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I. Introduction
A. Introduce self
1. Years RN
2. Education
3. Years ICU; Certification
4. Goals
B. Definitions
1. 1800s Nightingale clusters acutely ill patients
2. 1900s TB & Polio pandemics result in specialty units and new equipment to
manage airways w/qualified individuals to use them
3. 1940s 1950s War reinforced the concept of the need for specialized triage
and nursing units. This translated to the hospital setting.
4. 1960s Ushered in more sophisticated equipment for hemodynamic
monitoring (i.e. pulmonary artery catheters, arterial lines, and central lines.
More sophisticated diagnostic tools, too blood gasses off the new lines,
central venous pressures, and electrocardiograms.
5. 1960s Coronary Care Units were developed to specialize in the
management of acute myocardial infarction and heart failure patient
populations. This allowed for continuous monitoring through the new ECGs
for dysrhythmias. These dysrhythmias also allowed for the onset of protocol
management of patients to advance their plan of care.
6. 1970s standardized unit in hospitals worldwide. In the US there are
approximately 6,000 ICUs that can hold up to 1 million critically ill patients.
7. Continued growth of technology to current times allows for rapid diagnosis
and treatment, extending life (i.e. rapid response teams and the electronic
ICU). Patients tend to be clustered in specialty unit by diagnosis or age.
There are neonatal and pediatric ICUs, neurologic, surgical, cardiovascular,
medical, and burn units to treat these specialized patients.
8. Critical Care Nurse also known as an intensive care nurse although not
found exclusively in the ICU may be seen on progressive care units, cath
labs, or emergency departments.
9. Definition from American Association of Critical Care Nurses, critical care
nursing is a specialty dealing with the human response to life-threatening
problems. With the correct orientation and mentoring, associate and bachelor
prepared nurses are prepared to provide critical care. Advanced practitioners
include educators in the ICU, Clinical Nurse Specialists, and Advanced
Registered Nurse Practitioners. These advanced providers are Masters or
Doctorate prepared. Certification for all levels of providers can be obtained
from the American Association of Critical Care Nurses. Each certification
requires particular amounts of clinical hours and continuing education credits.
Regardless of certification, however, every nurse should participate in
continuing education in order to remain current with best practice and
evidence-based standards.
C. Responsiblities

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1. Responsibilities of the critical care nurse nursing process: early assessment
of life-threatening conditions, institute interventions using critical care
knowledge, and evaluating the effect of those interventions.
2. How to fulfill responsibilities advanced knowledge of anatomy and
physiology, pharmacology, advanced assessment skills, and ability to utilize
the technology to assess, implement changes, and evaluate the patient
response. The nurse must do all this while providing holistic care to the
patient and family. Critical care nursing is a team effort that requires effective
communication, collaboration, effective decision making, correct staffing,
recognition, and leadership in order to provide the best care and a healthy
work environment. Without correct support, the critical care nurse can
experience overwhelming ethical dilemmas and burnout. Many ethical
dilemmas surround the advanced care and use of technology with an ailing
and aging population. Arguments arise over dignified care and the use of lifesaving measures in futile patient cases.
D. Critically ill patients
1. Reasons for an ICU admission of a patient include physiologic instability,
potential or real complications associated with a disease process requiring
frequent assessment or invasive equipment, and the need for complicated
nursing care. According the Society of Critical Care Medicine, there are more
than 5 million admissions to ICUs annually. Top 5 diagnoses are respiratory
failure, post-operative management, ischemic heart disorder, sepsis, and heart
failure. Because of the advances in technology and care, there are more
people living longer and surviving previously deadly diseases, but also require
higher levels of care. In fact, it is estimated that at least the U.S. population
will be admitted to an ICU at some point in their lives, most often in the last
year of their lives. There is a direct correlation, too, to these older, sicker
patients, and death rates for ICUs. Despite advanced and aggressive care,
those that are older, have comorbid conditions, or have longer ICU stays are
least likely to survive.
