Critical Care Nursing Theory
Scope of Critical Care Nursing
Scope of Critical Care Nursing
- Critical care nursing is subspecialties of medical surgical nursing. The
reason of being of “Nursing” in any setting is the provision of holistic
nursing care.
- The adjective “Critical” is characterized by actual or potential crises for the
recipients of nursing care –
- Critical – is defined as pertaining to a crisis, involving danger or risk.
- Critical care practice areas began to develop in the late 1960’s in response
to:a- Developments in medical science and technology
b- Related changes in community values and attitudes.
Definition:
- The American Nurses’ Association defined Nursing as:
- “The diagnosis and treatment of human response to actual or potential
health problem.
- In 1984, the American Association of Critical Care Nurses’ (AACN)
defined Critical Care Nursing:
- “Critical care Nursing is that specialty within nursing that deals
specifically with human responses to life- threatening problems”
- Analysis of these definitions reveals several important concepts.
- The basis of the definition rests with the words human responses.
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
1
Critical Care Nursing Theory
Scope of Critical Care Nursing
- Critical care nurses deal with
a- The total human being
b- His or her response to actual and potential health problems.
- This suggests that the critical care nurse is involved with prevention as well
as cure.
- Additionally, human response can take the form of :a- a physiological phenomenon.
b - a psychological phenomenon.
- Ex: a critical care nurse can teach patient methods to lower blood
cholesterol levels, which may prevent a life-threatening problem.
- Scope of critical care nursing practice
- A scope of practice statement provides a framework within which an
individual can provide a particular service.
- The AACN’s Scope of Critical Care Nursing Practice statement provides a
definition and description of the practice of critical care nursing.
- The scope of critical care nursing practice is described as a dynamic
process with three components:
1- The critically ill patients and their significant social relationship.
2- The critical care nurse.
3- The environment where critical care nursing is practiced.
- Central to the scope are nurse-patient interactions.
- The goal of critical care nursing is :- To ensure effective interaction of these three requisite elements to affect
competent nursing practice and optimal patient outcomes
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
2
Critical Care Nursing Theory
Scope of Critical Care Nursing
1- Critically ill patient:- Critical care patients share one or more of a number of defining
characteristics:
a- A significant health breakdown problem which is life threatening.
b- Biophysiological health breakdown problems of such acuity and / or
chronicity that they may lead to extraordinary dependence on health care
providers, and possibly technology for health maintenance or life support.
- The American Association of Critical Care Nurses (AACN) described the
critically ill patient as follows:
- “The critically ill patient is characterized by the presence of actual and / or
potential (being at risk for developing) life- threatening health problems.”
- The needs of these patients require continuous assessment (observation)
and intervention to restore health and prevent complications.
- As man is biopsychosocial being the concept of the critically ill patient
includes the family and / or significant others.
- The needs of the critically ill are considerable. These needs may be
categorized as physical or non-physical
1- Physical needs:- are equated with basic physiological or biological needs for ex, for air,
nutrition, and elimination.
2- Non-physical needs:- may include social, spiritual, and psychological needs. Social integrity
(self-esteem), information, and communications are also included.
- The comfort and support provided by social relationships can enhance
effective coping. Therefore the concept of the critically ill patient includes
the interaction and impact of the patients’ family and / or significant
others.
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
3
Critical Care Nursing Theory
Scope of Critical Care Nursing
- The nature of critical care is such that physical needs are considered a
priority and are almost always met. However, the critical care environment
can actually obstruct the fulfillment of non-physical needs contributing to
the stressful nature of critical illness.
- “Identity and social integrity can be very difficult to maintain when a
person is in a strange situation without their usual clothes, hair style, and
when work and conversation or discussion goes on around and over them
without including them as a person.”
- The obstructed need for identity and social integrity may lead to the
development of a range of negative emotional or psychological status for
ex. Loss of self-esteem & confidence.
