Nursing Care in the Intensive Care Unit Setting: The Role ...

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Gwendolyn Vance, debra Koczen-doyle, deborah McGee-MccullouGh, anne Marie KuzMa, and Marianne butler-lebair

Nursing Care in the Intensive Care Unit Setting: The Role of the Nurse in the ICU

CHAPTER 13

LEARNING OBJECTIVESAfter studying this chapter, you should be able to:

Identify the role the critical care nurse (CCN) plays as an ■

advocate for the critically ill patients and their family.Recognize the contribution of the CCN to the critical care ■

team through collaboration and communication.Describe the role of the CCN in patient assessment and ■

subsequent formulation of the plan-of-care.Categorize the critical nursing interventions that can ■

prevent or mitigate nosocomial infections and common complications seen in the critically ill patient.

CHAPTER OUTLINELearning ObjectivesCase StudyIntroduction

The Roles of the Critical Care NurseEducational Preparation for Critical Care NursesHospital OrientationCertification

Critical Care Nurse: Scope of PracticePatient AdvocacyCollaboration and CommunicationPatient EducationPatient Assessment and the Development of the Interdisciplinary Care PlanPrevention of Nosocomial Disorders in the ICU patientEnd of Life/BereavementEthics

SummaryReview Questions

AnswersReferencesAdditional Reading

226 G. VANC E, D. KOC z EN-DOyLE, D. MCG EE-MCC U LLOUG H, A.M. KU z MA, AN D M. B UTLER-LEBAI R

the initial nursing evaluation of suitability for home mechanical ventilation included assessing:

Medical stability on chronic ventilator settings■■home accessibility■■Safety■■Psychosocial health and adequacy of social support■■cognitive ability■■compliance■■access to insurance and or finances for homecare/medical equipment■■readiness for learning■■

once the patient was deemed an appropriate candidate for home mechanical ventilation by the multidisciplinary team, patient and family education included:

airway care and clearance – tracheostomy care, suctioning, and inner cannula cleaning.■■Ventilator care – cleaning equipment, power options, assembly of tubing.■■alarm troubleshooting.■■infection control – hand washing, sterile technique, proper equipment handling, and gen-■■eral health maintenance such as flu and pneumonia immunizations.emergency techniques – manual breathing, loss of airway, power failure.■■Gastrostomy tube feeding, pump function.■■Patient transfers and mobilization – specialty or adaptive equipment education, general ■■home safety.oxygen use and safety.■■Medication administration.■■

after the patient and his wife demonstrated safe and appropriate management of the tracheo-stomy, mechanical ventilator, and medication administration, a final safety check of the home by the durable medical equipment company was completed. this included electrical safety, cleanliness, and accessibility. Final preparation for discharge included:

written medication schedule including aerosolized medication treatments.■■written troubleshooting guide with emergency information.■■Phone numbers for homecare agencies, durable medical equipment providers, and primary ■■care and specialty physician offices.Follow-up appointments with specialty and primary physicians.■■notification of utility companies of life-support equipment at home.■■notification of emergency fire rescue department that ventilator-dependent person may ■■require assistance in household and may be nonverbal.

CAS E STU Dy

A 55-year-old male with a past medical history of leukemia, sta-tus post bone marrow transplant two times, and status post renal transplant with BOOP was transferred to the intensive care unit (ICU) following admission for ventilator-dependent respiratory failure at a local hospital. During his ICU stay, the patient had an open lung biopsy which revealed interstitial lung disease with fibrosis. The patient had a prolonged hospital course complicated by shock, Klebsiella pneumonia, and tracheomalacia requiring placement of a customized tracheostomy, critical illness polyneu-

ropathy, and a pulmonary nontuberculosis mycobacterial infec-tion. He was stabilized and transferred to the ventilator rehabilitation unit for reconditioning and weaning from the ven-tilator. He was able to gradually regain the ability to speak, swal-low, eat with additional enteral feeding via gastrostomy tube, and stand and ambulate with assistance; however, despite aggressive reconditioning, the patient was unable to be weaned from the ventilator. He requested to be discharged to home on mechanical ventilation instead of a long-term care facility.

227 C HAPTER 13 • N U RS I NG CAR E I N TH E I NTENS IVE CAR E U N IT S ETTI NG

the specialty nurse continued with daily phone calls to the patient, home care, and durable medical equipment providers to monitor patient progress, troubleshoot problems, and pro-vide emotional support and additional resources or social service contact information as needed. during outpatient visits with specialty physician, the specialty nurse also meets with patient in the outpatient clinic for ongoing management and monitoring of progress.