E. Challenges
1. Caring for intensive care patients brings risk for complications. Typically, the
patients are immobile increasing the risk for skin disorders, invasive lines lend
to infection sources, nutrition deficits, anxiety, pain, sensory disorders (most
likely to pharmaceuticals and sleep deprivation), and impaired
communication.
a) Nutritional deficits occur because most patients are admitted with
either hypermetabolic, catabolic disease states, or are malnourished on
admission. Continued malnutrition in the setting of ICU leads to
higher morbidity and mortality. Collaboration for early goal directed
nutrition between the nurse, dietitian, and the ordering intensivist or
licensed independent provider should occur at admission. We used to
wait 24 hours and realized the detrimental outcome on patients.
Wounds cannot heal, diseases worsen, and the natural flora of the GI
tract translocates to other sources within the body. This is why the
enteral route is preferred to the parenteral route. Other reasons include

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increased rates of infection and increased cost associated with
parenteral nutrition. Goals in feeding rates or caloric intake should
also consider frequent interruptions in feeding related to typical ICU
care (i.e. medication administration, lying down to turn and give skin
care, testing, etc.).
b) Anxiety and Pain More than 70% of ICU patients have uncontrolled
pain. This can lead to further anxiety and stress response, thus
worsening disease states. Anxiety levels in critically ill patients are
usually related to worry over physical health, stimulation in the
environment, and loss of control over self. Treatment of pain or
anxiety can be both environmental and chemical. Easing the fears of a
patient, reducing noise and light, and providing basic needs should be
attempted prior to or in addition to medications. When medications
are used, the patient must have pain or anxiety reduced while still
allowing the nurse to assess their neurologic status. When over
sedation occurs, proper assessment can suffer.
c) Sensory Problems Delirium is acute and reversible. It is very
common in the ICU patient. Limiting benzodiazipines, clustering care
to preserve sleep-wake cycles, and natural light helps to prevent
increased risk for delirium. Family members and reorientation are
often helpful, too. If pharmacologic intervention is needed to secure
safety, the use of Haldol, a neuroleptic, is the preferred drug
d) Impaired communication invasive equipment and medications can
lead to communication disturbances, thus increasing anxiety in the
patient. The use of direct eye contact, hand gestures, communication
devices like keyboards or picture boards, and nonverbal
communication cues can assist with verbal communication deficits.
One should always be culturally competent in their care, too,
recognizing the need for an interpreter for those that do not speak
English or the comfort level with touch of those with diverse cultural
backgrounds.
e) Cultural competence perspective on the illness, death, and dying
preferences of the patients cultural should be considered. Holistic
care is the goal with attention to the culture and family. Families can
provide immense support to the patient and nursing staff, but also may
need support of their own. This support comes from the critical care
nurse. Caretakers can become exhausted, requiring direction from the
nurse to care for themselves while feeling secure in the care of their
loved one. The best support the critical care nurse can provide to a
family is information. Consistent and accurate updates, notification of
progression in plan of care, and prognosis will provide the best
support. The family is an active member of the care team and should
be included in plan of care decision making and care of the patient.
Rigid visitation schedules in the ICU are becoming a thing of the past,
instead moving to a model of open hours to family.
E. Future of Critical Care Nursing

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1. Critical care can be mobile. We mentioned earlier rapid response teams and
electronic intensive care units. The critical care expertise and knowledge
branch out to other departments in the hospital when a change in patient status
is noticed during the rapid response team. Multiple members of the ICU team
(nurse, intensivist, respiratory therapist) go to the patient in question and
provide early intervention to circumvent a demise and possible ICU
admission. The electronic ICU or eICU is a monitoring environment that
augments bedside ICU care from a remote location.
