and their services the numbers of ICU beds are always limited across the globe. Along with the development of Critical Care Medicine, Critical Care Nursing (CCN) has now also emerged as a Nursing Specialty around the globe and thus with formation of Critical Care Nurses Association of Nepal (CCNAN), CCN has been established as a specialty program and thus CCNAN is working on to developed structured training program in CCN.

Training in Critical Care Nursing varies between different universities and countries and till date there are few ICU training programs run on institutional basis by few hospitals with varying curricula. Thus CCNAN has developed this curriculum for CCNTP in Nepal with the objective of maintain minimum standards of knowledge and skills for the nurses working in ICU.

A Critical Care Nurse is a Nurse who has completed her nursing school and registered in the Nepal Nursing Council and completed: Three months Critical Care Nurse Training Program (Accredited / Endorsed by

CCNAN)

A Critical Care Nurse should have the knowledge and skills to handle and manage critically ill patients including skills in resuscitation, airway management, mechanical ventilation, hemodynamic support, management of poly trauma, postoperative management of complex surgical conditions including cardiac, neuro and transplant surgeries, basic and advanced life support, toxicology and management of various other conditions like sepsis, septic shock, ARDS, VAP, endocarditis etc. or other life-threatening situations. The Critical Care Nurse should be the Nurse specialist who will provide full range of Critical Care Nursing Care to critically ill patients.

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Various levels of ICUs have been defined across the world. Since, Nepal has not started the process of Accreditation of ICUs, the levels of ICUs will be as follows:Level I: Facility for Basic Monitoring (ECG, HR, SPO2, NIBP, Temperature),

No In house Doctor, Nurse Patient Ratio of 1:3. Patient with impending organ dysfunction/failure or requiring observation are admitted in Level I Units.

Level II: Facility for Basic Monitoring, No In house doctor, Nurse Patient Ratio of 1:2, Temporary Organ Support System including Mechanical Ventilator/Vasopressors (for short period till Level III bed is available). Patient with some level of organ dysfunction but not requiring organ support systems are admitted in Level II Units.Level II Facilities will be considered equivalent to Step Down Unit, High Care Unit, and High Dependency Unit.

Level III: Facility for Basic & Invasive hemodynamic monitoring (Arterial Pressure, CVP, ETCO2, etc.), Presence of In house doctor round the clock, Nurse Patient Ratio of 1:2 or less, Facility for Organ Support systems including Mechanical Ventilation, Vasopressors, Renal Replacement Therapy, Arterial Blood Gas, Portable USG, ECHO, Endoscopy inside the ICU.Patients with or impending one or more organ dysfunction and/or requiring support are admitted in Level III ICU.

GOALThe goal of Critical Care Nurse Training Program (CCNTP) is to train a Nurse specialist in the field of Critical Care Nursing who has got relevant knowledge and skills.

OBJECTIVES:The objectives are divided into two components:

1. Knowledge2. Skills

Knowledge:At the end of the course, the Critical Care Nurse will be able to:

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Review of anatomy and physiology of circulatory, respiratory, nervous, gastrointestinal, genitourinary, endocrine, and different body systems.

Discuss the clinical features pathophysiology of common ICU conditions like Sepsis, ARDS, Hospital Acquired Infections

Discuss Basic and Advanced Cardiopulmonary Resuscitation. Describe principals of mechanical ventilation and mode of ventilation. Describe the nursing management of the ventilated patient, and explain how to

prevent complications. Identify patient care needs for multisystem disorders and assist with care

planning, utilizing a systematic approach, through the nursing process. Explore the potential consequences of the disease/condition with the patient

and/or others with whom the patient wishes this to be discussed. Apply knowledge of Critical Care Nursing in their Clinical Practice

Skills:At the end of the course, the Critical Care Nurse will have adequate skills and will be able:1. Demonstrate advance skills/competence in managing critically ill patients with

dysfunction of different organ systems 2. Demonstrate skill in handling various equipment/gadgets used in critical care

unit:a. Infusion Devices, b. Noninvasive and invasive monitoring, c. Airway management and Bronchoscopyd. Mechanical Ventilatione. Renal Replacement Therapyf. ABG Machine, USG Machine

3. Perform Basic and Advanced Cardiopulmonary Resuscitation4. Interpret diagnostic/monitoring results and communicate their significance and

possible consequences to relevant members of the multidisciplinary team.5. Acquire skills in critical care transportation within hospital and between

hospitals in same city or different regions6. Illustrate safe and effective practice in the administration of drugs and assess

the effects of drug therapy.7. Identify and implement evidence-based care strategies to prevent hospital-

associated infections and complications.

