Intensive Care Nursing

A Framework for Practice

Philip Woodrow

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351864268
• Edition: 4
• Topic: Medicine
• Subtopic: Nursing

Especially written for qualified nurses working in intensive care units, this comprehensive text has been developed to be as accessible as possible. This fourth edition has been revised throughout to ensure the evidence base is completely up to date and the content reflects contemporary best practice.

Intensive Care Nursing is structured in user-friendly sections. The chapters contain sections outlining the "fundamental knowledge" needed to understand key chapters, "implications for practice" boxes, further reading and resources overviews, "time out" sections for revision and clinical scenarios with questions included. Reviewed throughout by experienced practitioners and teachers, it covers:

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• patient-focused issues of bedside nursing;

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• the technical knowledge necessary to care safely for ICU patients;

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• the more common and specialised disease processes and treatments encountered;

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• how nurses can use their knowledge and skills to develop their own and others' practice.

Written by a practice development nurse with a strong clinical background in intensive care nursing and experience of teaching nursing, Intensive Care Nursing is essential reading for nurses and health professionals working with seriously ill patients, particularly those undertaking post-registration training in the area.

Part I
Contexts of care

Chapter 1
Nursing perspectives

Contents

Introduction

Technology

The patient …

… Their relatives …

… And the nurse

Stress

Duty of care

Implications for practice

Summary

Further reading

Clinical questions

Introduction

This book is about nursing care of critically ill (Level 3 – see Table 1.1) patients; a companion book (Woodrow, 2016) focuses on Level 2 patients.

The 60 years of intensive care units (ICUs) have seen various technologies, drugs and protocols developed to treat problems of critical illness. While many have found a valid niche, initial hopes have often been largely disappointed. What has been constant is the contribution of nurses and nursing to outcomes for critically ill patients. So what is the purpose of nurses in ICU? What does critical illness, and admission to intensive care, cost patients and their families? In the busyness of everyday practice, these fundamental questions can be too easily forgotten. Nursing is expensive, costing more than one quarter of acute trust budgets, and although ICU staffing costs vary, high nurse:patient ratios necessitate the need for ICU nurses to clarify their value (Bray et al., 2009). This book explores issues for ICU nursing practice; this section establishes core fundamental aspects of ICU nursing. To help readers articulate the importance of their role, this first chapter explores what nursing means in the context of intensive care, while Chapter 2 outlines two schools of psychology (Behaviourism and Humanism) that have influenced healthcare and society.

A recurring theme of pathologies described are two responses:

• inflammation
• stress

These are innate defensive/protective responses. Balanced responses (appropriate to the threat) often help resolve non-critical illness. Critical illness typically occurs with imbalanced responses – insufficient response means disease can cause death, while excessive responses themselves become pathological.

Table 1.1 Levels of care

Level 0	Patients whose needs can be met through normal ward care in an acute hospital.
Level 1	Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice and support from the critical care team.
Level 2	Patients requiring more detailed observation or intervention including support for a single failing organ system or post-operative care and those “stepping down” from higher levels of care.
Level 3	Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure.

Source: D.O.H., 2000a; I.C.S., 2015

Technology

Intensive care is a young speciality. Ibsen is widely credited with creating the first “modern” ICU in 1953 (Reisner-Senelar, 2011). The first purpose-built intensive care unit (ICU) in the UK opened in 1964 (Ashworth, personal communication). ICUs offer potentially life-saving intervention during acute physiological crises, with emphasis on medical need and availability of technology.

Technology facilitates monitoring and treatment but can also be dehumanising (Almerud et al., 2007). Patients, not machines, should remain the focus of care (Bagherian et al., 2017). Nurses should ensure that the use of technology is compatible with the safety, dignity and rights of people (I.C.N., 2012). ICU patients, often disempowered by their disease and drugs, are confronted with environments designed for medical and technical support which can create barriers for patients and their care (Eriksson et al., 2010), so advocacy remains a fundamental nursing role (Williams et al., 2016). Nurses should develop therapeutic and Humanistic environments which help the patient as a whole person towards their recovery (Almerud et al., 2007). For patients, caring behaviour and relieving their fear and worries are the most valuable aspects of nursing (Hofhuis et al., 2008a).

The patient …

Patients are admitted to intensive care because potentially reversible physiological crises threaten one or more body systems, and life (Crunden, 2010). Care therefore needs to focus primarily on supporting failed systems. This book discusses various aspects of technological and physiological care, many chapters focusing on specific systems and treatments. But these aspects should be placed in the context of the whole person. People are influenced by, and interact with, their environment. Extrinsic needs for:

• dignity
• privacy
• psychological support
• spiritual support

define each person as a unique individual, rather than just a biologically functioning organism.