- Obstruction of these non-physical needs increases the stress experienced by
fragile, critically ill patients.
- Obviously the needs of the patient’s family and significant others must also
be considered and met as far as possible.
- If all the needs of the critically ill are to be met, both physical and nonphysical needs should be considered in planning holistic nursing care.
2-Critical Care Nurse:- The critical care nurse is a licensed professional, who is responsible for
ensuring that all critically ill patients receive optimal care.
- Nurses practicing in critical care areas have to make clinical judgments to
prevent clinical deterioration in their patients.
- Anticipation and early prevention of patient problems are central
requirements of critical care nursing practice, and these requirements
mandate highly developed skills of :1- Assessment.
2- Clinical judgment.
- The very essence of critical care nursing is anticipation and early
intervention in problems besetting the critically ill.
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
4
Critical Care Nursing Theory
Scope of Critical Care Nursing
- Prediction of patient problems must be based on:1- A sound understanding of anatomy and physiology
2- Astute assessment skills.
- From the perspective of the Australian Society of Critical Care Nurses
(ASCCN),
- Critical care nursing practice is based on the following:
1- Individual professional accountability.
2- A thorough knowledge of biophysical and social sciences.
The application of this knowledge requires :a- Skills in clinical assessment
b- Appropriate nursing and technological intervention.
3- Recognition and appreciation of the holistic basis for nursing practice.
This includes recognizing:a- The individual’s uniqueness, wholeness,
b- Significant social and environmental relationships.
- Acknowledgment of the interaction and collaborative roles of all members
of the health team
(Coordination of the care delivered by various health care providers).
- Since the clinical requirements of the critically ill are such that the team
caring for any single patient may consist of :- Various medical officers,
- A nurse,
- A pharmacist,
- A dietician,
- A physiotherapist,
- A radiographer,
- A social worker.
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
5
Critical Care Nursing Theory
Scope of Critical Care Nursing
- The knowledge base, which underlines critical care nursing practice, is
highly specialized and it is constantly subject to revision and development
as a consequence of:a- Research activity
b-Technological innovation.
- Preparations for practice in critical care must emphasize the importance of
a holistic approach to nursing care. Such an approach is most likely to meet
the needs of the critically ill person.
3- Critical Care Environment:- Critical care nursing takes place in a specialized environments that are
designed and organized to give the best possible patient care in an area
where significant change in patient morbidity can occur rapidly, and often
does.
- The safety of both patients and staff in the CCU is a primary consideration
in designing the milieu in which critical care nursing is carried out.
- The critical care environment is viewed from three prospective:
1-The conditions and circumstances surrounding the direct interaction
between the critical care nurse and the critically ill patient.
- The environment must contain resources that constantly support this
interaction. E.g. emergency equipment and supplies.
2-The setting within which critically ill patient receive care. Here critical
care management and administrative structure ensure effective care
delivery through provision of:- Adequate human and financial resources,
- Quality control systems, and maintenance of standard of nursing care.
-Factors that influence the provision of care to the critically ill:-
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
6
Critical Care Nursing Theory
Scope of Critical Care Nursing
- Legal,
- Regulatory,
- Social,
- Economic,
- Political factors.
- The presence and application of technology as a common component of
patient management is another key feature of critical care nursing practice.
- Critical care nurses are required to be competent in the use of a wide range
of technological devices, many of which are necessary for life support.
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
7
Critical Care Nursing Theory
Scope of Critical Care Nursing
Stress
- Is defined as non-specific response of the body to any demands made upon
it.
Stressor:
- It is stress inducing demands (factor that disturbs the body’s equilibrium).
- The stressor could be physical or emotional, pleasant or unpleasant, leading
to a series of physiological responses, which then require the individual to
adapt. (G. A. S).
- General Adaptation Syndrome (G. A. S.) (Selye’s theory) Comprises 3
stages:
1- Stage of alarm reaction:- Initial reaction, the defenses of the whole body mobilized and prepared to
action.