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8. Acquire skills in end of life and palliative care including alleviation of pain and suffering

ADMISSION CRITERIA:1. Eligibility:

a. Minimum Qualifications:The Candidate should be registered with Nepal Nursing Council and have:

i. PCL Nursing, Orii. Bachelor of Science in Nursing Science / Post Bachelor Nursing

b. Entrance Examination: o The entrance examination shall consist of multiple-choice questions

(MCQs) of Critical Care Nursing and related subject. The organizing institution shall conduct this examination, which should include 50% questions from General/Basic Nursing, 25% from Critical Care and 25% from Skills in Nursing, Infection Prevention, Communication, Ethics, Documentations, Leadership etc. The pass mark in the entrance examination shall be at least 50%.

2. Selection criteria for admission:After the candidates has passed the Entrance examination:a. The organizing institution might take an interview to assess the attitude

of the trainee and will have the final decision about the admitting trainees.

b. The candidate once selected will not be allowed to do any other nursing practice during that training period in any institution.

c. The candidate registered for the course, should agree not to enter any other training programs until the completion of the course.

d. The candidate should agree to abide by the rules and regulations of CCNAN and the organizing institution or else may face expulsion from the program on disciplinary ground.

DURATION OF THE COURSE: The CCNTP should be at least three months (Thirteen weeks) duration, but not more than six months with following minimum duration in Clinical rotations:

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o At least 8 weeks in Level III ICU o At least 2 weeks in Level II ICU or Step down units (SDU/HCU/HDU)o At least 1 week in Coronary Care Unit (CCU)

If the institution does not have these Units, the institution shall arrange for these clinical rotations in other institutions with these units.

TIME ALLOCATION / ROTATION OF CANDIDATES: The candidates shall be assembled for theory teaching and divided into various groups for clinical rotations. Each candidate will go through the following rotations:

BASIC MODULETHEORY:ONE WEEK

CLINICAL ROTATION:TWO WEEKS: LEVEL II / Step Down UnitTWO WEEKS: LEVEL IIIAcademic Teaching: At least 2 hours every week

ASSESSMENT OF BASIC MODULEADVANCED MODULE

THEORY:ONE WEEK

CLINICAL ROTATION:SIX WEEKS: LEVEL IIIONE WEEK: CCUAcademic Teaching: At least 2 hours every week

ASSESSMENT OF ADVANCED MODULEFINAL EVALUATION

CERTIFICATION OF CCNTPRemarks: 1. The program coordinator will arrange rotations (according to availability of

staff nurses, instructors and patient admission status in ICU). 2. All candidates will have to work as per the institution shift practice

(Morning/Evening/Night or Day/Night)3. Its also advised that the Institution should organize BASIC for Nurses program

and give the BASIC For Nurses Training (Organized by Chinese University of Hong Kong) to the candidates during their Basic Module of the CCNTP.

CCNTP: TRAINING SITE REQUIREMENTS

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Any institutions within the country, which has the following mentioned minimum requirements, can only organize the CCNTP. So the institution should apply to CCNAN for endorsement / accreditation of the CCNTP with documents to verify the minimum requirements.