F. eICU
1. It is a branch of medicine known as TeleHealth. Telehealth or telemedicine
can provide acute or chronic care for a variety of medical issues from a remote
location. This can be elopement monitoring for home based Alzheimer
patients, vital sign monitoring for patients at home or in rehab facilities to
provide early intervention and prevent patient demise and readmission, or
continuous monitoring in the intensive care environment as a collaborative
patient care team member. In the changing world of healthcare, telehealth
technology can save lives, improve workflow, and improve financial
outcomes.
2. As you know, there is a nursing shortage. This is felt more acutely in
specialty departments like the ICU. It is the same for Intensivists. In order to
monitor the 5 million patients that are admitted to the ICU setting annually,
there would need to be approximately 35,000 intensivists. There are about
6,000 now. The eICU allows one intensivist the ability to remotely monitor
and provide preventative care or acute interventions on over 100 patients at
the same time. The intensivists in the eICU are board certified critical care
physicians that assist the nurses in monitoring of the patient population of the
intensive care unit. This is a collaborative effort with eICU based nursing and
pharmacy and in conjunction with the bedside team.
3. Alongside the intensivist is the eRN. A minimum of 3-5 years critical care
experience is required as is certification in Fundamentals of Critical Care
Support from the Society of Critical Care Medicine. Further certification in
Critical Care in the form of a CCRN from the American Association of
Critical Care Nurses is highly recommended.
4. The nurse and intensivist both monitor SmartAlerts and remotely round on
patients based on an acuity assignment. This form of technology allows for a
6-24 hour trend in blood pressure, respiratory, and heart rate monitoring so
that patient demise can be prevented as opposed to intervened on. As
undesirable trends in the patients vital signs or labs are noted, the eRN can
alert both the intensivist present and the bedside team in order to provide
quick and early care to the patient based on the latest evidence based practice.
The eRN also assesses for best practice standards and requests changes to the
plan of care based on those standards (low tidal volume ventilation for ARDS,
sepsis and ventilator bundles for that population, DVT prophylaxis, early
nutrition, etc.).
5. Nurses and intensivists are busier and have more responsibilities as healthcare
dynamically changes and the shortage in qualified individuals continues. The

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eICU can provide collaborative care with the bedside and assist in a closer
monitoring of the patient during this time of transition. Direct phone lines,
alert buttons in every room, mobile carts for rapid response calls, and old
fashion fax machines help to keep the bedside and eICU connected on behalf
of patient care.
6. Typical shift
7. Videos
G. Hemodynamic Monitoring
1. CV System Review
a) Cardiac Output - volume of blood pumped by the heart in 1 minute (48L/min). Stroke volume is the volume of blood pumped in 1 minute.
CO = SV x HR.
b) Preload - volume within the ventricle at the end of diastole. Typically
measured in pressure to estimate volume. Left heart pressures can be
monitored with a pulmonary artery catheter and right heart pressures
can be measured with central venous pressure equipment connected to
a central line in the vena cava or right atrium. CVP = 5-10 mm Hg.
Remember preload is affected by Frank Starlings law. The more the
heart muscle stretches with preload, the more forceful the contraction,
but this leads to more need for oxygen to the myocardium. Consistent
stretch also leads to hypertrophy, or thickening, of the heart muscle
and the eventual ineffective pump. This is a form of heart failure.
c) Afterload - the forces opposing ventricular ejection. Includes
systemic arterial pressure, resistance across the aortic valve, and the
amount and density of the blood being ejected. Increased after load
decreases cardiac output. More resistance = less volume leaving the
heart. This again leads to stretching of the cardiac muscle, oxygen
demand, hypertrophy, and eventual heart failure. A pulmonary artery
catheter assists in obtaining after load measurements from the left side
of the heart.
d) Systemic Vascular Resistance - resistance of the systemic vascular
system. Along with resistance in the pulmonary vascular system, this
comprises after load. (800-1200 dynes/sec/cm-5)
e) Contractility - the length of contraction. No direct measurement.
Indirect measurement is done with a pulmonary artery catheter
through wedge pressures and cardiac output numbers. Inotropic drugs
help affect contractility. If a drug is a positive inotrope (i.e.
norepinephrine, epinephrine, dobutamine, etc.), it increases the
contractility of the muscle. If the drug is a negative inotrope (alcohol,
acrid channel blockers, some beta blockers), contractility is decreased.