INTRODUCTION

the most visible member of the icu healthcare team is the critical care nurse (ccn). the ccn provides highly skilled nursing care for the patient in the icu and often facilitates communication between the various practitioners involved in the care of the patient. the nurse’s expertise and ongoing presence promote early recognition of subtle, but often sig-nificant changes in the patient’s condition, thereby helping to minimize the complications of critical illness.1

ccns practice in settings where patients require complex assessment, high-intensity therapies and interventions, and continuous monitoring. ccns rely upon a specialized body of knowledge, skills, and experience to provide care to patients and families and create envi-ronments that are healing and humane. in the past, nursing practice was traditional and ritu-alistic.2 changes in the healthcare community have lead to evidence-based nursing practice. nursing care must be efficient and cost effective; cognizant of patient satisfaction and qual-ity-of-life issues, and based on demonstrated effectiveness-of-practice.

Foremost, the ccn is a patient advocate. the american association of critical care nurses (aacn) defines advocacy as respecting and supporting the basic values, rights, and beliefs of the critically ill patient.

The Roles of the Critical Care Nurseccns work in varied settings, fulfilling multiple roles that include bedside nurses, clinical nurse specialists (cnS), nurse practitioners, nurse educators, nurse managers, and nurse researchers. with the onset of managed care and the resulting migration of patients to alter-native settings, ccns are caring for patients who are sicker than ever before.3 Managed care has also fueled a growing demand for advanced practice nurses in the acute care setting.

advanced practice nurses are those who have received advanced education at the mas-ter’s or doctoral level. in the critical care setting, they are most frequently cnS or acute care nurse practitioners (acnP). a cnS is an expert clinician in a particular specialty – critical care in this case. the cnS is responsible for the identification, intervention, and manage-ment of clinical problems to improve care for patients and families. they provide direct patient care, including assessing, diagnosing, planning, and prescribing pharmacological and nonpharmacological treatment of health problems. acnPs in the critical care setting focus on making clinical decisions related to complex patient care. their activities include risk appraisal, interpretation of diagnostic tests, and providing treatment, which may include prescribing medication.4

Educational Preparation for Critical Care Nursesa registered nurse (rn) is a person who has successfully completed a nursing program and passes a national licensing exam. entry level education for a rn may be either through earn-ing a diploma in nursing, an associate’s degree in nursing (adn), or a bachelor’s degree in nursing (bSn). requirements vary as dictated by each state’s board of nursing.

Hospital Orientationalthough it is typical for nursing curriculums to offer students clinical rotations in critical care, the ccns specialty education and orientation is provided by the employer. course work over several weeks to months is both didactic and clinical. Most employers utilize a

The CCN’s primary role in the ICU setting is early recognition of changes, early intervention, evaluation, and communication with healthcare team member.

Rapid changes in healthcare administration, laws on limits to physicians working hours, and length of stay concerns have necessitated implementation of diverse nursing models in the ICU setting.


preceptor or mentor program to facilitate the clinical orientation. the critical care nursing curriculum focuses on the management of complex patients with emphasis on analytic think-ing, decision making, hemodynamic monitoring, pharmacology, nutrition support, and psy-chosocial education for the critically ill. the nurse is eligible to sit for the certification examination in critical care after working in the icu for more than 2 years and demonstrat-ing proficiency in the care of the acutely or critically ill patient.4

Certificationalthough certification is not mandatory for practice in a specialty like critical care, many nurses chose to become certified. Some employers prefer to hire critical care certified nurses as the certification demonstrates acquisition of a specific high level of knowledge through successful completion of a rigorous, psychometrically valid, job-related examination. in order to be eligible, for example for the ccrn certification examination offered by aacn, a ccn must care for critically ill patients for a minimum of 2 years.4 continuing education and ongoing clinical experience are commonly required for the certified ccn to renew cer-tification. this practice assures that certified nurses validate their knowledge of current prac-tices in acute/critical care nursing.

because of the availability of Medicare and managed care reimbursement to clinical nurse specialists, a growing number of employers are requiring advanced practice certifica-tion. additionally, as state boards of nursing attain statutory authority to issue advanced practice nursing licenses, nurses are often being required to pass a nationally recognized certification examination. certified nurses validate their continuing knowledge of current practices in acute/critical care nursing through a renewal process that includes meeting con-tinuing education and clinical experience requirements.

CRITICAL CARE NURSE: SCOPE OF PRACTICE

Patient Advocacythe ccn is responsible for continuous bedside management of the critically ill patient. the nurse in icu setting has emerged as the patient’s advocate and works toward realistic out-comes that are in accordance with the best practices and the patient’s wishes. in the icu, the very nature of patients’ life–threatening illnesses and the heightened urgency can create crisis within the patient and family, which makes the ccns “holistic” approach to healthcare integral to the patients overall outcome.5

the most essential skill the ccn utilizes is the ability to assess quickly and anticipate patient responses to a variety of physical and psychological changes. the nurse utilizes evidence-based knowledge and his or her own experience in dealing with patients’ responses to external and internal stressors. the goal is to create an environment which promotes heal-ing or if necessary allows a peaceful, dignified death the american nursing association defines the role of all nurses in the 2003 Social Policy Statement as:

The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.