A. Hospital Requirement: a. Mixed Multispecialty Hospital b. At least 150 Hospital bedsc. Established for at least 2 years

B. ICU Requirements: 1. Level III Mixed Medical Surgical ICU –

a. At least 10 Beds, b. Functioning since 2 years, c. Occupancy >50 %,

OR2. Combined Level II & III Beds in Same Unit –

a. At Least 20 Beds, b. Functioning since 2 years, c. With minimum 10 Level III Beds

AND1. Level II ICU – Minimum 5 Beds, Functioning since 2 years2. CCU – Minimum 5 Beds, Functioning since 2 years

The requirements given above are for 20 participants only. For higher number of participants, the Level III ICU Bed should be increased in 2:1 Ratio. (E.g. For additional 10 participants, there should be 5 additional Level III ICU beds)

But if the institution plans to run CCNTP with less number of participants, the minimum criteria should be fulfilled (without decreasing facilities mentioned for 20 participants)

C. Human Resources Requirements:a. Doctors: Level III ICU Must have following Facilities:

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o Academically Certified Critical Care Physician (Intensivist) – at least one – with minimum one year training in Critical Care – designated as the Director / Incharge / Clinical Coordinator for that Level III ICU.

o An In-house specialist doctor or MD Resident round the clock.b. One Critical Care Nurse Educator / Coordinator for CCNTP with following:

o Bachelor In Nursing / BSC Nursingo At Least 3 Year Experience in Level III ICU, OR

Critical Care Nurse / ICU Training – Minimum 3 months, ORDiploma in Critical Care Nursing, ORMasters in Critical Care Nursing

o Should not be the Incharge of the ICU and should be fully dedicated to the CCNTP

c. An Infection Control Nurse: At least 1 years experience in Infection Prevention and Control

d. A full time Physiotherapist dedicated only for ICU (for 10 beds)e. Logistic Manager: Management Person or Nurse to support the program

Coordinatorf. Administrative Assistant/Office Secretary: One allocated from the

management to support with administrative workg. Cleaner / Helper / Attendant: One allocated for the training location and sites

and during training sessions

CCNTP INSTRUCTORS: Eligibility, Responsibility & Certification

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A. Eligibility:o Minimum Requirement:

1. Should be a Life Member of CCNAN2. PCL or BSc Nursing or Post Basic Bachelor of Nursing with

o At least three month ICU Training, ORo At least 2 years experience in Level III ICU, ORo Instructorship in BASIC For Nurses course for at least 1 years, ORo Instructor in existing ICU Training within Nepal for at least 2 years

3. Willing to work as instructor for CCNAN for CCNTP within the country (Nepal) for duration of at least two years after the certification as Instructor.

All interested applicants should apply to CCNAN and CCNAN will select final list of instructors based on assessment of teaching techniques and interview. This will be done by CCNAN as per need felt by CCNAN executive committee.

B. Minimum Responsibility of CCNTP Instructor:The Instructors once selected MUST be available during the first training program in following ways:o Take at least 9 hours of sessions during Theory of Basic moduleo Take at least 1 session (3 hours) every week during the Basic clinical rotationo Attend at least 1 academic session (2 hours, out of 4 session) during the Basic

Clinical rotationo Take at least 9 hours of sessions during Theory of Advanced moduleo Take at least 1 session (3 hours) every week during the Advanced Clinical

rotationo Take at least 1 academic session (2 hours, out of 6 session) during the

Advanced Clinical rotationo Participate in Assessment of Basic and Advance Module and Final Evaluation

of candidates as instructed by Course Coordinator – Helping in preparing questions, taking competency evaluation, correction of answer papers, etc.

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B. Certification: Once the first CCNTP is complete, CCNAN will evaluate the instructors and

then certify as Instructors for CCNTP. Once certified, these CCNAN Certified “CCNTP Instructors” should be eligible

to teach and conduct CCNTP program in any institutions within the country as instructed by CCNAN.

The CCNTP Instructor Certificate will be valid for a period of two years. To continue certification or for further recertification as CCNTP Instructor, the

CCNTP Instructors should at least participate in one CCNTP within a period of 2 years and,

o Take at least 9 hours of sessions during Theory of Basic moduleo Take at least 1 session (3 hours) every week during the Basic clinical

rotation and teach/attend at least 1 academic session (2 hours, out of 4 session) during the Basic Clinical rotation

o Take at least 9 hours of sessions during Theory of Advanced moduleo Take at least 1 session (3 hours) every week during the Advanced

Clinical rotation and teach/attend at least 1 academic session (2 hours, out of 6 session) during the Advanced Clinical rotation

o Participate in Assessment of Basic and Advance Module and Final Evaluation of candidates as instructed by Course Coordinator – Helping in preparing questions, taking competency evaluation, correction of answer papers, etc.

