Critical Care Nursing

Monitoring and Treatment for Advanced Nursing Practice

Kathy J. Booker

• Publisher: Wiley-Blackwell
• Year: 2014
• Print ISBN: 9780470958568
• eBook ISBN: 9781118939161
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Providing an easy-to-use reference, Critical Care Nursing outlines best practice for the assessment, monitoring and treatment of critically ill adult patients. Each chapter includes research and evidence-based strategies for treating commonly-seen conditions.

Initial chapters introduce ICU set-up and operation, the rapid response team, vitals measurement and shock management strategies.  Subsequent chapters, structured by organ system, focus on care relating to specific organ function and dysfunction, including the respiratory, cardiovascular, neurologic, renal and gastrointestinal systems.  Key information on monitoring for overdoses, special considerations in traumatic injury and end-of-life concerns is also included.

Critical Care Nursing is a comprehensive and informative resource for experienced staff nurses and advanced practice nurses working with critically ill patients on ICUs, PCUs, transitional care units and within emergency care departments.

Chapter 1
Philosophy and treatment in US critical care units

Kathy J. Booker

School of Nursing, Millikin University, Decatur, IL., USA

In this chapter, the evolution of critical care practice and advanced nursing roles are explored. An examination of factors that contribute to safe monitoring and treatment in critical care units includes certification processes and national support for critical care nursing practice, perspectives on patient and family-focused care, and the evolution of rapid response team (RRT) roles in hospital settings.

US critical care units

Critical care units were formally developed in the United States in the years following World War II. Common elements driving the origin of critical care units remain important even today, including close patient monitoring, application of sophisticated equipment, and surveillance-based interventions to prevent clinical deterioration or health complications. Today’s critical care units are often diverse, specialized areas of care for patients at high risk or those undergoing critical health events requiring nursing attention. The critical care team is generally quite complex, including medical management increasingly supported by intensivists, residents, acute care nurse practitioners (ACNPs), clinical nurse specialists (CNSs), and other nursing personnel. Additional vital practitioners include respiratory therapists, dietitians, pharmacists, social workers, and physical/occupational therapists. Over the last 50 years, sophisticated treatment modalities, technology, and care philosophies have evolved to promote a strong patient-centered care ethic coupled with technological complexity.

The cost of delivering care to the critically ill continues to rise. The Society of Critical Care Medicine (2013a) identified increasing costs of critical care medicine in the United States, with current projections of $81.7 billion (13.4% of hospital costs) in the care delivery of over 5 million patients annually in the nation’s critical care units.

Organization of critical care delivery

Haupt et al. (2003) published guidelines for delivering critical care based on a multidisciplinary review of the literature and writing panelists with representation from important critical care providers including physicians, nurses, pharmacists, respiratory therapists, and other key critical care team representatives. A three-level system of intensive care unit (ICU) care was promoted in these guidelines, acknowledging various ICU care systems based on the availability of key personnel, educational preparation, certification, and fundamental skill requirements. These general guidelines for hospitals in establishing and maintaining critical care services assigned levels of care as follows:

1. Level I care: units that provide medical directorships with continual availability of board-certified intensivist care and appropriate minimal preparation recommendations for all key and support personnel.
2. Level II care: comprehensive care for critically ill but unavailability of selected specialty care, requiring that hospitals with units at this level have transfer agreements in place.
3. Level III care: units that have the ability to provide initial stabilization and/or care of relatively stable, routine patient conditions. Level III units must clearly assess limitations of care provision with established transfer protocols (Haupt et al., 2003, p. 2677).

Emphasis on intensivist medical management, diagnostic testing availability, and specialty interventional availability guides hospitals to provide optimal care to the critically ill. This has also been supported by the Society of Critical Care Medicine (SCCM, 2013a). Haupt et al. (2003) also made recommendations for graduate education and/or certification by critical care nursing managers within the leadership structure. Transfer protocols for higher levels of care were recommended if selected life-saving services were unavailable, suggesting that protocols be incorporated into patient management systems in all hospitals without the full range of service based upon these guidelines. Despite the fact that these guidelines were advanced over 10 years ago, critical care practice remains diverse across the nation due in part to the availability of key personnel, state emergency system organization, system restrictions due to population and area coverage, and cost constraints. Emergency management and trauma support guidelines have been advanced by the American College of Surgeons (ACS) though the Advanced Trauma Life Support courses and guidelines for the transfer of patients in rural settings are also published on the ACS web site (Peterson and the Ad Hoc Committee on Rural Trauma, ACS Committee on Trauma, 2002).

