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Fundamentals of Critical Care. A Textbook for Nursing and Healthcare Students. Edition No. 1

  • Book

  • 544 Pages
  • September 2022
  • John Wiley and Sons Ltd
  • ID: 5837275

Fundamentals of Critical Care

A Textbook for Nursing and Healthcare Students

In Fundamentals of Critical Care, a team of clinicians and health educators deliver an accessible, timely, and evidence-based introduction to the role of nurses and healthcare practitioners in critical care. The book explores fundamental concepts in critical care and their implications for practice. Each chapter outlines essential knowledge necessary to understand key concepts and includes high quality, full-colour artwork to enhance learning and recall.

Readers are also provided with clinical scenarios, practice questions, and red and orange flags to indicate physiological and psychological alerts respectively. Covering a range of common and specialised disease processes and treatments requiring critical care, the book provides:

  • A thorough introduction to the critical care unit, including philosophies of care, ways of working, humanisation, and outreach
  • Comprehensive exploration of organisational influences, including political, local, national, and international influences
  • Practical discussion of legal, ethical, and professional issues, as well as evidence-based approaches to critical care
  • In-depth examination of nursing care assessment tools, nursing communication, cognition, pharmacology, and more

Perfect for nursing students and trainee nursing associates, Fundamentals of Critical Care: A Textbook for Nursing and Healthcare Students will also earn a place in the libraries of healthcare students in physiotherapy, paramedicine, medicine, and those returning to practice.

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Table of Contents

Contributors xix

Preface xxv

Acknowledgements xxvii

How to use your textbook xxix

About the companion website xxxi

Chapter 1 The critical care unit 1
Vikki Park

Introduction 2

Levels of care 2

The critical care environment 2

Critical care patients 3

Level 1 care 4

Level 2 care 4

Level 3 care 4

Critical care competence 5

The interprofessional team 6

Communication 7

Ways of working 7

Understanding philosophies of care 8

Humanising critical care 8

Surviving critical care 9

Death in critical care 9

Resilience 9

Nursing considerations and recommendations for practice 11

Future challenges 11

Conclusion 11

References 12

Chapter 2 Organisational influences 14
Vikki Park

Introduction 15

The four UK nations 15

Legislation 15

Professional Statutory Regulatory Bodies (PSRBs) 15

Shared decision making 16

Capacity for shared decision making 16

Confidentiality 17

Decisions relating to end-of-life care 17

Risk management 18

International influences 18

National influences 18

UK government organisations 18

Networks 19

National guidelines 20

Quality assurance 20

Local policies 21

Nursing considerations and recommendations for practice 21

Conclusion 21

References 22

Chapter 3 Legal and ethical issues 24
Leonie Armstrong, Tracey Carrott, and Jacqueline Newby

Introduction 25

Confidentiality 25

End-of-life care and best interest decisions 26

Ethical themes 27

Mental Capacity Act 27

Organ donation 29

Consent (authorisation in Scotland) for organ donation 30

First person consent 31

First person opt-in 31

First person opt-out 31

Appointed/nominated representative (not Scotland) 31

Deemed consent 31

The ethics of deemed consent 32

Consent from a person in the highest-ranking relationship 32

Cadaveric organ donation 33

The organ donation process 33

Post organ retrieval 34

Organ allocation 34

Conclusion 35

References 35

Chapter 4 Professional issues in critical care 37
Aurora Medonica

Introduction 38

Opportunities for learning 38

NMC Code in critical care units: journey to independent, safe practice 38

The core principles 39

UK National Competency Framework: critical care 41

Development of critical thinking in healthcare 42

The prioritising process 42

Support systems: the student 44

Conclusion 44

References 45

Chapter 5 Using an evidence-based approach 46
Sadie Diamond-Fox and Alexandra Gatehouse Introduction 47

What is evidence-based practice (EBP)? 47

Step 1: formulating a clinical question - the PICO method 48

Step 2: locating the evidence/research: performing a systematic literature review 48