It will be the responsibility of the Instructor to maintain their attendance and log book of their class / session conducted and get it signed from the CCNTP Coordinator at the organizing institutions, which shall be presented at the end of the CCNTP to CCNAN for recertification of Instructor of CCNTP.

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CORE CONTENTS

1. BASIC MODULE

Knowledge:At the end of the Basic Module, the candidate shall have knowledge about following:

1. Cardiovascular system Anatomy and Physiology: Review

(BP, HR, SV, EF, SVR, CO, CPP, Cardiac cycle) Temperature monitoring and Recording Taking ECG and ECG Monitoring ECG: Basic and Common ECG Interpretation

2. Respiratory System Anatomy and Physiology: Review

(Lung Volumes, Muscles of Respiration, Mechanics of Breathing, Gas Exchange, Respiratory Cycle)

Assessment of Respiratory System:o RRo Breathing Patterno Auscultation of Breath Soundso SPO2 Monitoringo Respiratory Secretions

Airway management:o Basics: Bag and Mask, Oral airway, Nasopharyngeal airway, o Advanced: Laryngeal Mask Airway, Laryngoscopy and

Intubationo Use of Bougie and Stylet

Oxygen Therapy and Management:o Cannula, Masks, Venturi Devices, Ambu Bag, Bain Circuit

ABG Analysis – Basics: Normal Values, Acidosis, Alkalosis, Types, Simple Acid Base Disorders

Mechanical Ventilation: Basics – Initiation, Set up

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3. Neurological System Nervous System : Anatomy and Physiology Neurological assessment:

o GCS, Pupils, Orientationo RASS o CAM – ICU, Delirium Screening Checklist (ICDSC)o Sensory Systemo Motor System: Power, Tone, Bulk, Reflexes

Investigation: Lumber Puncture and CSF Analysis

4. Gastrointestinal (GI) System Anatomy and Physiology NG, OG Insertion Nasogastric tube, Oro-gastric tube, Naso-jejunal tube, Gastrostomy,

Jejunostomy Assessment: Bowel Sounds, Stool evaluation (Quantity & Qualitative)

5. Genito-Urinary (GU) System Anatomy and Physiology Acute Kidney Injury: Etiology, Diagnosis, Management, RIFLE

Criteria Chronic kidney disease: Etiology, Stages ESRD Management Foley's Catheterization, Bladder irrigation Suprapubic Catheterization: Basics Intake / Output Balance, Total Fluid Intake, Cumulative Balance Urine Assessment and Quality

6. Endocrine System: Anatomy and Physiology

(Pituitary, Thyroid, Parathyroid, Adrenal Glands) IV Insulin Protocol

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7. Critical Care Concepts: Basicsa. Infection Prevention and control:

i. Basicsii. Hand Hygiene

iii. Hospital Acquired Infectioniv. Isolation Practices

b. Care of Unconscious patientc. Care of Intubated patientd. Drugs used in ICU / CCU

i. Indicationsii. Dose, dilution, preparation,

iii. Adverse effectse. Sampling in ICU: ABG, Blood, blood C/S, Scvo2, Sputum, Endo-

tracheal aspirate or Deep Tracheal Aspirate, Urine, Pus, CSF, Body Fluids.