For the ccn, the role is magnified because of the fast-paced nature of critical care medi-cine. the patient and the family often require a consistently available presence to assist them in understanding and interpreting an ever changing clinical picture. in order to assure a trust-ing, beneficial relationship, the nurse must first become the patient’s advocate.

Vulnerable patients who may be too sick or confused to convey their wishes depend on nurses to protect their autonomy and individual rights with regard to receiving or refusing treatment. because of the close physical proximity of nurses to the patient and the holistic approach to care, nurses are well suited for this role. ccns strive to create a safe, healing atmosphere primarily through effective communication with physicians, allied healthcare members, family members, and the patient.5 in a complex, multifaceted environment such as

Critical care certification for ICU nurses (CCRN) validates that the nurse has current and ongoing clinical expertise in the general care and management of the critically ill person.

The primary role of all nurses is to function as the patients advocate. In the ICU, this role is heightened due to the intensity of stressors, complexity of medical interventions, and the decreased ability of the patient to protect his or her rights secondary to sensory overload.


the icu, nurses must function as the “air traffic controllers” of patient care. in consultation with the multidisciplinary icu team, nurses assess the practicality of interventions such as physical therapy, the timing of transportation off the unit for diagnostic testing and the patient’s readiness to endure stressors such as weaning from the ventilator. the paramount concern is always patient safety and how to best meet the demands of delivering highly technical, invasive, and advanced care to an anxious patient and how to communicate this to family members in a way which minimizes stress.

equally important is that the patient or his surrogate receives accurate and understandable information, which will allow them to give informed consent for procedures and invasive therapies. consent to treat and especially informed consent for clinical research trials include assuring that the patient not only hears what the procedure is but also understands the impli-cations and risks versus benefits associated with the procedure and any other alternative treatments or diagnostic tests available. Patients are often queried after their discussions with the medical team and asked to repeat back their understanding of what has been communi-cated to them.

Collaboration and CommunicationFor the entire multidisciplinary team, daily rounds are the primary tool used to share infor-mation, assess patient’s status, evaluate clinical interventions, and formulate a daily care plan. collaborative discussions, which allow each discipline’s perspective to be voiced, will enhance patient outcomes.6 ccns advocate for the patient during daily rounds by communi-cating to the team patient information that may impact decision making. For example, if an intubated patient has been displaying signs of delirium, such as thrashing in bed and consis-tently triggering high pressure alarms on the ventilator, the nurse may inquire regarding the need for pharmacologic intervention. nurses understand that they are not to prescribe medi-cations, but they can relate to the managing intensivist the behaviors of distressed patients and suggest evidence-based strategies to the team.

Since nurses have a uniquely close proximity to the patient during direct care, they develop relationships in which the patient may convey information that would not be given during their interactions with other team members. Frequently, patients are anxious, forgetful, or intimidated by physicians during rounds and may underreport or minimize symptoms or pain. Family members or surrogates can also become stressed and may not disclose details that could impact overall medical care or discharge planning. nurses often obtain crucial information gathered during the time spent performing routine patient care and then relay this information to the team. nurses may also have to intercede with fami-lies to assure that the patient’s directives are implemented. they achieve this through establishing trust with the family, listening to their concerns, and relaying what the patient has conveyed to them. educating family on the equipment being used, rationales for ther-apies, or lack of certain therapies may also assist the adjustment to illness. Families, dur-ing crisis, are typically very anxious, struggle with feelings of helplessness, and may cope by displaying anger. Some refuse to cooperate with the team or create distractions that have the potential to impair the team’s ability to provide focused patient care. the nurse can mitigate some of these problems by empowering the family through education and keeping them informed of changes. nurses are often viewed as a “safe” person to whom concerns can be directed; they can also help facilitate access to the patient and medical staff. Most critical care units have flexible visitation policies that can be adjusted consid-erably, based on the medical condition of the patient. initiating contact with daily phone calls, and providing phone access on night shifts, alleviates some of the anxiety and pow-erlessness that families experience. ultimately, caring for the patient means caring for the family as well.

nurses and other medical professionals must also strive to avoid becoming too rigid and inflexible, in their roles, and entrenched in their perceptions of care management. respectful discussions benefit the patient and promote team-building. again, the multidisciplinary team approach best integrates all members into the decision-making process and results in improved patient outcome.3

Communication with the patient and family must be conveyed in clear concise language such that the patient and family are able to accurately reiterate the essential concepts.

Patients may underreport or omit critical information to the team on rounds secondary to feelings of intimidation or becoming overwhelmed with information. Patients may be more forthcom-ing during routine nursing care because of the close, extended personal contact required for such care. Therefore it is impor-tant that rounds are attended by the CCN to impart that informa-tion to the team.