Step 3: critical appraisal and the hierarchy of evidence 49

Step 4: extracting the most relevant and useful results 51

Step 5: implementing research into practice 52

Quality healthcare in critical care 53

Clinical audit and quality improvement 53

Research and development in critical care 55

Conclusion 56

References 56

Chapter 6 Nursing care 58
Sarah Crowe and Fiona McLeod

Introduction 59

Standards of care 59

Physical care 63

Mobility 66

Critical care bundles 67

Conclusion 67

References 68

Chapter 7 Skin integrity 70
Victoria Clemett

Introduction 71

Anatomy and physiology of the skin 71

Impact of ageing on skin and tissue integrity 71

Pressure ulcers 71

Nursing assessment 75

Prevention of pressure ulcers 76

Management of pressure ulcers 79

Wound healing 79

Patient factors that affect wound healing 79

Nursing assessment 79

Recognising wound infection 81

Management of non-healing wounds 83

Conclusion 83

References 84

Chapter 8 Shock 86
Barry Hill

Introduction 87

Shock 87

Hypovolaemic shock 87

Blood analysis 88

Multiple organ dysfunction syndrome 89

Staging of hypovolaemic shock 89

Principles of managing hypovolaemic shock 90

Fluid resuscitation 91

Training and education for Registered Nurses 91

Cardiogenic shock 91

Obstructive shock 93

Altered pathophysiology 93

Tension pneumothorax 94

Cardiac tamponade 94

Pulmonary embolism (PE) 94

Distributive shock 95

Conclusion 96

References 97

Chapter 9 Communication 98
Paul Jebb

Introduction 99

Communicating effectively with patients 100

Communicating during a pandemic 100

Communication with families 102

Conclusion 103

References 103

Chapter 10 Electronic health records 105
Timothy Kuhn

Introduction 106

Digitisation within healthcare 106

Understand your responsibilities and the law in relation to record keeping 107

Intensive Care Society Guidelines 107

Understanding the different types of EHRs in critical care and how they are used 108

Understanding what patient data is available within the critical care unit and how this is recorded in an electronic health record 109

Understanding how EHRs are used in critical care audit and research 110

Understanding the benefits and barriers to EHRs 112

Conclusion 113

References 113

Chapter 11 Pharmacology 115
Sadie Diamond-Fox and Alexandra Gatehouse

Introduction 116

Principles of pharmacology and pharmacotherapy 116

The processes of drug therapy 116

Medication safety in critical care 119

Drugs and dialysis 120

Core drugs utilised within critical care 120

Respiratory drugs 120

Cardiovascular drugs 122

Haematological drugs 126

Renal drugs 126

Fluids and electrolytes 127

Gastrointestinal drugs 128

Insulin 129

H2-histamine antagonists and proton pump inhibitors (PPIs) 129

Anti-emetics 129

Laxatives and anti-diarrhoeal drugs 130

Neurological drugs 130

Analgesics 130

Opioids 130

Non-opioid analgesics 130

Epidural and regional anaesthesia 130

Sedatives and anxiolytics 131

Muscle relaxants 131

Anticonvulsants 132

Antideliriogenics 132

Immunomodulatory drugs 132

Antibacterial agents 132

Antifungals 133

Antiviral drugs 134

Corticosteroids 134

Immunoglobulins 134

Toxicology 134

Conclusion 135

References 135

Chapter 12 Anaesthesia and sedation 138
Lorraine Mutrie and Iain Carstairs

Introduction 139

Indications for sedation and anaesthesia 139

Anaesthetic and sedative medications 142

Sedative drugs 142

Neuromuscular blocking agents and reversal agents 143

Sedation management 145

Conclusion 147

References 148

Chapter 13 Medicines management and drug calculations 150
Jan Guerin

Introduction 151

Purpose of pharmacological interventions in the critically ill adult patient 152

Legal and professional issues 152

Collaborative multidisciplinary team working 154

Medication errors 154

Overview of routes and methods of administering medications in CCU 155

Rights of medication administration 158

Managing and reporting a medication error 159

Anaphylaxis 160

Pathophysiology and clinical manifestations of DIA 160

Management for DIA 160

Medication calculation formulae 160

Displacement 165

Conclusion 165

References 166

Chapter 14 Neurological critical care 167
Samantha O’Driscoll

Introduction 168

Neurological anatomy and physiology 168

Central nervous system 169

Neurological assessment 174

Signs and symptoms of increasing ICP 179

Primary and secondary brain injury 180

Management of raised ICP 180

Nursing care 181

Transfer 182

Conclusion 184

References 184

Chapter 15 Cognition 186
Barry Hill and Sadie Diamond-Fox

Introduction 187

Cognitive impairment 187

Causes of cognitive impairment 187

Signs of cognitive impairment 188

Delirium 188

Risk factors 190

Management of delirium 191

Sleep 193

Assessment of sleep in ICU 193

Conclusion 195

References 195

Chapter 16 Respiratory care: intubation and mechanical ventilation 197
Barry Hill and Lorraine Mutrie