2. Principles
a) These lines are invasive. The monitoring equipment is disposable. It
includes a catheter, pressure tubing, flush system, and transducer.
b) Phlebostatic axis - In order to measure properly, the equipment must
be zerod to the environment and the right atria of the patients heart.
This is done by placing the transducer at the phlebostatic axis. To do

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this, the patient is laid supine and two imaginary, intersecting lines are
drawn. One down the sternum to the 4th intercostal space and one on
the side of the patient that divides the anterior and posterior chest.
Where the two intersect is the phlebostatic axis.
H. Types of Hemodynamic Monitoring
1. Arterial lines - Can be inserted by respiratory therapists or MDs. Provides
continuous blood pressure monitoring via a radial or femoral artery. A
flexible catheter (like a longer IV catheter) is used to cannulate the artery and
then connect to the monitoring equipment. The pressure bag with the
equipment provides about 3 ml/hour of fluid to both keep the catheter open
against the pressure of the arterial blood flow and to also assist in
measurement of the pressure through the transducer. This should be saline
only. It used to be heparin at all times, but it is now known that this leads to
increased complications, including heparin induced thrombocytopenia.
Complications of arterial lines include hemorrhage, infection, thrombus, nerve
damage, and loss of limb from vascular compromise.
2. Pulmonary Artery Catheters - Inserted by an Intensivist or cardiologist. An
introducer is inserted into the vena cava and the catheter is floated in to the
pulmonary artery at the level of the distal port, which is the dip of the catheter.
Oxygen saturation is measured via mixed venous blood samples. Proximal
port in the right atrium and right ventricle allow for CVP monitoring and CO
measurements. Blood can be sampled and temperatures monitored directly
from the core. These catheters are mostly used in the cardiothoracic ICU
setting to monitor CO, CI, SVR, and other hemodynamics in the post-open
heart patients so that drug therapy can be adjusted to optimize oxygen delivery
to the myocardium and systemic system. Rarely the PA catheters are used in
other ICUs to measure for pulmonary HTN and hemodynamics associated
with hyper metabolic states such as sepsis. It has been found that the risk of
complication does not outweigh the benefit in a majority of cases.
a) The nurse assists with insertion by correcting electrolyte disturbances
pre-insertion. The catheter floats through the right ventricle and this
can irritate the muscle, causing dysrhythmias, and the late replacement
will make the muscle less irritable. The nurse sets up the equipment,
monitors the ECG tracing to alert the intensivist as to where in the
heart they now are and any complications, monitors VS, and inflates
to balloon when requested in order to float the distal tip of the catheter
into the pulmonary artery. The balloon is then deflated and the line
secured. A pCXR reconfirms what is noted on the ECG tracing. The
nurse then records the measurement on the line at the point of exit.
This should be checked at each assessment and during hemodynamic
monitoring.
b) Systolic, diastolic, and mean pressures are usually monitored. After
an initial pulmonary artery wedge pressure is obtained, it is correlated
with the diastolic pulmonary artery pressure. These numbers should
be almost, if not exactly, the same. This prevents further need for

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complications of wedging, such as pulmonary artery infarction from a
balloon accidentally being left inflated.
c) Complications - infection, air embolus, and pulmonary artery
infarction or rupture are complications associated with PA catheters.