Patient EducationMost patients and families are neophytes to the highly complex critical care environment. Many have rarely been in a hospital and may have never experienced a highly technical icu. the most frightening element upon entering the icu is most certainly the monitors, alarms, and specialized equipment. all patients will have eKG, oxygen saturation, and blood pres-sure monitoring. Some may have more advanced hemodynamic monitoring such as arterial, central venous, or Pa catheters or intracranial pressure monitoring. all technical equipment (infusion pumps, mechanical ventilators, continuous renal replacement, intra-aortic balloon pumps, ventricular assist devices, and specialty beds) have monitors and alarm systems, which can appear both terrifying and confusing to families. these emotions can be moder-ated by explaining in layman’s terms the basic rationale for each piece of equipment or monitoring device. orientation to the members of the unit staff and their roles should occur, and the written names of the staff nurse and nurse manager, should be distributed.

uncertainty, due to a sudden illness for which the patient and family were unprepared, will be lessened by basic explanations regarding the disease process and the treatment plan. education techniques should be tailored to the patient’s educational level and communication style. Many patients want a detailed and highly technical overview of their condition, while others become overwhelmed by too much information. documenting the patient’s learning needs assessment, and evidence of learning is essential in communicating to the members of the team. whatever the method, nurses are responsible for assuring that patients comprehend what is happening and have the knowledge to give an informed consent to treatment.

in the broader public arena, ccns work in conjunction with public health practitioners to educate the public regarding disease prevention, disease management, and end-of-life issues.

Patient Assessment and the Development of the Interdisciplinary Care Planthe ccn caring for acutely and critically ill patients has a responsibility to assess and ana-lyze the level of care needed by the patient. this assessment is an organized, systemized approach to the icu patient and incorporates both:

an understanding of the pathology of the disease processes affecting the patient allows ■■for areas of assessment on which to focus.a thorough head-to-toe approach to assessment includes a systematic physical examina-■■tion, review of patient’s history, and analysis of the patient’s laboratory and diagnostic testing data.

data collected from a thorough history and physical examination contribute to both the medi-cal and nursing decisions for therapeutic interventions and allow the ccn to anticipate and plan key nursing interventions for and with the patient. the ccn participates in the develop-ment of the plan-of-care by incorporating the elements of the physical examination, review of history, and data to identify the patient’s problems. the ccn develops realistic goals and cor-responding interventions, and evaluates successful completion of the goals; revising the plan-of-care as necessary.7 the ccn physical assessment includes but is not limited to:

Neurological Assessment

level of consciousnessSpeechMotor functionPupillary functionGlascow coma Scalerespiratory patternsany changes in mental statusMaintenance of chemical paralysis

Identifying impediments to learning and interpreting the patients’ level of understanding are the initial assessments required to initiate patient education.


Cardiovascular Assessment

Pulses and capillary refillJugular venous distentionPacemaker settings and functionPresence of edemaheart rate and rhythmblood pressureheart sounds

Pulmonary Assessment

respiratory pattern/effortbreath soundsSecretionsVentilator/noninvasive ventilationchest tube data including air leaks/drainageairway including tracheostomies or endotracheal tubes

Gastrointestinal Assessment

bowel soundsGi tubes including location and drainagePresence or absence of bleedingnutrition including weight, diet, signs of wasting

Renal Assessment

edemaweightintake and outputdialysis access

Patient Safety

risk for fallneed for restraints

Skin Integrity Assessment

Presence of pressure wounds/stagingneed for specialty bedPresence of abnormalities – rash, abrasions, other injuries

Pain Assessment (In Conscious and Unconscious Patients)

Source of painintensity (using the 1–10 scale, greater than 4 requires intervention)indicators of pain – physiologic or behavioraleffect of pain intervention

Psychosocial Assessment

Patient/family’s response to stressSocial support


Patient’s ability to get sleepconfusion/agitation – need for sedationPatient’s environmental influencesSpiritual needsadjustment to illnessadjustment to functional decline, self care deficits, and body image changes can delay or prevent a patient’s return to a preillness state.

documentation of the physical assessment, data derived from patient monitoring, patient and family education, and the plan-of-care, has traditionally been done using a critical flow sheet.

critical care nursing documentation in a flow sheet format provides access to information in a standardized manner and allows for rapid communication among team members. additionally, assessment parameters can be organized on the form to communicate stan-dards-of-care, facilitate the nursing process, and save nursing time. the structure of a flow sheet format results in standardized documentation that simplifies quality assurance review and eliminates duplicate documentation. nursing staff members comment on how easy charting is when the standards for documentation are clear and consistent.8

increasingly, hospitals are moving to electronic medical records (eMr). Paper charts have multiple problems including illegible handwriting, inaccessibility, and misfiled or lost records. Some of the potential benefits to an eMr include improved information access, better ability to manage and store data, improved and legible documentation, reduction in medication errors, and support for clinical research. these improvements in information access will ultimately lead to improved patient care.

