Learning Objectives
By the end of this section, you will be able to:
- Identify admission criteria for intensive care
- Explain the required nursing skills and technological and pharmacological therapies that are unique to the critical care setting
- Describe the ethical and legal considerations of providing nursing care to critically ill patients
Critical care nurses are responsible for assessing, monitoring, and caring for high-acuity patients with multisystem disorders. These patients have complex medical conditions that require extensive medical intervention and nursing care. To provide optimal care to patients in the ICU, critical care nurses must skillfully display attention to detail, technical competence, and excellent communication skills. Caring for patients in these settings can be especially challenging because of the severity of their illness and the resulting stress and trauma experienced by patients and their families. Additionally, there are legal and ethical considerations that affect patients and their families in the critical care setting, often making this area of nursing even more challenging.
Admission Criteria for Intensive Care
Patients can be admitted to critical care settings for a variety of reasons, but most often there is a life-threatening medical condition that requires intensive monitoring and extensive medical and nursing care (Smith & Nielson, 1999). Some of the most common reasons for admission to the ICU are listed in Table 35.1.
| Reason for Admission | Clinical Examples | Rationale |
|---|---|---|
| Requires interventions or therapies that are only available in critical care settings |
|
Critical care nurses have received extensive, specialized training and obtained certifications that qualify them to provide and manage complex interventions and therapies in the critical care setting. |
| Clinical instability |
|
Admission to the ICU allows clinically unstable patients to be monitored closely and have easier access to life-saving therapies, should they be needed. |
| Postcardiac arrest |
|
Patients experiencing cardiac arrest are at high risk for experiencing another cardiac event. Admission to the ICU allows for close monitoring and access to life-saving therapies. |
| Surgical recovery |
|
Patients are admitted to the ICU after invasive surgical procedures because they are at high risk for hemodynamic instability and life-threatening postoperative complications. |
Risk Assessment Models
When a patient is admitted to the ICU, it is important to determine the severity of their condition because this information influences nurse staffing ratios and the allocation of other unit resources. This information also helps estimate the patient’s survival rate, which is used to monitor and evaluate patient outcomes during and after their stay in the ICU. There are several risk assessment models that aid in determining the severity of the patient’s medical condition. Two of the most widely used models are the Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II Scoring System (Medscape, n.d.) and the Sequential Organ Failure Assessment (SOFA). Both models evaluate several physiologic variables (e.g., temperature, heart rate), resulting in a score that reflects the severity of their condition. SOFA was originally used to determine the risk of organ failure in patients with sepsis (see Figure 23.7), but it is now used more broadly with patients admitted to the ICU. Scores from 0 to 4 are given in six key categories (e.g., respiration, renal); a higher score indicates a higher risk for organ failure and is associated with worse patient outcomes.
Link to Learning
This webpage provides information about the APACHE II Scoring system and includes a template for calculating a score. A higher overall score indicates more severe disease and increased risk of hospital death.
Multisystem Organ Dysfunction
Though patients are often admitted to the ICU for one primary medical problem, it is common for critically ill patients to experience dysfunction of several body systems at once, contributing to the overall complexity of their care. This is known as multiple organ dysfunction syndrome (MODS) and is the leading cause of death for patients admitted to the ICU (Society of Critical Care Medicine, n.d.). Multiple organ dysfunction syndrome most often occurs in patients experiencing trauma-related events (e.g., motor vehicle accident) or systemic conditions such as shock or sepsis. When multiple body systems are affected, patient outcomes are negatively affected.
Required Skills for Critical Care Nurses
Working as a nurse in the critical care setting requires many skills, one of the most important being attention to detail. Because of the high acuity of patients in the ICU, it is important that critical care nurses can accurately assess and detect subtle changes in patient conditions that can quickly deteriorate and become life-threatening without appropriate intervention. Critical care nurses also must possess the technical skills and competence required to manage multiple IV medications and technological therapies at the same time. Critical care nurses need excellent communication skills to function well within a interdisciplinary team and to relay complex medical information to patients and their families. Additionally, it is imperative that critical care nurses be able to translate complex patient data into accurate and detailed documentation to be included in the patient’s medical record as a resource for the rest of the interdisciplinary care team. The care of a patient in critical care commands a lot of time and detail; therefore, nurse-to-patient ratios are low in this setting; typically, one nurse cares for two critically ill patients during a shift.
Technological Supports Used in Critical Care
Critical care units are designed to provide life-sustaining care to critically ill patients while still maintaining a sense of comfort. Most ICUs consist of several single-bed rooms that are arranged for easy viewing from the nurses’ station. Each patient room contains bedside equipment to monitor the patient’s vital signs and other hemodynamic parameters, all of which are also in view of the nurse. There are usually several storage areas on the unit that contain medication-dispensing machines and other equipment such as ventilators and the crash cart. Storage areas should be easily accessible and located near patient rooms in case of medical emergency.
Though critical care units can be overwhelming for families and patients, especially when patients are hooked up to multiple IV pumps and other machines, they are usually designed to promote patient and family comfort. Some critical care units offer private family waiting rooms with couches as well as furniture in the patient rooms to support visitors’ comfort when visiting the patient. Figure 35.2 shows a typical ICU room.
