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Critical Care Nursing

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I have several goals regarding my future nursing career; however, my long term nursing goal is to work in critical care. My exposure to this area of nursing occurred when my mother was in the intensive care unit following exploratory surgery due to severe abdominal pain which revealed necrosis of a large portion of her large intestine. Following this, she spent many weeks in the intensive care unit with a diagnosis of septic shock. During her time in the ICU, she was mechanically ventilated for several weeks. In addition, she had evidence of kidney injury and subsequent hyperkalemia that resulted in cardiac irregularities. Her experience as a patient and my experience as the family point person in communicating with the healthcare team and observing the nursing staff played an important role that led to my decision to focus my future nursing career on critical care nursing. I was inspired by the overall knowledge, commitment, and diligence of the night shift nurse who cared for my mother consistently. He was very compassionate with us, extremely knowledgeable in responding to all of our questions about the pathophysiology of her condition, and explaining the rationale of the treatment approach made a positive difference in her outcome. “Critical care nursing is that specialty within nursing that deals specifically with human responses to life-threatening problems. A critical care nurse is a licensed professional nurse who is responsible for ensuring that acutely and critically ill patients and their families receive optimal care.” (aacn.org) Requirements for a critical care nurse involve both certification and skills.
Certification: The minimal requirement to be a critical care nurse is an RN degree. A BSN is preferred over an ASN degree, but not typically required. Certification is not mandatory for this Critical Care Nursing 3 practice; however, many nurses choose to become certified. From an employer standpoint, it is preferred (although not typically required) to have the CCRN certification because through this certification, you can gain a higher level of knowledge and rigorous training. In order to apply for the CCRN programs through AACN (American Association of Critical Care Nurses), a nurse must have at least two years of critical care experience. Getting that initial opportunity to work in the ICU may be difficult as a new graduate, as most employers prefer at least one year of nursing experience. Once certified, the certification is valid for three years and in order to renew this certification, RNs must meet the requirement of continuing education and also be currently practicing in critical care.
Skills: Adequate skills are essential in being a successful critical care nurse. Good interpersonal skills, empathy, critical thinking and decision making are important in order to adequately perform the role of critical care nurse. Because of the complexity of issues as well as psychosocial aspects to caring for the patient as well as the family, critical care nurses need able to effectively assess and evaluate critically ill patients including complications of their conditions. Critical care nurses care not only for the patient, but also the family, which can be a heavy load due to the psychosocial aspects that this type of stress can cause a family. Teaching, specifically the family, is also a major role for the critical care nurse. For this reason, good interpersonal communication skills are beneficial in successfully meeting the needs of the patient and family. In addition, good stress management is important for the nurse to prevent overload or burnout.
Critical Care Nursing 4
Advantages of working in critical care:
If you are a focus-oriented person, it is helpful that you are working with fewer patients in the ICU. This is not to say you are not busy, but you can prioritize your assessments and interventions for two people rather than six. Nurses who find it challenging to keep track of all of the specifics of six patients might prefer working in critical care where all of their critical thinking is centered on two patients at a time. If you have a passion for complex pathophysiology conditions, being a critical care nurse would be an advantage to you, as you have the opportunity to experience various diagnoses and treatment plans as well as taking into consideration the patient’s current comorbidities that may potentially complicate the patient’s condition and/or treatment plan. This allows the nurse to exercise good critical thinking. Disadvantages of working in critical care:
Physical demands: Critical care nurses are usually required to work long hours (12 hour shifts) including nights, weekends, holidays. It is a fast paced job with requirements for prolonged standing, lifting , bending and stretching. This can take a toll on your emotional and physical condition. A recent status report (published in American Association of Critical Care Nurses 2014 issue) indicates job satisfaction among critical care nurses has declined since 2008. Specific issues in decline contributing centered around poor leadership, poor staffing, less respect from administration and management. These advantages can lead to poor patient outcomes, which will add more stress to this job and lead to further detrimental job dissatisfaction. Emotional demands: Managing a critically ill patient is stressful. Then you add the stress of the family. Their questions alone can add more stress on the nurse, especially if you are not sure what to tell them. Critical care nursing is hard on the heart some days. It’s not for everyone. Critical Care Nursing 5
Family Presence: Managing continued presence of family members in the ICU can make it difficult. Some families are insistent on staying in the room even during non-visiting hours. They are anxious, fearful and oftentimes difficult to manage. A serious issue that healthcare workers in the ICU deal with routinely is sepsis. Sepsis is the leading cause of death in hospitalized patients. It carries a high mortality and affects all ages. Sepsis occurs when our body’s inflammatory response goes into overdrive when the body is faced with an infection. When an infection occurs, the immune system responds by activating inflammatory mediators resulting in vasodilation, increased capillary permeability and edema. These mediators are released in mass numbers and out of control and the response becomes too much for the body. The mass inflammatory effect (SIRS) on the endothelial of the blood vessels triggers a clotting reaction in order to repair the damage, resulting in multiple micro-clots throughout the body, which can occlude blood to the tissues/organs thus causing further damage due to decreased perfusion. SIRS is diagnosed if a patient has at least two of the four criteria involving abnormalities in heart rate, respiratory rate, temperature and WBC count. The criteria for sepsis includes a systemic inflammatory response + a documented infection (bacterial, viral, fungal). If a patient reaches this point of sepsis, vasodilation, anaerobic cellular metabolism, and hypotension resulting in poor perfusion to organs and tissues will result. Severe sepsis results when you have SIRS + documented infection + organ dysfunction. Septic shock criteria includes hypotension that is not improved by adequate fluid resuscitation. The nurse monitors all patients who are at risk for sepsis. Through knowledge of the stages of septic shock in addition to various laboratory studies, they can also determine whether a Critical Care Nursing 6 patient is improving or progressing. The initial phase of shock is not clearly evident in the patient’s symptoms. They may experience anxiety due to the decreased perfusion to the brain resulting from the decreased cardiac output and decreasing blood pressure. Warm skin will be manifested in the patient due to the initial massive vasodilation occurring in the body. The body’s compensatory (vasoconstriction) response will kick in and you will begin to see symptoms in the patient. In this stage, the blood pressure is adequate to perfuse the brain and heart but not adequate to perfuse the nonvital organs. Increased respiratory rate is an obvious sign. The heart rate will increase in order to maintain blood pressure to the vital organs (heart and brain). Blood flow to the nonvital organs will be shunted away manifesting cool/pale skin, decreased urine output, hypoactive bowel sounds, high blood sugars and water/sodium retention. In order to improve the outcome of this patient’s condition, recognition and treatment at this stage or sooner is important. Once the compensatory mechanisms fail, the condition goes into the progressive stage where decreased mental status and a crash in the blood pressure are evident. Here, the blood pressure can no longer adequately perfuse the heart and brain. The organs will begin to show signs of dysfunction including crackles in the lungs and increased work of breathing due to respiratory failure/ARDS development, cool and clammy skin with profound edema and possibly signs of bleeding on the skin due to DIC development. In this stage, the labwork will show increased lactic acid, ammonia and liver enzymes (liver), increased BUN/creatinine (kidney), increased bleeding times, and by this stage blood sugars may be low due to depletion of glycogen and protein stores. If the patient progresses into the next stage, mortality is very high. The patient will demonstrate profound hypotension and hypoxemia. The
Critical Care Nursing 7 organs are failing at this point and the nurse is monitoring for areflexia, anuria, cardiac arrhythmias, no bowel sounds, cyanosis and mottling of the skin and progression of DIC. Treatment protocol of sepsis and nursing responsibilities are based on the evidence-based guidelines within the Surviving Sepsis Campaign (formed in 2002) and published updates in
2008. The guideline recommendations include 3-hour and 6-hour care bundles and includes implications for nursing care:
|Within 3 hours of severe sepsis, nurses will: |Within 6 hours of initial s/s of septic shock, nurses will: |
|-Measure lactate level |-Apply vasopressors (if hypotension does not respond to adequate fluid|
|-Obtain blood cultures |resuscitation to maintain a MAP >65 mmHg. |
|-Administer antibiotics | |
|-Administer crystalloids for hypotension or for lactate >4 mmol/L. |If the patient continues to be hypotensive despite adequate fluid or |
| |if initial lactate >4 mmol/L, nurses will: |
| |-measure central venous pressure |
| |-measure central venous O2 saturation. |