Prevention of Nosocomial Disorders in the ICU Patientthe literature has repeatedly documented that meticulous nursing care, in association with strict adherence to clinical practice guidelines, leads to improved patient outcomes.9 all patients admitted to the icu must have prophylactic strategies implemented, in accordance with current practice guidelines, to prevent or decrease the incidence of the following com-mon complications:

Deep Vein Thrombosis (DVT)

nurses must assess patients’ mobility status and assess the risk of developing a dVt. Patients requiring admission to the icu are at risk for developing dVt secondary to prolonged bed rest related to critical illnesses and the monitoring required to manage the patient’s care, which also contributes to limited mobility. the decision to institute pharmacological or mechanical measures to prevent the development of a dVt should be initiated based on the patients’ level of mobility and sensitization to pharmacological agents used for prophylaxis. nurses should be aware that even low-dose heparin may cause platelet dysfunction in the sensitive patient. contraindications to anticoagulant therapy include:

active bleeding■■cerebral vascular hemorrhage■■Platelet dysfunction or bleeding disorder■■allergy to heparin■■Patients who are at high risk for falls■■noncompliance■■

Patients recovering from recent surgical procedures respond well to the application of inflat-able compression devices; these should be implemented in the operating room, prior to sur-gery and continued into the postoperative period.

Nursing care plans and goals should intergrate the treatment plan and reflect the multidisci-plinary approach to the patients management.


Skin Breakdown

immobility, impaired nutritional intake, and exposure to moisture and medications contrib-ute to skin breakdown in the critically ill patient. nurses have an excellent opportunity to examine the patient’s skin while delivering routine nursing care. Subtle changes that may progress to the development of skin breakdown can be noted by nurses and timely interven-tion may prevent decubitus ulcers from forming. the nurse must assess the patient’s sever-ity-of-illness and if a specialized bed is warranted. Specialty bed manufacturers offer numerous choices, for a variety of patient needs. Most specialty beds have low pressure air mattresses that evenly distribute, and therefore minimize, pressure to the dependent portions of the patient’s body; air circulation promotes drying. these beds may have additional fea-tures such as rotation & percussion, chair positioning, and the ability to place the patient safely in a prone position. low air loss, such as clinitron therapy and water beds may be used with burn and skin-grafted patients. however, the time-tested approach of turning and repositioning the immobilized person every 2 hours, in conjunction with massaging pressure points to reestablish circulation, are still effective interventions to prevent skin breakdown. consultation with specialized wound care nurses to ascertain which specialty bed is appro-priate should occur as soon as the patient is determined to be at risk.

Infection Control

development of nosocomial infections in the hospital has generated a great deal of concern from the healthcare industry, public health organizations, insurance companies, and patient rights organizations. the reasons for an increased incidence of nosocomial infections are varied but include:

rapidly growing population with increased crowding■■impaired immunity secondary to advancing age■■Pathogen adaptation and drug resistance■■over use of antibiotics■■improper infection control and hand sanitation■■

infections are more likely to be acquired in an icu than on a general medical floor because of the increased use of invasive monitoring lines, indwelling catheters, and an impaired immune response secondary to critical illness. common sites for nosocomial infections include surgical wounds, the urinary tract, and the lower respiratory tract. despite the preva-lence of invasive catheters and higher risk factors in the icu, there are proactive steps that the multidisciplinary team can implement to decrease the likelihood of infection. Since nurses are a constant presence at the bedside, they should ensure that:

all hospital personnel wash hands with an approved rinse-less foam or gel, or soap and ■■water before and after patient contact.healthcare providers, dietary and housekeeping staff consistently utilize protective ■■equipment.Strict adherence to isolation protocols, ensuring signage is prominently displayed and ■■isolation carts are stocked and accessible.negative pressure ventilation is maintained when appropriate.■■disposable, single patient use equipment is utilized■■thorough cleaning of all nondisposable equipment with an antimicrobial solution is ■■provided.room cleanliness between patients including terminal cleaning in rooms that have housed ■■patients with resistant organisms is assured.

an important part of nursing advocacy is to assure that the above is followed consistently by all members of the healthcare team. it is a daunting task to remind clinicians in authority to wash hands, wear protective clothing, or note that sterility has been broken during a proce-dure; however, as a patient advocate, the nurse should not ignore breeches in protocol.10


Moreover, nurses are responsible to assure that best care practices are consistently imple-mented. they will be held accountable for known lapses in protocol.