Skills / Competency Demonstration

At the end of the Basic Module, the candidate shall be able to perform: Head to Toe assessment of Critically ill patient Transfer of Critically ill patient – Inside hospital Implement Basic/common Protocols in ICU

At the end of the Basic Module, the candidate shall also be able to assist and manage during following procedures:

ET Tube Insertion / Intubation, Bed side Care of Intubated patient Arterial Lines: Insertion, Maintenance, Waveforms, Removal Central Venous Pressure: Measurements and Waveforms, Indications,

CVC Insertion, Sites, Care of CVC, Removal of CVC

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2. ADVANCE MODULE

Knowledge:At the end of the Advance Module, the candidate shall have knowledge about following:

1. Cardiovascular System Non invasive and Invasive Cardiac Investigations:

o ECHO, TMT, DST, CAG, Cardiac Catheterization Arrythmias and Management, Antiarrhythmic Agents Conduction Disturbances: Types, Management Pacemaker: Types, Management Disease of Cardiovascular System:

o Acute Coronary Syndromes: Angina, Unstable Angina, NSTEMI, STEMI, and Management

o Rheumatic Heart Disease, Infective Endocarditis, Pericarditiso Cardiomyopathy (DCM, HOCM), Heart Failure

CARDIAC SURGERY: Post operative Management

2. Respiratory System Respiratory Failure: Causes, Types and Management ABG Analysis – Advance: Types of Abnormalities, Clinical Scenarios Mechanical Ventilation: Modes, Troubleshooting, Alarms, Weaning,

Extubation, Tracheostomy and Management Diseases of Respiratory System:

o COPD, Bronchial Asthma, o Pneumonias (CAP, HAP, HCAP, VAP), o ARDS: Diagnosis, Managemento Interstitial Lung Disease

Chest Tube Insertion: o Indications, Techniques, Management of Chest Tube, Negative

suction, Removal of chest tube THORACIC SURGERY: Postoperative Management Epidural Catheters: Insertion, Indications, Drugs, Care of Epidural

Catheter, Removal of Epidural Catheters

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Tracheostomy: Indications, Techniques, Complications, Post Tracheostomy Care, Decannulation

3. Neurological System ICP Monitoring: Principal and Methods Basic EEG, Nerve Conduction Studies, Basic Neuro Imaging: CT Scan, MRI Management of Traumatic Brain Injury Management of Neurosurgical Patient in ICU Disease of Neurological System:

o Meningitis, Encephalitiso Cerebrovascular Accident / Strokeo G B Syndrome, Myasthenia Gravis, o Status Epilepticso Subarachnoid Hemorrhageo Disease of Spinal Cord: Acute and Traumatic spinal cord injury

4. Gastrointestinal System Liver Failure: Acute, Chronic, Fulminant Hepatic Failure Cirrhosis: Causes, Clinical Features, Management Ascites: Causes and Management Portal Hypertension, Hepatic Encephalopathy GI Bleeding: Types, Causes and Management Pancreatitis: Types, Causes, Management Major GI/Intra-abdominal Surgery: Post Operative Management Intra abdominal Hypertension: Classification, Management, Bladder

Pressure Measurement

5. Genito-urinary System Renal Replacement Therapy: Basic principles and Management

o Peritoneal dialysis (PD)o Hemodialysis (Principles, Circuit, Running, Complications,

Troubleshooting, IHD vs. SLEED), Continuous Renal Replacement Therapy (CRRT)

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6. Endocrine System Diabetic Ketoacidosis (DKA) and management Hyper and Hypo-thyroidism Cushing Syndrome, Addison’s Crisis / Disease

7. Critical Care Concepts: Advanced SEPSIS: SIRS, Sepsis, Septic Shock, MODS:

o Definition, Pathophysiology, Management (EGDT), Surviving Sepsis Campaign Guidelines 2016

Nutrition in ICU:o Enteral: Blended Tube Feedings, Requirements, Techniqueso Parenteral: Total Parenteral Nutrition (TPN) – Indications, administration

Sedation and Analgesia in ICU:o Drugs used and management – Case Basedo Delirium in ICU: Diagnosis, Prevention and Management

Physiotherapy:o Early Mobilization in ICU, o Positioning in ICU (Including Prone Position and Management)

Scoring systems in ICU:o GCS, FOUR SCORE, APACHE, SOFA, VAS, NRS, RASS, CAM-ICU

Ethics in ICU, Palliative care and End of life care in ICUo DNR / DNI / Do not escalate Treatment, o Withdrawal of Active Life Supporting Treatment (WALST)