Introduction 198

Respiratory failure 198

Hypoventilation 198

Ventilation/perfusion (V/Q) mismatch 199

Work of breathing 199

Arterial blood gases (ABGs) 200

Non-invasive

ventilation (NIV) 201

Continuous positive airway pressure (CPAP) 204

High flow nasal oxygen 204

Intubation 204

Mechanical ventilation 206

Artificial ventilation 207

Minute ventilation (Vm) 207

Fraction of inspired oxygen 207

Positive end-expiratory

pressure (PEEP) 207

Volume control 207

Pressure control 207

Inspiratory:Expiratory (I:E) ratio 208

Inverse ratio 208

Synchronisation 208

Humidification 208

Benefits of mechanical ventilation 208

Risks of mechanical ventilation 208

Ventilator care bundles 209

Prone positioning 209

Prone positioning in COVID-19 209

Weaning from mechanical ventilation 210

Conclusion 210

References 211

Chapter 17 Lung function in critical care 213
Rana Din and Joyce Smith

Introduction 214

Anatomy and physiology 214

Composition of air 215

Alveolar gas 215

Expired air 216

Lung volumes 216

Pulmonary ventilation 216

External respiration 217

Ventilation/Perfusion 217

Transport of gases 217

Internal respiration 218

Assessment of lung function 220

Normal breath sounds (vesicular) 221

Absent Sounds 221

Wheeze 222

Crackles 222

The work of breathing 222

Compliance 222

Resistance 222

Emphysema 222

Asthma 223

Obstructive sleep apnoea 224

Prone positioning 224

Conclusion 225

References 226

Chapter 18 Cardiac physiology 227
Paul Sinnott

Introduction 228

Functions of the cardiovascular system 228

Anatomy of the heart and great vessels 228

Pericardium 229

Layers of the heart 229

Chambers of the heart 230

Valves of the heart 230

Coronary circulation 232

Cardiac conduction system 235

The cardiac cycle 236

Cardiac output and blood pressure 237

Regulation of heart rate 238

Stroke volume 239

The regulation of blood pressure 240

The microcirculation 242

Capillary exchange 243

Effects of ventilation on the cardiovascular system 245

Conclusion 245

References 246

Chapter 19 Cardiovascular critical care 247
Alice Shaw and Paul Sinnott

Introduction 248

Cardiovascular assessment 248

Heart rate and rhythm 248

Atrial ectopic beats 249

Ventricular ectopic beats 253

Blood pressure 254

Invasive blood pressure monitoring 255

Central venous catheters (CVCs) and central venous pressure (CVP) 256

Markers of organ and tissue perfusion 258

Neurological status 258

Urine output 258

Blood results 259

Advanced haemodynamic monitoring 260

Cardiac pacing 262

Nursing considerations and recommendations for practice 263

Conclusion 263

References 263

Chapter 20 Fluids and electrolytes in critically ill patients 265
Barry Hill

Introduction 266

The role of the critical care nurse 266

Intravenous fluids 266

Crystalloids versus colloids critical care 267

Fluid management 268

Third spacing 269

Assessment and monitoring 269

Training and education 271

Electrolyte replacement therapy 271

Management of hyperkalaemia 272

Oral sodium and water 272

Oral rehydration therapy (ORT) 272

Oral bicarbonate 273

Parenteral preparations for fluid and electrolyte imbalance 273

Plasma and plasma substitutes 276

Plasma substitutes 276

Fluid overload 276

The four Ds of fluid management 276

Hyponatraemia 277

Hypernatraemia 277

Hypokalaemia 277

Hyperkalaemia 277

Hypophosphataemia 278

Hypocalcaemia 278

Hypomagnesaemia 278

Conclusion 279

References 279

Chapter 21 Critical care emergencies 280
Alexandra Gatehouse and Sadie Diamond-Fox

Introduction 281

A - Airway 282

B - Breathing 290

C - Circulation/Cardiovascular 291

D - Disability 298

E - Everything else (exposure, endocrine, electrolytes and environmental) 301

Care of the patient post return of spontaneous circulation (ROSC) 307

Critical care emergencies and human factors 307

Debriefing 309

Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) 309

Conclusion 310

References 310

Chapter 22 Gastrointestinal critical care 313
Anna Riley, Joe Box, and Aileen Aherne