Patient Safety

the ccn plays an important role in assuring patient safety. a patient safety practice has been defined as “a type of process or structure whose application reduces the probability of adverse events resulting from exposure to the health care system across a range of diseases and procedures; in other words, practices that make health care safer.”11

to improve care, the primacy of patient safety must be enhanced through training, an administration that supports a culture of safety, and by making clinical systems function efficiently while providing redundant safety measures. a culture of safety has been described as “how the organization behaves when no one is watching.” institutional systems’ policies and procedures depend upon the actions of individuals and groups for their successful imple-mentation. the successful and safe execution of a procedure requires the actions of properly trained individuals who understand the importance of the underlying intent, accept their responsibility for the task, and appreciate that taking a potentially unsafe shortcut would be wrong.

the values of the group help shape the beliefs and attitudes of the individual, which in turn, play a significant role in determining individual behaviors.12

Patient safety is every healthcare team member’s business and priority. Knowing and understanding the Joint commission’s national Patient Safety Goals (nPSG) are just one step in achieving a culture of safety that makes healthcare safer for a patient. the 2009 nPSG as defined by the Joint commission are:

improve the accuracy of patient identification.■■improve the effectiveness of communication among caregivers.■■improve the safety of using medications.■■reduce the risk of healthcare-associated infections.■■accurately and completely reconcile medications across the continuum.■■reduce the risk of patient harm resulting from falls.■■encourage patients’ active involvement in their own care as a patient safety strategy.■■identify safety risks inherent in the patient population.■■improve recognition and response to changes in a patient’s condition.■■the organization meets the expectations of the universal Protocol.■■

understanding the policy on patient-restraints, being trained to correctly insert a central line, practicing universal precautions correctly, performing a time-out prior to an invasive proce-dure, clear and concise communication, and checking that the correct medication with the correct dosage has been ordered are all examples of patient safety issues.

another example of how the ccn advocates for patient safety is during transport (See chapter 14 on transport of the critically ill patient). transportation of critically ill patients is always challenging and the nurse must relate to the ordering physicians the practicality of moving an unstable patient. often the risk vs. benefit ratio does not favor transport. too often, in the quest to determine the cause of the disease, unreasonable expectations are cre-ated. certainly, diagnostic testing is necessary for making an appropriate diagnosis, but a nurse’s responsibility is to assure that the patient does not assume unreasonable risk in the process. For example, the patient with severe ardS will often desaturate during minimal exertion such as turning or suctioning; transporting such a patient safely may not be possible. ccns are responsible for discussing their observations and concerns with the ordering phy-sician. often, there are alternative bedside options to the planned test or procedure, or trans-port may be delayed until later in the hospital course.

Pain Management

unrelieved pain in the icu can significantly impact patient satisfaction, morbidity and mortal-ity, and length of stay. despite advances in assessment through Face, legs, activity, cry, consolability (Flacc) scales, pharmacologic advances, and overall education of healthcare

Inadequate pain management leads to increased morbidity and mortality as well as prolonged length of stay. Utilization of pain scales which consider objective and observational data as well as the patients perceived level of pain will guide appropriate pain relief measures.


providers, patients continue to have avoidable pain in icu settings.13 the primary cause is that pain is a subjective and variable individualized response that can be difficult to assess in the nonverbal, critically ill patient. however, it is also true that clinicians have been inappropri-ately concerned with the potent, addictive nature of opioids and have undermedicated moder-ate-to-severe pain. the Joint commission in healthcare has established guidelines for pain management with the goal of eliminating all preventable pain. ccns are required to assess for the presence of pain and evaluate treatment at frequent intervals. nurses are skilled in the ver-bal and nonverbal signals of distress in patients that may be unable to articulate pain. nurses utilize Flacc scales; assess increased guarding, heart and respiratory rates, diaphoresis, and facial grimacing in minimally responsive or intubated patients. nurses also attempt to decrease pain using alternative pain relief measures such as body positioning, thermal pads, massage, and relaxation techniques. when appropriate, pain management physicians are consulted.

End of Life/BereavementFacing end-of-life decisions is daunting and can be overwhelming for the patient and family. the ccn is integral to this process. the ccn, as well as other healthcare providers “play a critical role in shaping the experience at the end-of-life.”

“the results of this survey suggest that for patients and families, physical care is expectedly crucial, but is only one component of total care. whereas physicians tend to focus on physical aspects, patients and families tend to view the end of life with broader psychosocial and spiri-tual meaning, shaped by a lifetime of experiences. while physicians’ biomedical focus is a natural outgrowth of medical care that emphasizes the physical self, physicians should recog-nize patients’ other needs and facilitate means for them to be addressed. Physicians should also recognize that there is no one definition of a good death. Quality care at the end of life is highly individualized and should be achieved through a process of shared decision-making and clear communication that acknowledges the values and preferences of patients and their families.”14

as the patient approaches end of life, the ccn assesses for the presence of an advance directive and/or dnr orders. the ccn will communicate regularly with the patient family to answer questions and facilitate communication with other members of the healthcare team. the goal is for the decision-making process to be focused on the patient and the patient’s fam-ily. throughout the end-of-life process, the ccn works to ensure that the patient and family’s emotional, spiritual, and practical needs are acknowledged and, if possible, met. the ccn collaborates with the healthcare team to provide for symptom management and comfort care.

Ethicsthe american nurses association provides the source of ethical guidance for the nursing profession. the 9 provisions are:

1. the nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by consider-ations of social or economic status, personal attributes, or the nature of health problems.