2- Stage of resistance:- Body’s adaptation takes place\ body attempts to cope.
3- Stage of exhaustion:- If exposure to the same stressor is prolonged, the adaptation energy is lost.
Coping:
- “an attempt to gain mastery over conditions of threat”
or
- “efforts to manage environmental and internal demands and conflicts
which tax or exceed a person’s resources”.
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
8
Critical Care Nursing Theory
Scope of Critical Care Nursing
Physiologic adaptation:
- There are a large number of physiologic responses of the human body to
stressors.
- The common adaptive mechanisms
1- The endocrine adaptive response.
2- The neurologic adaptive response.
3- The inflammatory adaptive response.
4- The immunologic adaptive response
Stress response indicators
- (Lab investigations, diagnostic procedures and the other indices of stress)
include:
- Blood and urine analysis to demonstrate change in hormonal levels and
hormonal breakdown products.
- Blood levels of catecholamines, corticoids, and adenocorticotrophic
(ACTH).
- Drop in eosinophils.
- Blood creatinine / creatinine ratio, and elevation of cholesterol and free
fatty acids.
- Immunoglobulin assays.
- Electro-encephalogram may be used to measure brain activity.
- Galvanic skin resistance which measures the electrical conductivity of the
skin. (To measure of sweat excretion, which rises in stress)
- Blood pressure and heart rate and other indices of stress that may be
observed by others or by the person himself. (both physical and behavioral
changes)
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
9
Critical Care Nursing Theory
Scope of Critical Care Nursing
- (Increase respiratory rate, excessive sweating and thirst, sleep disturbance,
and anxiety).
Physiological stress responses of the critically ill patient:
- Blood volume is enlarged,
- Respiration become faster and deeper,
- Cardiac output becomes larger,
- Protein, fat, glycogen are converted to glucose for energy.
- So the alarm stage should be limited, if it sustained it leads to death.
- The body moves into stage of resistance, in which it attempts
to cope with the stressor.
- Secretion of adrenal cortical and medullary hormones returns to normal.
- If the body not returned to the normal state exhaustion will occur.
- Potassium depletion may be a major factor in exhaustion.
The symptoms of this stage include:1- Irregular pulse,
2- Hypotension,
3- Weakness,
4- ECG chances.
- The catecholamine release will cause  hypermetabolism and 
-  Blood pressure and pulse rate and RR and alertness 
- This can pose special problems for the persons who has pulmonary and
cardiovascular problems because he will be unable to meet the  O2 needs,
or to handle the circulatory demands.
- Also the selective vasoconstriction of the vessels that serve vital body
parts. E.g. Kidney cause 
-  releasing of rennin to  its supply and this will lead to 
- Peripheral vasoconstriction.
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
10
Critical Care Nursing Theory
Scope of Critical Care Nursing
- If stress reaction is very severe or prolonged  permanent damage to
Kidney or lactic acidosis can result.
- Gluconeogenesis, from Protein and fat will cause  Blood sugar, this is
very dangerous for diabetics.
- Also catecholamine stimulate the release of clotting factors, although these
effects are basically protective, they can cause  blood viscosity and
predispose to stasis.
- Fluids must be given with great care to the severely stressed person.
(because of the increased intravascular volume) that cause  (Fluid
overload, and  urinary output).
Psychological stress responses of the critically ill patient:
A- Delirium.
B- Catastrophic reaction.
C- Euphoric response.
A- Delirium.
- Is abnormal mental condition
(clinical picture includes:
1- Reduced ability to focus, shift, and maintain attention
2- Disorganization of thinking or speech,
3- Illusions and hallucinations,
4- Disturbed sleep wake cycles,
5- Altered psychomotor activity
6- Disorientation
7- Memory impairment).
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
11
Critical Care Nursing Theory
Scope of Critical Care Nursing
B- Catastrophic reaction.
- It is a passive response to severe anxiety.