Aseptic insertion and care techniques must be observed to decrease
the risk of infection. The nurse monitors for clinical signs of infection
such as fever, redness, and further hemodynamic instability. Air
embolism can be introduced through the monitoring system, direct
injection, or a ruptured balloon. The nurse should check the integrity
of the balloon before insertion, check for blood flow prior to air
introduction to the balloon, and check all stop-cocks on the monitoring
lines to ensure they are secure. In addition to the balloon being left
inflated like previously discussed, the pulmonary artery may become
compromised if the balloon ruptures and air or debris is introduced to
the PA or if the catheter floats further into the PA and becomes lodged,
thus obstructing blood flow. The nurse monitors waveforms closely
and maintains the continuous flow of saline via a pressure bag, the
same as discussed with arterial lines.
d) Patient assessment - Besides obtaining numbers on a monitor, the
nurse should clinically correlate the findings to the patient. The
numbers may look good, but how does the patient look? Are they
neurologically intact and alert? How does their skin look? Are they
warm and dry? Are they pink? How are their pulses? What is the
urine output? What is the trend in their appearance? All of these
things are clues to hemodynamic monitoring without the equipment
and should always be used in conjunction.
3. Circulatory Assist Devices - Ventricular Assist Devices and Intraaortic
Balloon Pumps
a) Intraaortic Balloon Pumps
1) Intraaortic Balloon Pumps are usually inserted in the cath lab
and provide assistance to reduce afterload and arterial diastolic
pressure, thus improving myocardial oxygenation through the
coronary arteries. This is seen a lot in severe myocardial
infarctions and in the open heart population. A catheter with a
large balloon on its sheath is inserted through the right femoral
artery to the descending thoracic aorta below the level of the
left subclavian artery, but above the renal arteries. A
connected machine inflates the balloon during the patients
diastole and deflates it immediately before systole. This is
coordinated through monitoring of the ECG tracing with
deflation on the upstroke of the R wave and inflation on the t
wave. The machine can provide augmentation to each beat,
every other beat, or every third beat depending on the acute
need of the patient.

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2) Complications - infection, skin/lung complications from
immobility, arterial trauma from the line, thromboembolism,
hemorrhage, and balloon rupture.
3) Along with clinically correlating the effects of the IABP (how
does the patient look as discussed with PA catheter), the nurse
must monitor the equipment in conjunction with respiratory
therapy and monitor for complications. Comfort measures to
reduce pain and anxiety should be employed. Skin care and
pulmonary hygiene should be used to counteract the
immobility. Peripheral pulses and urine output should assessed
every hour and arterial waveforms continuously observed to
monitor for arterial compromise. Prophylactic heparin or lowmolecular heparin should be administered to reduce the risk of
thromboembolism or platelet aggregation on the catheter. The
nurse should have equipment standing by for emergent
removal in the case of balloon rupture.
b) Ventricular Assist Devices
1) Used as a more long-term bridge to transplant as they can
provide mobility for months, unlike the balloon pump. Can
also be used more temporarily in the patients that cannot wean
from bypass during open heart surgeries.
2) Can be internal or external
3) Replaces the pumping of the ventricle
4) Can replace the action of the left ventricle or both
5) Nursing care much like IABP - monitor equipment and clinical
presentation of tissue perfusion.
6) Educate, educate, educate!
I. Artificial Airways
1. Endotracheal Tubes - tube inserted through the nose or mouth, bypassing
upper airway structures, advanced past the larynx, to the trachea.
a) Need - Indications = upper airway obstruction, apnea, inability to
protect airway/risk for aspiration, respiratory distress.
b) Types 1) nasal intubation is least preferred but indicated for some
patients (i.e. some cranial and maxillofacial surgeries or
suspected cord injury). Contraindications are facial or basilar
skull fractures. Nasal tubes increase the work of breathing
because the tube is smaller with higher resistance. They are
uncomfortable and can lead to higher rates of ventilator
associated pneumonia as the sinuses are consistently irritated
and can lead to micro aspiration past the cuff of the tube.
2) oral intubation is the preferred method. The airway can be
secured quickly in an emergency. There is visualization of the
larynx and vocal cords, increasing accuracy of placement.
c) Insertion - controlled, RSI vs. conscious sedation, proper patient
positioning, gathering equipment, bag valve mask w/100% 3-5

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minutes, intubate, check placement with auscultation and CO2
detector, bag, secure, attach to O2 source, pCXR, note measurement at
lip/teeth.
d) Nursing management
1) tube placement - minimum of every 4 hours or when patient
condition changes signally a possible dislodgment.