2. the nurse’s primary commitment is to the patient, whether an individual, family, group, or community.

3. the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.

4. the nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care.

5. the nurse owes the same duties to self as to others, including the responsibility to pre-serve integrity and safety, to maintain competence, and to continue personal and profes-sional growth.

6. the nurse participates in establishing, maintaining, and improving healthcare environ-ments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective effort.

The end-of-life process should always be centered on directives the patient has specified after adequate information has been given about the options for care. The goals of the process should strive for dignity, comfort, and respect for physical, psychologi-cal, and spiritual needs.


7. the nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.

8. the nurse collaborates with other health professionals and the public in promoting com-munity, national, and international efforts to meet health needs.

9. the profession of nursing, as represented by associations and other members, is respon-sible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.

SUMMARy

the ccn is a highly visible and respected member of a multidisciplinary healthcare team. ccns, utilizing a specialized body of knowledge and skills, seek to create an environment supportive of healing for patients and their families. these nursing professionals practice in settings where patients require complex, high-intensity therapies and interventions, and con-tinuous (often invasive) monitoring.

in the complex world of modern healthcare, the ccn also often collaborates with hospital and health system administrators, to ensure that appropriate policies and procedures are in place and consistently followed by all members of the healthcare team.

in addition to the high-tech armamentarium of the modern icu, and the crucial manage-ment and administrative roles that many ccns assume, the ccn also provides comfort and succor directly to the patient; this has always been the providence of the nursing profes-sional. they are the individuals, who because of their close and ongoing presence at the bedside often are the first to notice new problems, or a change in the patient’s status.

Finally, although the ccn has many roles and responsibilities, they are the first and fore-most patient advocate. they respect and support the basic values, rights, and beliefs of the critically ill patient; in this role they serve not only the patient, but also the patient’s family.

The CCN ‘s role in the ICU is to manage the complex, rapidly changing, highly technical care required by the critically ill patient while principally advocating and protecting the patients’ rights and directives.

1. The CCN functions as a patient advocate in which of thefollowingways?A. uses a holistic approach to the critically ill patient’s problems

and concernsB. utilizes evidence-based knowledge and experience in reacting

to patient responsesC. Facilitates the protection, promotion, and optimization of the

critically ill patient’s health and abilitiesD. all of the above

2. Oneofthenurse’sfunctionsaspartofthecriticalcareteamisto:A. evaluate and communicate the patient’s response to therapiesB. recite vital signsC. diagnose complex metabolic disordersD. the nurse does not need to be included in patient rounds

3. TheCCNscontributiontodevelopingtheinterdisciplinaryplan-of-careforthepatientisbasedonallofthefollowingexcept:A. an understanding of the pathology of the disease processes

affecting the patientB. repetition of a consultant’s recommendation

C. review of patient’s history and analysis of the patient’s labora-tory and diagnostic testing data.

D. Systematic physical examination

4. Whichofthefollowingare2009NPSG?A. improve the accuracy of patient identificationB. improve the safety of using medicationsC. reduce the risk of healthcare-associated infectionsD. all of the above

5. Whichof the following is the“time-tested”nursing interven-tiontopreventskinbreakdownintheimmobilizedpatient:A. low air loss mattress therapyB. rotating bedC. repositioning patient every 2 hoursD. application of protective skin gels

REVIEW QUESTIONS


1. d. the aacn defines advocacy as respecting and supporting the basic values, rights, and beliefs of the critically ill patient. in order to advocate for the critically ill patient, the ccn must utilize a comprehensive approach to coordinate the care of the patient and family, relying on knowledge and experience.

2. a. as a member of the critical care team, and the caregiver who interacts with a patient throughout their stay, the ccn is a valuable source of information regarding the minute to minute status of the patient’s condition, and response to therapy. documentation of clinical data is but one part of the process, as the ccn assists in assessing the patient to further reach the goal of treatment.

3. b. the ccn caring for acutely and critically ill patients has a responsibility to assess and analyze the level of care needed by the patient. the process involves assessing the needs of the patient, making realistic goals to achieve them, planning the interventions, assessing the results, and revis-ing the plan as necessary.

4. d. the Joint commission’s nPSG are just one step in achieving a culture of safety that makes healthcare safer for a patient. each individual healthcare facility has to achieve a safe environment by assuring that each of these goals is met. Specific policies are devised to achieve this goal. the ccn is responsible for implementing safe practices in areas such as restraints, medication administration, infection control, and fall prevention.

5. c. while there are many ways to prevent and treat skin breakdown such as gels, and low air loss mattresses, the simple procedure of turning a patient from side to side every 2 hours is effective in preventing decubiti. the chal-lenge in the critical care environment is the patient’s hemo-dynamic status which must be assessed before turning a patient. Patients who are critically ill may not be candidates for every 2 hours turning and other methods must then be utilized to prevent patient breakdown.