Critical care units use a wide range of technology and equipment to provide care to the critically ill. One of the most common pieces of equipment is the ventilator. Patients in the ICU are often unable to breathe effectively, indicating the need for intubation. This process involves the insertion of a flexible plastic endotracheal tube (ETT) through the mouth and into the trachea down to the airway; the ETT can then be connected to a ventilator. The ventilator is programmed by the respiratory therapist (RT) to provide effective control over the patient’s breathing pattern when they are unable to adequately control it themselves. Another machine commonly used in critical care settings is the IV medication pump (IV pump). It is not uncommon to see patients in the ICU connected to multiple IV pumps at one time, receiving several different medications to maintain hemodynamic stability and comfort.
Pharmacological Supports Used in Critical Care
As mentioned, critical care patients being cared for in the ICU often receive multiple medications at one time. One of the most common classes of medications is vasopressors. These medications are used when patients cannot maintain adequate blood pressure on their own, which often is seen with conditions like shock. The critical care nurse is responsible for frequently adjusting the titration rate of these medications to keep the patient’s blood pressure within the specific range prescribed by the health-care provider, which is why constant, detailed monitoring is an essential nursing skill. There are six major vasoactive medications used in this setting. The first five are vasopressors, which are indicated for blood pressure support, and include epinephrine, norepinephrine, phenylephrine, vasopressin, and dopamine. Another vasoactive agent, indicated for cardiac output (CO) support, is dobutamine.
Another medication class is sedatives. Patients who are connected to a ventilator or other invasive equipment often require sedation to ensure they stay calm and do not disconnect themselves from the life-saving machines. The nurse is responsible for titrating these medications to maintain an appropriate level of sedation for the patient’s condition. Patients may also receive opioid analgesic medications to mitigate pain, either via IV push or continuous infusion. Other common medication classes used in the critical care setting include anticoagulants, antidysrhythmic medications, and insulin. It is important to note that most of the medications given in the ICU must be administered intravenously (as opposed to orally) to deliver more immediate physiologic effects in critically ill patients.
Ethical and Legal Implications Confronted in Critical Care
Critical care nurses are often faced with ethical and legal issues in their day-to-day practice. Many of these issues are related to the complexity of the patients’ conditions and the beliefs and values of the patients and their families. Dealing with highly emotional situations frequently can also have a profound impact on the critical care nurse, including feelings of depression and caregiver fatigue. It is important for nurses to be aware of their emotions and use resources such as counseling for their own mental health as needed. The two most common legal and ethical issues encountered by the critical care nurse include decision-making related to life-sustaining therapy and organ and tissue donation.
Life-Sustaining Therapy Decision-Making
As medical technology has advanced, there are more options for therapies that can be used to keep patients alive who previously would have died of their illnesses. Most of the legal and ethical issues surrounding life-sustaining care arise when there are questions relating to whether the patient would want particular interventions and what their anticipated quality of life would be. In some cases, the patient has proactively created an advance directive, which is a document that provides instructions for medical care if the patient cannot communicate their wishes. Often, patients who are on life-sustaining therapies are unable to convey their personal wishes. If they do not have an advance directive, medical decisions are made by their next of kin or a designated person via authorization called a durable power of attorney (DPOA), depending on state laws and/or previously identified wishes (e.g., the choice to withhold resuscitative measures) made by the patient. A person may be previously identified in a living will or advance directive as having DPOA for the patient. This may be an appointed family member, friend, or court-appointed attorney.
A related document is a do-not-resuscitate (DNR) order that indicates that the patient does not want cardiopulmonary resuscitation to be conducted if their heart stops. Do-not-resuscitate orders are discussed in are discussed in Chapter 32 Palliative Care.
If the patient has not previously explicitly written their health-care wishes, the designated person with DPOA or the patient’s family is faced with determining what kind of care the patient would want to receive. This can be difficult to do, especially when there are multiple family members or legal decision-makers who have conflicting opinions, values, and beliefs. Ultimately, these decisions should be made based on knowledge of the patient’s previous health status and determining whether the use of life-sustaining therapies could restore their quality of life to a level that would be acceptable to the patient. There are many moral and ethical considerations associated with these kinds of decisions and every patient situation is unique. Hospitals have developed ethics committees that can intervene and assist with decision-making if legal decision-makers and families are unable to determine the best course of action for the patient. Critical care nurses must be prepared to collaborate with these committees and advocate for their patients when necessary.
Organ and Tissue Donation
Although some critically ill patients make a full recovery, many others do not. Sometimes patients have experienced traumatic events or complications so great that they have lost all brain stem functioning, resulting in brain death, which is defined as the cessation of brain function, due to irreversible brain injury. In these situations, ethical and legal issues arise related to the potential for organ and tissue donation. Legal decision-makers or families may choose to continue life-sustaining therapy knowing that the patient will not recover neurologically, or they may choose to withdraw the life-sustaining therapies. If the decision is made to withdraw care, the potential for organ and tissue donation often becomes part of the conversation. Organ and tissue donation can be a difficult subject to discuss, and some families are not comfortable with having a loved one’s organs harvested after death. The family or patient may have cultural or religious beliefs that affect whether they consider organ donation. Often, families also have fears related to misinformation or unknowns about the donation process that need to be addressed before the decision can be made to donate organs.
Because of the serious nature of these conversations, local organ procurement organizations should be called when death is anticipated, so that organ-donation nurses may come speak directly to the family. These professionally trained nurses have extensive experience with organ donation and can better speak to the process and provide details and emotional support to families. Most hospitals mandate that staff nurses not approach families about organ donation and instead wait for the organ procurement organization nurses to speak with them. This ensures that there has been no coercion or inaccurate information relayed to the family, minimizing the risk of future legal or ethical issues.