2) cuff inflation - usually maintained by the respiratory therapist
by checking the pressure with a manometer, but the nurse
should be aware that too much pressure leads to tracheal
erosion and too little leads to an air leak wherein proper
ventilation does not occur.
3) Monitoring oxygenation/ventilation - two separate things.
Oxygenation is the chemical procedure and ventilation is the
physical act. The chemical process of oxygenation can be
monitored through ABGs, venous blood gases, SpO2, patient
color, neurologic status, and dysrhythmias. Ventilation is
monitored through observation of symmetric chest rise and
fall, lack of accessory muscle use, auscultation of bilateral
breath sounds, and CO2 monitoring either with ABGs or endtidal CO2 equipment.
4) Tube patency/oral/skin care - periodic suctioning and mouth
care, typically every 2 hours, through closed suction technique.
Open techniques are used as minimally as possible because
every break in the closed system may lead to the introduction
of bacteria and the loss of recruited aveoli. The tube should be
rotated with the assistance of the respiratory therapist every 24
hours in order to maintain skin integrity.
5) Comfort/communication - minimal sedation/pain meds to
decrease anxiety/pain and foster better communication. New
studies show that over sedation and over use of
benzodiazepines in the form of continuous drips actually leads
to more anxiety and delirium and an increased length of
stay/complications. New recommendations include keeping
patients on ventilators more awake in a day/night sleep cycle
pattern and the use of prn IVP sedation.
6) Vent bundle - along with frequent assessments and monitoring
for unplanned extubations, the nurse should ensure that vent
bundles are ordered. This includes stress ulcer prophylaxis
with either an H2 antagonist or proton pump inhibitor or early
nutrition, mouth care, do not open the closed circuit, and head
of bead elevation. This helps to prevent ventilator associated
pneumonia. These patients are also immobile more often than
not, although vented patients can be walked as appropriate.
This means they need thromboembolism prevention either
mechanically with stockings or chemical with heparin/low

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molecular weight heparin. They also need preventative skin
care.
J. Trauma Nursing
1. May begin in the ER, OR, or in the surgical ICU.
2. As a patient is triaged as a trauma patient, care is broken into primary and
secondary surveys.
3. Primary
a) A, B, C, D
1) A - airway and cervical spine immobilization
2) B - breathing - bilateral air movement, assess for
pneumothorax/flail chest/hemothorax, VS stability, patient
color
3) C - circulation - vital signs, signs of blood loss, neurologic
status, insertion of large IVs, volume resuscitation. Shock
garments are no longer recommended as when the garments
are removed, the patient has a massive venous dilatation and
refractory hypotension that is insurrmountable.
4) D - disability - brief neuro exam, pupils/glasgow coma scale
4. Secondary
a) E, F, G, H, I
5) E - environmental - clothes removed, warm to prevent further
acidosis from hypothermia
6) F - full vitals, five interventions (ECG, pulse ox, catheter,
gastric decompression, labs), family presence
7) G - give comfort - pain/anxiety
8) H - history/head to toe - mechanism of injury may help narrow
assessment and diagnostic testing, head to toe anterior exam,
health history with AMPLE
(a) A - allergies
(b) M - medication history
(c) P - past medical
(d) L - last meal
(e) E - events preceding injury
9) Inspect the posterior surfaces - log roll, look for abrasions,
cuts, bruising, bleeding, exit wounds, deformities
5. Role - Recording findings, ongoing assessment and intervention, evaluate
interventions, screen for tetanus prophylaxis, transport for testing, A, B, C
always the highest priority.
6. Challenges - grief, certain patient populations, organ procurement process
7. Education - TNCC - Trauma Nursing Core Course - benchmark course for
trauma nursing - identify, assess, intervene. 2 day course with both didactic
and simulated experiences. 4 year certification.