Monitoring and surveillance in critical care

In the care of critically ill patients, the use of monitoring technology to support care is central to evidence-based practice. Research on the frequency and types of monitoring that affect the best patient outcomes is growing. Selected technologies, such as the use of pulmonary artery catheters in the critically ill, have been studied extensively. But the rapid growth of new technologies for monitoring at the bedside are often labor-intensive, requiring considerable nursing time to set up and manage to ensure good outcomes. In addition, ethical, humane application of technology must be continually considered so that the effect of intrusive or invasive technology is continually monitored in individualized care (Funk, 2011). Effective monitoring requires familiarity with the patient’s condition and preferences, the equipment, the processes inherent in obtaining the data, and the interpretation of monitored data, all affected by potential error in acquisition and management. Monitoring allows for the calculation of critically ill patients’ physiological reserve and effectiveness of interventions but also carries the caveat that practitioners must be familiar with the pitfalls associated with data interpretation commonly found in all areas of acute and critical care practice (Andrews and Nolan, 2006).

Young and Griffiths (2006) reviewed clinical trials monitoring acutely ill patients and observed that “to display data which cannot influence the patient’s outcome might increase our knowledge of disease processes but does not directly benefit the monitored patient. Nor is it harmless, more information brings with it more ways to misunderstand and mistreat” (p. 39). More monitoring may not be the answer to improving the treatment of critically ill persons but individualized monitoring of the right parameters to guide therapy and improve patient outcomes is the goal of the critical care team. Revolutionary changes in patient outcomes have been obtained with the development of selected technology, including pulse oximetry, bispectral index for depth of anesthesia, and noninvasive measurement of cardiac output and stroke volume (Young and Griffiths, 2006). Despite the expansiveness of monitoring, many have noted the paucity of evidence of its effectiveness. Particularly in the arena of hemodynamic monitoring, studies have been equivocal regarding the effectiveness of monitoring data to influence patient outcomes (see Chapter 5).

Surveillance

Kelly (2009) studied nursing surveillance and distinguished monitoring from surveillance by noting that surveillance informs decision making and involves action steps that stem from more passive monitoring. Kelly (2009) defined surveillance as “a process to identify threats to patients’ health and safety through purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making in the acute care setting” (p. 28). Surveillance is a core role of critical care; while not unique to nursing, surveillance is applied continuously in critical care units worldwide. Henneman, Gawlinski, and Giuliano (2012) identified surveillance as a nursing intervention critical to patient safety. In a review of practices recently studied in acute and critical care nursing, Henneman, Gawlinski, and Giuliano (2012) examined the use of checklists, interdisciplinary rounds, and other clinical decisional support and monitoring systems important to surveillance and prevention of errors.

The need for monitoring systems that produce reliable and accurate data has never been more urgent. Monitoring systems should be designed to foster action and supportive care to improve patient and family experience and physiological outcomes for patients. Practices that do not improve patient outcomes should be eliminated. In addition, clinicians need to help patients and family members understand monitoring systems. Continua...

Table of contents

• Cover
• Title page
• Copyright page
• Contributors
• Critical Care Nursing: Monitoring and Treatment for Advanced Nursing Practice
• Chapter 1: Philosophy and treatment in US critical care units
• Chapter 2: Vital measurements and shock syndromes in critically ill adults
• Chapter 3: Monitoring for respiratory dysfunction
• Chapter 4: Electrocardiographic monitoring for cardiovascular dysfunction
• Chapter 5: Hemodynamic monitoring in critical care
• Chapter 6: Monitoring for neurologic dysfunction
• Chapter 7: Monitoring for renal dysfunction
• Chapter 8: Monitoring for blood glucose dysfunction in the intensive care unit
• Chapter 9: Monitoring for hepaticand GI dysfunction
• Chapter 10: Traumatic injuries: Special considerations
• Chapter 11: Oncologic emergencies in critical care
• Chapter 12: End-of-life concerns
• Chapter 13: Monitoring for overdoses
• Index
• End User License Agreement