1- Patient exhibits flat affect,
2- Hyperalterness,
3- Immobility,
4- Lack of spontaneity, with monosyllabic response to questioning
5- Passive cooperation with treatment.
C- Euphoric response.
1- The patient try to deny the seriousness of their illness
2- Patients are noted to be extremely active and his activities are contrary to
the therapeutic limitations).
Sources of stress in the critical care unit:
- In addition to the trauma, disease, surgery,the following factors are
considered to be stressful factors for the critically ill patient.
- Pain.
- Fear of death.
- Presence of tubes.
- Monitors.
- Ventilators.
- Lack of sleep.
- Immobility.
- Isolation.
- Admission to the I. C. U.
- Too much light (sensory overload).
- Extreme of temp.
- Noise.
- Separation from family and friends.
- Presence of very ill patient in the CCU.
- Nurses and doctors.
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
12
Critical Care Nursing Theory
Scope of Critical Care Nursing
Coping patterns:
A- Problem-focused coping patterns,
B- Emotion-focused coping patterns,
A- Problem-focused coping patterns,
- Which directed to manage the problem by dealing with demands.
1- Try to maintain some control over the situation.
2- Try to change the situation.
3- Talk the problem over with some one who has been in the same type of
situation.
4- Draw on the past experience to help handle the situation.
B- Emotion-focused coping patterns,
- Which directed at lessening the emotional distress
1- Pray.
2- Work off tension with physical activity.
3- Go to sleep.
4- Seek comfort or help from family or friends.
1- Explanation and clarification:
- Explain his illness to him.
- Correct any misconceptions about disease and its consequences
- Provide orientation to the place, personnel, time,
- Explain every procedure before its performance.
2- Fostering optimism:
- Allow the patient to continue to use deny their emotional feelings as a
means of coping with stress at least to a certain point.
- Treat the patient with the conviction that recovery is fully anticipated.
- Emphasize survival and recovery rather than risks and dangers.
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
13
Critical Care Nursing Theory
Scope of Critical Care Nursing
3- Reassurance:
- Provide reassurance by talking to the patient in the most encouraging
fashion possible.
- Act in a calm, positive, efficient manner.
- Inform the patient with any evidence of progress toward recovery.
- Avoid broad promises such as, “Don’t worry, everything will be all
right”
4- Listening:
- Listen attentively and demonstrate genuine to assist the patient to ventilate
his feelings which decrease fears ,to recognize the sources of the problem,
and be able to deal with them.
5- Manipulating environment:
- Maintain a peaceful atmosphere which helps the patient to relax
and regain his emotional equilibrium.
- Provide rest periods for the patient during whom visitors or the staff does
not disturb time.
- Allow radio, television, and newspapers to prevent a feeling of isolation.
- Allow the patient to sit in a bedside chair (if the condition permits) is
usually a source of encouragement.
6- Anticipating emotional reactions:
- Explain that emotions experienced by patient are normal, common reaction
and anticipated response during this period.
7- Drug therapy:
- Administer tranquilizers during the first few days of hospitalization.
- Adjust the dosage so that the patient is not constantly drowsy or sleepy.
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
14
Critical Care Nursing Theory
Scope of Critical Care Nursing
Delirium
Definition:- It is a reversible global impairment of cognitive process, usually of sudden
onset, .
Clinical manifestation:1- Disorientation,
2- Impaired short-term memory,
3- Altered sensory perceptions (hallucinations),
4- Abnormal thought processes,
5- Inappropriate behavior.
Incidence of delirium:- Delirium is probably more prevalent than generally recognized and is
difficult to diagnose in the critically ill patient.
- The incidence ranges from 30% to 70% in medical-surgical critical care
patients.
Causes of delirium:1- Metabolic
2- Intracranial
3- Endocrine
4- Organ failure
5- Respiratory
6- Alcohol withdrawal
7- Heavy metal poisoning.