Uniquely among healthcare workers, nurses are with the patient throughout their hospital stay. A fundamental role of nurses is to be with and be for the patient, as a whole person (McGrath, 2008). Person-centred care is widely cited in strategic documents, policy statements and organisational values, but its evaluation tends to be narrow and reductionist (Manley and McCormac, 2008).

… Their relatives …

Relatives are an important part of each person’s life (Wong et al., 2015), giving patients courage to struggle for survival (Bergbom and Askwall, 2000). So, caring for relatives is an important part of patient care (Davidson et al., 2017). Of all staff, nurses are best placed to meet relatives’ needs, and are a valuable source for updating relatives about progress (Iverson et al., 2014; Wong et al., 2015).

In contrast to the often-high-tech focus of staff, families of intensive care patients often focus on fundamental aspects of physiological needs, such as pain relief and communication (Tingle, 2007). Rather than ruminate by bedsides, afraid to touch their loved ones in case they interfere with some machine, relatives should be offered opportunities to be actively involved in care (Davidson et al., 2017).

Physiological crises for patients often create psychological crises for their relatives (Wong et al., 2015). Holistic patient care should include caring for their families (Bagherian et al., 2017).

Relatives experience a range of emotions, including anxiety, anger and frustration (Turner-Cobb et al., 2016). They are usually angry at the disease, but it is difficult to take anger out on a disease. Instead, anger, complaints or passive withdrawal may be directed at those nearby, who are usually nurses (Maunder, 1997). Relatives may blame themselves, however illogically, for their loved one’s illness. They place low priorities on their own physical and physiological needs, such as rest and food (Padilla, 2014). Facilities for relatives should include a waiting room near the unit, somewhere to stay overnight and facilities to make refreshments (NHS Estates, 2003; B.A.C.C.N., 2012).

Relatives need information, both to cope with their own psychological crisis and to make decisions (Padilla, 2014; Gaeeni et al., 2015). Relatives, and patients, may seek information from the internet, often immediately available through mobile telephones and tablets. While many internet resources are reliable, some are not and can be a source for misinformation and confusion. Nurses should therefore clarify relatives’ understanding of pathological conditions, treatments and other aspects.

Relatives often have a psychological need for hope (Bagherian et al., 2017), but with nearly one fifth of patients dying on the unit (Vincent et al., 2009), and additional post-discharge mortality and morbidity, there may be little hope to offer. If death seems likely, relatives need to know so they can start grieving (Wright, 2007). Relatives often anticipate more positive outcomes than physicians (Lee Char et al., 2010), so may be unconvinced when bad news is broken. Changes in critical illness may be rapid and unpredictable. Where possible, both the nurse caring for the patient and a senior doctor should inform the family of anticipated outcomes, away from the patient’s bedside, preferably in a room where discussion will not be interrupted by others. The door should be closed for privacy, but access to doors should not be obstructed in case distressed relatives need to escape. Everyone should sit down, as family members may faint, and staff should not stand above relatives. Posture, manner and voice should be as open as possible. Tissues should be available. Having witnesses is useful in case relatives later complain. Detailed records of discussions should be recorded.

Relatives should be given time to think about information, express their emotions and ask anything they wish, and be offered opportunities for further discussions if they wish. An information book, including details of who to contact and support groups (such as CRUSE), is useful. Further discussion about end-of-life care can be found in Woodrow (2016).

… And the nurse

Nurses monitor and assess patients. But nurses also provide care. Assessment is fundamental to providing care, but excessive paperwork can hinder care. Nursing assessments should therefore remain patient-focused, enabling nurses and others to deliver effective care. Proliferation of policies, protocols and competencies is often intended to ensure quality and parity of care wherever patients are admitted and whoever cares for them. But each patient is an individual and needs individualised nursing care. While guidance and safeguards can be useful, increasing protocols does not correlate with either compliance or reducing patient mortality (Sevransky et al., 2015). Rather than introduce more proformas, nurses need to maintain and develop knowledge and skills to be able to adapt care to individualised patient needs.

Nurses should collaborate with other professions (N.M.C., 2015). Nurse-to-patient ratios for Level 3 patients should be 1:1 (I.C.S., 2015). The UK faces specific challenges: UK ICU patients are sicker than in most countries (Mandelstam, 2007), there are fewer ICU beds per 100,000 population (Adhikari et al., 2010) than in other developed, and many Third World, countries. There is also disparity between the four UK countries: I.C.S. (2015) cite England as having seven beds per 100,000 population, compared with 3.2 in Wales and Scotland and 4.7 in Northern Ireland. For Level 2 patients, nurse:patient rati...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• List of figures
• List of tables
• Preface
• Acknowledgements
• List of abbreviations
• Part I Contexts of care
• Part II Fundamental
• Part III Monitoring
• Part IV Micropathologies
• Part V Respiratory
• Part VI Cardiovascular
• Part VII Neurological
• Part VIII Abdominal
• Part IX Metabolic
• Part X Professional
• Glossary
• References
• Index