Skills / Competency DemonstrationAt the end of the Advance Module, the candidate shall be able to perform:

Mechanical Ventilation: Handling and Managing, Troubleshooting, Extubation and Care

NIV: Manage NIV ventilation including Portable BiPAP Machines Cardio Pulmonary Resuscitation – BLS & ACLS Management of Tubes and Drains:

o External Ventricular Drain, Chest tubes and drains, with/without negative suction, Abdominal and other drains

Monitoring: ICP, Bladder Pressure – using closed transducer system Communication with critically ill patients

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LEAVE:1. Trainee candidates shall not be entitled for any leave or off days for the entire

period. 2. They will not be entitled leave for any public holidays. 3. The candidates shall produce proof of sick for sick leave and should not be

more than 7 days in three months duration. 4. Any leave less than 7 days shall entitle candidate to continue the course and sit

for final evaluation but work in advanced rotation for the number of leave days.5. Any leaves more than 7 days will require the trainee to delay the final

evaluation by two weeks during which they should work in advanced rotation.6. Any leave more than 14 days will expel the candidate from the course and

should re-apply and re-register for the next course.

ASSESSMENTS AND FINAL EVALUATION:1. CCNAN Certified Instructors for CCNTP MUST do all the assessment and

evaluation for all candidates. The program coordinator of the organizing institution should coordinate the assessment and evaluation.

2. There shall be an assessment of each candidate after Basic Module and after Advanced Module. These assessment will be MCQ (10 marks) and Competency Evaluation (15 marks)

3. All candidates will have to pass the Basic module to be eligible to continue to advanced module.

4. All candidates will have to pass advanced module to appear for Final Evaluation.

5. To pass any module, the candidates will have to secure at least 50% of the maximum marks of that test (12.5 marks)

6. The final evaluation will be done on the last week of the course and will comprise of MCQs (10 marks), SAQ (15 marks) and Competency Evaluation (25 marks).

7. The completion of Course will done based on the final scores of the candidate which will be based on following:

a. 25 % from Assessment of Basic Moduleb. 25% from Assessment of Advanced Module c. 50% from Final Evaluation

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8. A candidate MUST score more than more than 50% on the overall to complete the CCNTP and become eligible for CCNTP Certification.

9. If the candidate does not score more than 50% in overall, they wont be eligible for CCNTP Certification.

a. A re-attempt of Assessment of Advanced Module and then Final evaluation shall be allowed after two more weeks’ rotation in advanced module.

b. If the candidate fails again for the second time, they will be subjected to another two weeks rotation in advanced module after which they will be allowed one more attempt (final attempt) of Assessment of Advanced module and then Final evaluation.

c. If the candidates fail again, they shall take the course again from the beginning with re-application and repayment of course fee.

CERTIFICATION:All candidates who have completed the course by securing more than 50% and become eligible for CCNTP Certification will be awarded the “certificate of completion” of CCNTP. This certificate will be provided by organizing institution but will have logo of CCNAN and signature of Chairman of CCNTP Accreditation Committee. This certificate will allow the participant to be eligible for Life Membership of CCNAN and also can practice as a Critical Care Nurse in Nepal.

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SUGGESTED READINGS:

1. Manual of Critical Care Nursing, Nursing Interventions and Collaborative Management. 6th Edition. Marianne Baird and Susan Bethel.

2. Introduction to Critical Care Nursing. 6th Edition. Deborah Goldenberg Klein, Marthe J. Moseley, and Mary Lou Sole

3. Priorities in Critical Care Nursing. 7th Edition. Kathleen M. Stacy, Linda Urden, and Mary E. Lough.

4. Critical Care Nursing: Diagnosis and Management, 8th Edition. Mary E. Lough5. The ICU Book. Paul L. Marino. 4th Edition6. TUTH ICU Protocols. Diptesh Aryal, Pramesh S. Shrestha, Gentle S. Shrestha,

Subhash P. Acharya.7. Manual of ICU CCU Training, Nursing In- Service Education Unit, TU

Teaching Hospital.

8.

9. The ICU Book, 4th Edition, Paul L. Marin

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APPENDICES

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