Treatment is focused on correcting hypoxia and hypoperfusion, as these are the primary sources behind the multisystem effects you see with sepsis. Interventions include 100% O2 and administering adequate fluid resuscitation with the use of crystalloids to improve oxygenation and perfusion. The expected outcomes of adequate initial fluid resuscitation include: CVP 8-12 mmHg, MAP >65 mmHg, urine output >0.5 mL/kg per hour and central venous oxygen saturation 70%. If these parameters are not met, vasopressors will be given. Blood cultures from two different sites are obtained before administration of antibiotics. If the culture cannot be obtained within 45 minutes, antibiotics must be administered. Lactate levels are used as a marker in determine tissue perfusion, as cells release lactate when they are lacking oxygen for metabolism.
Critical Care Nursing 8
Complete Sepsis Protocol. Hospitals have a policy for identifying sepsis and severe sepsis and another policy for managing sepsis, severe sepsis and septic shock. identifying sepsis:
Does the patient have 2 or more of the criteria of SIRS?
|Heart rate >90 |
|Temperature >100.4 or 20 or CO2 level 10% bands (immature WBCs) |

If YES( Does the patient have evidence of a new infection?
If YES→THE PATIENT HAS SEPSIS
Does the patient have one or more of the following new organ dysfunctions?
|BP (systolic

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