GENERAL NURSING PROTOCOL FOR CRITICAL CARE PATIENTS
nursebob
©10/10/2006


Normally the orientation for critical care nurses should last four to six weeks depending on the knowledge base of the nurse.  All orientation should be individualized.  This is in addition to that part of orientation call ed general hospital orientation.  By the time the new nurse arrives to the ICU they should have been introduced to the organization of the hospital, policies, hospital medication test, basic ICU knowledge assessment and the written emergency protocol skills lab should have all been completed.  Upon arrival to the ICU the new nurse should have identified weakness and strengths as a result of the basic knowledge and abilities test and the medication test.  The written exams for skills verification should have been competed.  After arrival to the ICU the performance checklist of specialized procedures should be completed within a few days.

Nursing, in conjunction with the ICU medical directors, will develop protocols which will define what medical therapy is to be started during emergencies.  Each emergency action protocol should be signed by each unit medical director and nurse manager and review annually. 

In addition to being able to perform each of the following all nurses providing care for ICU patients must be ACLS, PALS certified.

These protocols may include but are not limited to the following.

  1. Recognition and protocol treatment of life-threatening dysthrhymias (exam only)
  2. Defibrillation
  3. Cardioversion
  4. Transcutaneous pacing
  5. Central line insertions/ dressing changes
  6. Arterial puncture
  7. Suctioning
  8. Single pressure transducer system
  9. Arterial pressure monitoring, Pulmonary artery pressure monitoring
  10. Cardiac output determination
  11. Nursing care of patient on ventilator
  12. Interpretation of ABG
  13. Pediatric skills
  14. Intensive Care Unit Written Skills Verification Exam

Review of skills and knowledge should be conducted yearly and documented.

General Nursing Requirements of the Intensive Care Patient

The following are some general requirements for nursing care of the intensive care patients.

1.  No critical care patient will be left without a nurse in attendance.
            Rationale:  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.
            Rationale:  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. 
            Rationale:  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.
            Rationale:  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.
            Rationale:  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. 
            Rationale:  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.
            Rationale:  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.
            Rationale:  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, foley).
            Rationale:  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.
            Rationale:  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.
            Rationale:  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.
            Rationale:  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.
            Rationale:  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.
            Rationale:  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. 
            Rationale:  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.
            Rationale:  To ensure life-supporting tubes or lines are not disconnected.

17.  All restraints will be secured to allow rapid lowering of bedside.
            Rationale:  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.
            Rationale:  Correct tube placement is occasionally evaluated at post mortem.

 20.  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.
            Rationale:  To maintain consistency among all nurses.

21.  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.
            Rationale:  The night shift is quieter and less hectic

22.  All dressings unless otherwise indicated will be changed daily..
            Rationale:  To remove bacterial contaminates and replace with an aseptic dressing

23.  TED hose and SCD’s will be removed for thirty minutes once per shift.
            Rationale: To promote venous return and reduce thrombus formation and to permit circulation and inspection of the limb.

24.  Nursing care will be spaced out to allow periods of rest.
            Rationale:  Sensory overload predisposes the patient to disorientation.

25.  All patients who have not had a bowel movement will be checked for impaction q.3. days and the flow sheet updated.
            Rationale:  To monitor bowel function

26.  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.
            Rationale:  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.

27.  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.
            Rationale:  The critical nature of the patient's illness places tremendous strain on the patient and family unit.

28. 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.
            Rationale:  To reduce risks to patients, visitors, or staff.

 29.  Isolation technique will be followed as per infection control manual.
            Rationale:  To minimize cross infection to patients, visitors, and staff.

30.  Safety signs, such as,  "isolation", "can hear", or "neuromuscular blocking agent in use" will be posted when indicated
            Rationale:  To communicate important information

31. Sharps and glass will be disposed of into point of use sharps containers.
            Rationale:  To protect health care workers from injury/contamination.

32.  Any containers of body fluids (i.e. suction canisters or chest drainage sets) must be disposed in the approiate biohazard bag or box. 
            Rationale:  To reduce risk of contamination to health care workers during handling.

33.  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.
            Rationale:  Particularly with patients having access catheters into the heart, electrical shocks could pose serious risk for harm.

34.  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).
            Rationale:  To reduce risk for errors.

35.  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.)
            Rationale:  To ensure optimal management.

36.  Respiratory orders may only be carried out when written by the patients physician. Ventilatory changes will only be done upon receipt of written order. 
            Rationale:  To maintain optimal and consistent respiratory management

37.  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. Rationale:  To ensure all therapy is consistent with goals for the patient's management

38.  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.
            Rationale:  To maintain narcotic control.

39.  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. 
            Rationale:  It is important to communicate information to oncoming nurse to avoid discrepancies.

40.  The number of visitors will be limited to 2 at a time; hovever, the nurse may use discresion based on patient condition and room actiivity
            Rationale:  To promote privacy for other patients in the bay and to accommodate space limitations.

41.  The nurse/physician will notify families of significant deteriorations in the patient's condition.
            Rationale:  The family has the right to determine when they wish to attend their family member.

42. Support will be given to family’s that would like children to visit.  Special preparation of the children MUST BE done.
            Rationale: 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.

43.  A visitors 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.
            Rationale:  To reduce the anxiety associated with visiting in the critical care unit.  To provide information regarding resources available to families.

44.  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.
            Rationale:  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.

45.  All patients in the critical care unit will have a minimum IV access of two Heparin Locks.
            Rationale:  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.

46.  All change of shift reports will include a review of all physician orders, lab results, medication administration record, and joint review of neuro status.
            Rationale:  To ensure communication between shifts and reduce potential for medication or treatment errors.  Neuro status is jointly reviewed to ensure that both incoming and outcoming shifts are clear on interpretation of findings to be able to promptly detect a change in patient condition.

47.  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.
            Rationale:  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.

Reference: AACN Standards for Critical Care Nurses.

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