ANSWERS

1. Murray t, Simko lM. acute and critical care clinical nurse spe-cialists: synergy for best practices. Crit Care Nurse. 2008;28:68.

2. hardin Sr, Kaplow r. Synergy for Clinical Excellence: The AACN Synergy Model for Patient Care. Sudbury, Mass: Jones & bartlett; 2005.

3. Manojlovich M, antonakos cl, ronis dl. intensive care units, communication between nurses and physicians, and patients’ out-comes. Am J Crit Care. 2009;18:21-30.

4. Kendall-Gallagher d, blegen Ma. competence and certification of registered nurses and safety of patients in intensive care units. Am J Crit Care. 2009;18:106-113.

5. larson e. the impact of physician-nurse interaction on patient care. Holist Nurs Pract. 1999;13(2):38-46.

6. Vazirani S, hays rd, Shapiro MF, et al. effect of a multidisci-plinary intervention on communication and collaboration among physicians and nurses. Am J Crit Care. 2005;14:71-77.

7. higgins Pa, daly bJ, lipson ar, et al. assessing nutritional sta-tus in chronically critically ill adult patients. Am J Crit Care. 2006;15:166-176.

8. akhtar Sr, weaver J, Pierson dJ, and rubenfeld Gd. Practice vari-ation in respiratory therapy documentation during mechanical venti-lation. Chest. 2003;124:2275-2282; doi:10.1378/chest.124.6.2275.

9. ricart M, lorente c, diaz e, Kollef Mh, rello J. nursing adherence with evidence-based guidelines for preventing venti-lator-associated pneumonia. Crit Care Med. 2003;31(11):2693-2696.

10. Krimsky wS, Mroz ib, Mcilwaine JK, et al. a model for increas-ing patient safety in the intensive care unit: increasing the imple-mentation rates of proven safety measures. Qual Saf Health Care. 2009;18:74-80; doi:10.1136/qshc.2007.024844.

11. Shojania KG, duncan bw, Mcdonald KM, wachter rM, eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. rockville Md: agency for healthcare research and Quality; 2001. evidence report/technology assessment no. 43; ahrQ 01-e0.

12. http://www.jointcommission.org/patientsafety/nationalpatient-safetygoals/; 2009 accessed 08.08.09.

13. Gélinas c, Fillion l, Puntillo Ka, et al. Validation of the critical-care pain observation tool in adult patients. Am J Crit Care. 2006;15:420-427.

14. Steinhauser Ke, christakis na, clipp ec, Mcneilly M, Mcintyre l, tulsky Ja. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA. 2000; 284: 2476-2482.

REFERENCES

http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/

http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/


american nurses association. Code of Ethics for Nurses with Imperative Statements. washington, dc: ana; 2001.

american association of critical care nurses. AACN Standards for Establishing and Sustaining Healthy Work Enviroment: A Journey to Excellence. aliso Viejo, ca: american association of critical care nurses; 2005.

hardin Sr, Kaplan r. Synergy for Clinical Excellence: The AACN Synergy Model for Patient Care. Sudbury, Mass: Jones & bartlett; 2005.

Vazirani S, hays rd, et al. effect of a multidisciplinary intervention on communication and collaboration between nurses and physi-cians, and nurses. Am J Crit Care. 2005;14:71-77.

american association of critical-care nurses, aacn certification corporation. Safeguarding the patient and the profession: the value of critical care nurse certification. Am J Crit Care. 2003;12:154-164.

Manojlovich M, antonakos c, ronis d. intensive care units, commu-nication between nurses and physicians and patients outcomes. Am J Crit Care. 2009;18:21-30.

Kendall-Gallagher d, blegan M. competence and certification of reg-istered nurses and safety of patients in intensive care units. Am J Crit Care. 2009;18:106-113.

day l. advocacy, agency, and collaboration. Am J Crit Care. 2006;15:428-430.

Joint commission on accredidation of healthcare organizations. Healthcare at a Crossroads: Strategies for Addressing the Evolving Nursing Crisis. oakbrook terrace, il: Joint commission on accreditation of healthcare organizations; 2002.

rauen ca, chulay M, bridges e, et al. Seven evidence-based practice habits: putting some sacred cows out to pasture. Crit Care Nurse. 2008;28:98-123.

american association of critical-care nurses. 2004 National Critical Care Survey: Findings Report. aliso Viejo, ca: american association of critical-care nurses; 2005.

ahrens t, yancey V, Kollef M. improving family communications at the \ of life: implications for length of stay in the intensive care unit and resource use. Am J Crit Care. 2003;12:317-324.

hoffman la, happ Mb, Scharfenberg c, et al. Perceptions of physi-cians, nurses, and respiratory therapists about the role of acute care nurse practitioners. Am J Crit Care. 2004;13:480-488.

rose l, nelson S, Johnston l, Presneill JJ. decisions made by critical care nurses during mechanical ventilation and weaning in an australian intensive care unit. Am J Crit Care. 2007;16:434-443.

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