The
following are some general Nursing Protocol for Critical Care for nursing care
of the intensive care patients.
1.
No critical care patient will be left without a nurse in attendance.
ü
Critically ill patients may have life-threatening changes in their
condition; remove an invasive line or self-extubate
quickly.
2.
Each nurse will be responsible for
the entire care of his/her patient, and acts to coordinate care with other
health team professionals.
ü
The caregiver, by assuming full responsibility for monitoring the
patient's condition and care, can detect changes promptly.
3.
Breaks will be
arranged according to unit need/safe coverage by mutual agreement
between each nurse and his/her coworkers. The nurse must give a full report to
another staff nurse prior to leaving for a break. The second nurse assumes
responsibility for the patient and interacts with family/other health team
members in the principle nurse's absence.
ü
When many people are involved in the care, a principle caregiver
reduces the assumption that someone else did or did not complete a task, and
helps to maximize resources.
4.
The staff nurse will report any
changes in his/her patient's condition directly to the physician. The charge
nurse may be utilized to report the information, e.g.,
on nights. The nurse will ensure a physician is aware of all lab reports. The
staff nurse will keep the charge nurse informed of changes in the patient's
condition. The charge nurse will be notified if the
staff nurse needs any direction regarding procedure, policy or physician
interaction.
ü
The staff nurse is the one person who has current and detailed
information on the patient's condition.
5.
All critical care patients will have
continual ECG monitoring.
ü
A critically ill patient requires intensive monitoring
6.
Alarms must be
left on the ECG and arterial lines at all times. Appropriate limits will be
selected at the nurse’s discretion according to institutional
policy.
ü
To ensure rapid detection of heart rate or BP changes. To reduce risk associated with leaving alarm
disabled.
7.
An ECG strip will
be obtained and analyzed according to institutional policy. Generally, this is every four hours and as
needed for patients with a cardiac disorder.
The ECG strips are analyzed, rhythm identified and taped to the back of
the flow sheet. Changes are reported to the physician.
ü
Heart rate and rhythm are keys to determining the hemodynamic
stability of an intensive care patient.
8.
For a stable, non-acute patient
without invasive monitoring equipment, vital signs will be
done at the staff nurse's discretion, at least every hour.
ü
To ensure regular vital sign monitoring
9.
Temperatures will be measured on all
patients at least q4h by other than axilla route. Patients having abnormal
temperatures (< 36 or >37.5 C) will have temperature measured by a core
method (rectally, tympanic, pulmonary artery, esophageal).
ü
Temperature changes may indicate infection or other disease
states. Core represents a much more
accurate value.
10.
All patients admitted for
neurological problems will have hourly neurological assessments performed. All patients will have a neurological
assessment evaluated and recorded on the flow sheet at least once per shift,
using the Glasgow Coma Scale.
ü
To quickly reference previous, function if deterioration occurs.
This will provide a clear understanding of the patient's neurological status
and avoid uncertainty over assessments at shift change. Unconscious patients will have neurological
assessments done q.1-4h. At the nurse's discretion.
11.
The turning of all critically ill
patients every two hours around the clock is done
unless contraindicated, with skin assessment recorded as part of the every
four-hour assessment. If turning is
contraindicated, pressure points will be relieved q2h. If pressure relieve is
not possible, rationale will be documented.
ü
This is to relieve pressure points and allow for skin perfusion as
well as provide reference for comparison of skin care.
12.
All intensive care patients will
have chest PT q4h and PRN unless contraindicated. The frequency will be recorded on the flow sheet documented in progress
note.
ü
Immobility increases the risk for the retention of secretions and
reduced ventilation.
13.
All critical care patients will have
range of motion exercises q4h unless contraindicated (i.e. neuromuscular
blockers). This will be recorded on the flow sheet
treatment section and in clinical record.
ü
To reduce possible contracture formation, disuse atrophy,
"frozen joints", and to promote venous return.
14.
Perineal care will be done every
shift and as needed PRN for all patients.
ü
To promote hygiene and comfort.
15.
All Critical Care patients will have
mouth care done every four hours with inspection for oral skin sores. Teeth
will be brushed every shift and as needed.
ü
Intubation increases risk for developing mouth ulcers and/or
infections.
16.
The Critical Care nurse may restrain
patients at his/her discretion. Provided documentation done according to
hospital policies and procedures.
ü
To ensure life-supporting tubes or lines are not disconnected.
17.
All restraints will
be secured to allow rapid lowering of bedside.
ü
For rapid access in a crisis.
18.
Any
patient who expires, that falls into the classification of a coroner's
case, or who is going to have a autopsy must have all
lines/airways/tubes left in place unless the coroner confirms that they may be
removed.
ü
Correct tube placement is occasionally evaluated at post mortem.
19.
All routine dressing changes, I.V.
tubing changes and catheter changes will be done on
night shift. The Flow sheet will be updated with the
new date change, and the procedure documented in the clinical record.
ü
To maintain consistency among all nurses.
20.
Routine daily baths will be done on night shift. This will include total skin
care, fingernails and hair washing q. weekly and prn
dressing changes.
ü
The night shift is quieter and less hectic
21.
All dressings unless otherwise
indicated will be changed daily.
ü
To remove bacterial contaminates and replace with an aseptic
dressing
22.
Nursing care will
be spaced out to allow periods of rest.
ü
Sensory overload predisposes the patient to disorientation.
23.
All patients who have not had a
bowel movement will be checked for impaction q.3. Days
and the flow sheet updated.
ü
To monitor bowel function
24.
Procedures will be explained to
patients; person, place and time being repeatedly
stated to the patient. Sensory
stimulation, ie., radios, tape recorders, will be provided for patients as
indicated during the day.