Introduction 314

Anatomy and physiology 314

GI monitoring and investigation in the critically ill 317

Imaging and endoscopy 318

Bowel charts and abnormal GI motility 320

The acute abdomen in critical care 322

Common surgical procedures cared for in critical care 325

Post-operative monitoring 325

Abdominal surgical drains 326

Anaesthetics 326

Post-operative complications 326

Wound dehiscence 327

GI pharmacology 327

Conclusion 328

References 328

Chapter 23 Nutrition in critical care 330
Barry Hill and Lorraine Mutrie

Introduction 331

Pathophysiology 331

Fight or flight 332

Resistance 332

Exhaustion 332

Nutritional screening and assessment 333

Indirect calorimetry (IC) 333

Routes of administration 334

Nursing considerations and recommendations for practice 336

Care of people with feeding tubes 336

Glycaemic control 337

Refeeding syndrome 338

Discontinuing feed 339

Nutritional guidance 339

Conclusion 340

References 341

Chapter 24 Renal critical care 343
Alexandra Gatehouse and Sadie Diamond-Fox

Introduction 344

Anatomy and physiology of the renal tract 344

Vascular supply 344

Renin-angiotensin-aldosterone system (RASS) 344

The nephrons 345

Control of plasma osmolality 346

Electrolyte balance 346

Acid-base balance 352

Renal failure 352

Acute kidney injury 353

Classification of AKI 353

Pathophysiology 353

Organ cross-talk 354

Risk factors for AKI 355

Clinical features and examination 355

Investigations 355

Specific disorders associated with AKI 357

Drug-induced renal damage 357

Management of AKI 359

Clinical features and examination 361

Management 361

Chronic kidney disease 362

Management 362

Diabetic nephropathy 362

Continuous renal replacement therapy (CRRT) 364

Dosing of CRRT 364

Anticoagulation 364

Drug dosing and RRT 367

Kidney transplantation - critical care considerations 367

Conclusion 368

References 368

Chapter 25 Endocrine critical care 370
Geraldine Fitzgerald O’Connor and Emma Long

Introduction 371

Thyroid and parathyroid glands 371

Disorders of the thyroid gland 371

Thyroid crisis 372

Parathyroid glands 372

Disorders of the parathyroid glands 372

Hypocalcaemia 373

Pituitary gland 373

Disorders of the pituitary gland 373

Diabetes insipidus 374

Pathophysiology 375

Hyperglycaemia in the critically ill 376

Diabetic emergencies 376

Pathophysiology 380

Conclusion 383

References 384

Chapter 26 Haematological and immunological critical care 385
Barry Hill, Gerri Mortimore, and Pamela Arasen

Introduction 386

Normal physiology 386

Blood components 386

Haematopoiesis 387

Disorders of erythrocytes 387

B12 vitamin deficiency 387

Sickle cell anaemia 388

Genetic haemochromatosis 389

Haemostasis 390

Lymphoma 390

Disseminated intravascular coagulation 393

Thrombocytopenia 394

Neutropenia and sepsis 394

Vasculitis 396

Blood transfusions in adults 397

Blood sample collections 398

Blood groups 398

Compatibility 399

Indications for blood transfusions 399

Platelets 400

Fresh frozen plasma (FFP) 400

Cryoprecipitate 400

Granulocytes 400

Procedural safety 400

Pre-procedure and sampling 400

Administration of the blood product 400

Post-procedural care 401

Traceability 401

Patient information 402

Alternatives to blood transfusions 403

Summary of SaBTO recommendations on consent 403

Conclusion 408

References 408

Chapter 27 Musculoskeletal considerations in critical care 411
Clare L. Wade and Helen Sanger

Introduction 412

Trauma 412

Management of traumatic injury 413

Intensive care unit-acquired weakness 415

Assessment of musculoskeletal impairment or injury 418

Management of musculoskeletal injury and impairment 419

Conclusion 424

References 424

Chapter 28 Burn care within a critical care setting 426
Nicole Lee

Introduction 427

Classification of burn wound depths 427

Pathological considerations 429

Burn size estimation 430

An ABCDE approach to burn care 432

Breathing 433

Cardiovascular 433

Disability (neurological assessment) 434

Exposure (and everything else) 434

Psychological support 434

Acknowledgement 436

References 436

Chapter 29 Maternal critical care 438
Wendy Pollock

Introduction 439

Epidemiology 439

Adapted physiology 439

Recognising clinical deterioration 441

Nursing considerations and recommendations for practice 442

Conclusion 448

References 449

Chapter 30 Critical care transfers 451
Kirstin Geer, Mark Cannan, and Stuart Cox

Inter-hospital and intra-hospital patient transfers 452

Transfer of the critically ill adult 452

Critical care bed and repatriation 456

The risks of critical care transfer 457

Preparation for transfer 458

ABCDE process during critical care transfer 458

Conclusion 469

References 469

Chapter 31 Rehabilitation after critical illness 470
Helen Sanger and Clare L. Wade

Introduction 471

The impact of critical illness - what do we mean by morbidity? 471

Describing physical functioning and morbidity 472

Models of post-critical care morbidity 473

Assessment 473

Goals 475

Key timepoints in RaCI 477

Treatment 478

National guidelines and standards 480

Conclusion 481

References 481

Chapter 32 Dying and death 484
Helen Merlane and Leonie Armstrong

Introduction 485

End-of-life care 485

Palliative care 486

Dying 486

Recognising Dying 486

Advance care planning 488

Involve and support 489

Nursing the dying patient 489

The critical care environment 489

Symptom management 490

End-of-life care discharges from a critical care setting 491

Care after death 494

Conclusion 495

References 495

Index 497

Authors

Ian Peate University of Hertfordshire, UK. Barry Hill Northumbria University, UK.