8- Drug related
9- Additional causes
1- Metabolic
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
15
Critical Care Nursing Theory
Scope of Critical Care Nursing
- Acid-base disturbance,
- Electrolyte imbalance,
- Hypoglycemia.
2- Intracranial
- Epidural hematoma,
- Subdural hematoma,
- Intracranial hemorrhage,
- Meningitis,
- Encephalitis,
- Cerebral abscess,
- Tumor.
3- Endocrine
- Hyperthyroidism
- Hypothyroidism,
- Addison's disease,
- Hyperparathyroidism,
- Cushing's syndrome
4- Organ failure
- Liver encephalopathy,
- Uremic encephalopathy,
- Septic shock.
5- Respiratory
- Hypoxemia
- Hypercarbia.
6- Alcohol withdrawal,
7- Heavy metal poisoning.
8- Drug
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
16
Critical Care Nursing Theory
Scope of Critical Care Nursing
- Digitalis,
- Antibiotics,
- Steroids,
- Beta adrenergic blockers,
- Respiratory stimulant.
9- Additional causes
- Sleep deprivation,
- Sensory deprivation
- Sensory overload,
- Immobilization,
- Age over 60 years old.
The major categories to assess delirium :1- Acute onset of mental status changes or fluctuating course.
2- In-attention.
3- Disorganized thinking.
4- Altered level of consciousness, which include any level of consciousness
other than "alert" (vigilant, lethargic, stupor, coma).
Forms of delirium:A- Hyperactive delirium
B- Hypoactive delirium
C- Mixed delirium
A- Hyperactive delirium
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
17
Critical Care Nursing Theory
Scope of Critical Care Nursing
The patient may
- Become violent;
- Be extremely restless .
- Remove invasive devices (intravenous lines, catheters, machines, and
dressings
- Try to get out of bed;
- Pick at things in the air;
- Call out of persons who are not there.
Sympathetic nervous system responses are evident :- Tachycardia,
- Dilatation of pupils,
- Diaphoresis,
- Facial flushing
B- Hypoactive delirium
The patient may:- Complain of extreme fatigue,
- Be slow to respond,
- Have hypersomnolence that can progress to
loss of consciousness.
At times the patient
- is absorbed in a dreamlike state,
mumble to them,
- Experience vivid hallucinations,
- Make inappropriate gestures.
C- Mixed delirium ( sundown's syndrome )
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
18
Critical Care Nursing Theory
Scope of Critical Care Nursing
- It is a mixture of agitation and hypoactive behaviors that may vary
throughout the day.
- Symptoms and hallucinations seem to worsen during night, with more
lucid intervals during the day.
Management:
A- Prevention
- Preventive measures through correcting the underlying cause of delirium.
B- Non- pharmacologic strategies
1- Backmassage,
2- Music therapy,
3- Noise reduction in the environment,
4- Decreasing lights at night to promote sleep,
5- Clustering nursing care to provide some uninterrupted rest periods,
6- Speaking in calm, quit, and gentle voice.
C- Pharmacologic strategies:1- Sedatives for short-term use are prescribed for patients with hyperactive
delirium.
- Risperidone (Risperdal) is now preferred over Haloperidol in treatment
of delirium because it produces :- Less sedation
- Fewer anticholinergic effects
(e.g., dry mouth, constipation, urinary retention).
2- Narcotics can be administered when delirium is considered to be
secondary to pain,
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
19
Critical Care Nursing Theory
Scope of Critical Care Nursing
- However, the following can exacerbate the delirium.
a- The paradoxical effects of depressed respiration
b- The paradoxical effects of cardiac output
3- Neuromuscular blocking agents sometimes used for severely agitated
patients who are on mechanical ventilation
a- To decrease in oxygen consumption,
b- To promote synchrony with the ventilator,
c- To increase tissue oxygenation.
Dr. Abdul-Monim Batiha
Assistant Professor Of Critical Care Nursing
20