ü
It is not known how much an unconscious
patient can hear or comprehend. Sensory
deprivation leads to disorientation.
Anxiety decreases with an awareness of one's surroundings. Maintain a
normal sleep/wake pattern.
25.
Information and emotional support needs for the family and patient will be provided by the
nurse/physician/social work/pastoral care/palliative care, as required.
ü
The critical nature of the patient's illness places tremendous
strain on the patient and family unit.
26.
The environment will
be maintained in a mechanically safe condition through: dry floors, good repair of furniture, proper
placement of machines and equipment, cleanliness, freedom from clutter, and
good repair of equipment.
ü
To reduce risks to patients, visitors, or staff.
27.
Isolation technique will be followed as per infection control manual.
ü
To minimize cross infection to patients, visitors, and staff.
28.
Safety signs, such as,
“isolation", "can hear", or "neuromuscular blocking agent
in use" will be posted when indicated.
ü
To communicate important information
29.
Sharps and glass will be disposed of
into point of use sharps containers.
ü
To protect health care workers from injury/contamination.
30.
Any containers of body fluids (i.e.
suction canisters or chest drainage sets) must be disposed in the appreciate biohazard
bag or box.
ü
To reduce risk of contamination to health care workers during
handling.
31.
All electrical equipment will: be grounded, have
3-prong plugs, be used away from water or wet floors, be protected from
spillage of liquids, be inspected by Biomedical Department. Any equipment that malfunctions or appears
damaged will be reported to Biomedical Dept.
ü
Particularly with patients having access catheters into the heart,
electrical shocks could pose serious risk for harm.
32.
Labels will be affixed to: all bedside
medications, intravenous bags and bottles, all wound or bladder irrigations, multidose vials, multiple drainage bags/bottles,
hemodynamic transducers and monitors (identifying waves and pressures).
ü
To reduce risk for errors.
33.
All medications will be reviewed by
the Critical Care physicians (upon admission to Unit.) and either reordered or
stopped. Nursing staff will ensure this has been done prior to carrying out any medication,
treatment or investigative orders. Each
treatment/medication must be listed when reordered
(e.g., "Renew all preoperative meds" is NOT acceptable.)
ü
To ensure optimal management.
34.
Respiratory orders may only be carried out when written by the patient’s
physician. Ventilatory changes will
only be done upon receipt of written order.
ü
To maintain optimal and consistent respiratory management
35.
All orders written other than by the Critical Care physicians will be brought to the
attention of the Critical Care physician by the nurse prior to being carried
out.
ü
To ensure all therapy is consistent with goals for the patient's
management
36.
Narcotics MAY NOT be kept at the
bedside. If use is not immediate after withdrawal from the narcotic cabinet,
wastage as per narcotic protocol will be carried out.
ü
To maintain narcotic control.
37.
Visiting is
negotiated between the nurse and family, with consideration given to
unit activity and institutional policy. All exceptions should
be reported nurse to nurse.
ü
It is important to communicate information to oncoming nurse to
avoid discrepancies.
38.
The number of visitors will be
limited to 2 at a time; however, the nurse may use
discretion based on patient condition and room activity.
ü
To promote privacy for other patients in the bay and to accommodate
space limitations.
39.
The nurse/physician will notify
families of significant deteriorations in the patient's condition.
ü
The family has the right to determine when they wish to attend
their family member.
40.
Support will be
given to family’s that would like children to visit. Special preparation of the children MUST BE done.
ü
Research has shown that allowing children to participate in the
grieving process can have a positive impact on subsequent adjustment to family
tragedy. Improper preparation can have a
negative and lasting impact.
41.
A visitor’s handout will be given to one member of each patient's family. Indicate on Nursing Note the date and family
member who received the booklet.
ü
To reduce the anxiety associated with visiting in the critical care
unit. To provide information regarding
resources available to families.
42.
All patients in Critical Care Unit will be weighed daily and on admission and recorded on the flow
sheet. Per week. For new hospital admission, record weight on nursing
admission database also.
ü
To accurately measure Body Surface Area, for calculating
hemodynamic indexed values, to identify drug dosages, to assess nutritional
requirements, to assess adequacy of nutritional status, and to evaluate fluid
balance.
43.
All patients in the critical care
unit will have a minimum IV access of two Heparin Locks.
ü
To ensure rapid resuscitation with IV drugs or fluid if needed.
Critical care patients are at sufficient risk to warrant access. When a patient's illness has become chronic
but stable, they may not have an immediate need for an IV, and staff may be
unable to secure a peripheral site. If despite reasonable attempts by a skilled
individual a peripheral IV cannot be secured, the risk
associated with a central line insertion may be deemed greater than the benefit
of having an IV access. Appropriate documentation must be included in the
clinical record to justify this decision.
44.
All change of shift reports will
include a review of all physician orders, lab results, medication
administration record, and joint review of neuron status.
ü
To ensure communication between shifts and reduce potential for
medication or treatment errors. Neuro
status is jointly reviewed to ensure that both
incoming and outgoing shifts are clear on interpretation of findings to be able
to promptly detect a change in patient condition.
45.
All staff working at a bedside where
an acute trauma or actively bleeding patient is being managed
will wear protective goggles, masks and gloves.
Protective gear is also required anytime risk of splash from body fluids
exists e.g. suctioning.
ü
Current literature shows that it is during periods of acute crisis
when health care workers are at the highest risk for disease transmission. This
has also been shown to be the time when health care
workers are least compliant with universal precautions. Masks, goggles and
gloves in high risk situations are a requirement as
per Hospital Universal Precautions Policies.
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