Crtitical Care Nursing

Imran Yousafzai
Lecturer KMU
 Critical Thinking
Critical thinking is a multidimensional skill, a cognitive
or mental process or set of procedures. It involves
reasoning and purposeful, systematic, reflective,
rational, outcome-directed thinking based on a body
of knowledge, as well as examination and analysis of
all available information and ideas. Critical thinking
leads to the formulation of conclusions and the most
appropriate, often creative, decisions, options, or
alternatives (Ignatavicius, 2001; Prideaux, 2000).
 CRITICAL THINKING
IN NURSING PRACTICE
Using critical thinking to develop a plan of nursing care requires
considering the human factors that might influence the plan. The
nurse interacts with the patient, family, and other health care
providers in the process of providing appropriate, individualized
nursing care. The culture, attitude, and thought processes of the
nurse, the patient, and others will affect the critical thinking
process
from the data-gathering stage through the decision-making stage;
therefore, aspects of the nurse-patient interaction must be
considered
(Wilkinson, 2001).
 Critical thinking Continue…
Nurses must use critical thinking skills in all practice settings—
acute care, ambulatory care, extended care, and in the home
and community. Regardless of the setting, each patient situation
is viewed as unique and dynamic.

The unique factors that the patient and nurse bring to the health
care situation are considered, studied, analyzed, and
interpreted. Interpretation of the information presented then
allows the nurse to focus on those factors that are most relevant
and most significant to the clinical situation. Decisions about
what to do and how to do it are then developed into a plan of
action.
 End-of-Life Issues
Dilemmas that center on death and dying are prevalent in
nursing practice and frequently initiate moral discussion.
The dilemmas are compounded by the fact that the idea of
curing is paramount in health care. With advanced
technology, it may be difficult to accept the fact that
nothing more can be done, or that technology may
prolong life but at the expense of comfort and quality of
life. Focusing on the caring as well as the curing role may
assist nurses in dealing with these difficult moral
situations.
 DO-NOT-RESUSCITATE ORDERS
The “do not resuscitate” (DNR) order is a controversial issue.
When a patient is competent to make decisions, his or her choice
for a DNR order should be honored, according to the principles
of autonomy or respect for the individual (Trammelleo, 2000).
However, a DNR order is at times interpreted to mean that the
patient requires less nursing care, when actually these patients
may have significant medical and nursing needs, all of which
demand
attention. Ethically, all patients deserve and should receive
appropriate nursing interventions, regardless of their resuscitation
status.
 LIFE SUPPORT
In contrast to the previous situations are those in which a
DNR decision has not been made by or for a dying
patient. The nurse may be put in the uncomfortable
position of initiating life-support measures when,
because of the patient’s physical condition, they appear
futile. This frequently occurs when the patient is not
competent to make the decision and the family (or
surrogate decision maker) refuses to consider a DNR
order as an option. The nurse may be told to perform a
“slow code” (ie, not to rush to resuscitate the patient) or
may be given a verbal order not to resuscitate the
patient; both are unacceptable medical orders
The best
recourse for nurses in these situations is to be aware of hospital
policy related to the Patient Self-Determination Act (discussed
later) and execution of advance directives. The nurse should
communicate with the physician. Discussing the matter with the
physician may lead to further communication with the family
and to a reconsideration of their decision, especially if they are
afraid to let a loved one die with no further efforts to resuscitate
(Trammelleo, 2000). Finally, when working with colleagues who
are confronting such difficult situations, it helps to talk and listen
to their concerns as a way of providing support.
 Ethical Decision Making
As noted in the preceding discussions, ethical
dilemmas are common and diverse in nursing
practice. Although the situations vary and
experience indicates that there are no clear
solutions to these dilemmas, the fundamental
philosophical principles are the same, and the
process of moral reflection will help nurses to justify
their actions. The approach to ethical decision
making can follow the steps of the nursing process.
 STRESS AND ADAPTATION
Stress is a state produced by a change in the
environment that is perceived as challenging,
threatening, or damaging to the person’s
dynamic balance or equilibrium. The person is,
or feels, unable to meet the demands of the
new situation. The change or stimulus that
evokes this state is the stressor.
• The desired goal is adaptation, or adjustment
to the change so that the person is again in
equilibrium and has the energy and ability to
meet new demands.

• This is the process of coping with the stress, a

compensatory process with physiologic and
psychological components.
 Adaptation
• Adaptation is a constant, ongoing process that
requires a change in structure, function, or
behavior so that the person is better suited to
the environment; it involves an interaction
between the person and the environment. The
outcome depends on the degree of “fit”
between the skills and capacities of the person,
the type of social support available, and the
various challenges or stressors being confronted.
 Stressors
• Each person operates at a certain level of
adaptation and regularly encounters a certain
amount of change. Such change is expected; it
contributes to growth and enhances life.
Stressors, however, can upset this equilibrium.
A stressor may be defined as an internal or
external event or situation that creates the
potential for physiologic, emotional, cognitive,
or behavioral changes in an individual.
 TYPES OF STRESSORS
Stressors exist in many forms and categories. They
may be described as physical, physiologic, or
psychosocial. Physical stressors include cold, heat,
and chemical agents; physiologic stressors include
pain and fatigue. Examples of psychosocial stressors
are fear of failing an examination and losing a job.
Stressors can also occur as normal life transitions
that require some djustment, such as going from
childhood into puberty, getting married, or giving
birth.
 STRESS AS A STIMULUS FOR DISEASE

• Relating life events to illness (the theoretical

approach that defines stress as a stimulus) has
been a major focus of psychosocial studies.
This can be traced to Adolph Meyer, who in the
1930s observed in “life charts” of his patients a
linkage between illnesses and critical life
events. Subsequent research revealed that
people under constant stress have a high
incidence of psychosomatic disease.
 Coping With the Stressful Event
• Coping, according to Lazarus, consists of the
cognitive and behavioral efforts made to
manage the specific external or internal
demands that tax a person’s resources and
may be emotionfocused or problem-focused.
• Coping that is emotion focused seeks to make
the person feel better by lessening the
emotional distress felt. Problem-focused
coping aims to make direct changes in the
environment so that the situation can be
managed more effectively. Both types of
coping usually occur in a stressful situation
NURSING IMPLICATIONS
 NURSING IMPLICATIONS
• It is important for the nurse to realize that the
optimal point of intervention to promote
health is during the stage when the
individual’s own compensatory processes are
still functioning. Early identification of both
physiologic and psychological stressors
remains a major role of the nurse.
 NURSING IMPLICATIONS
The nurse should be able to relate the
presenting signs and symptoms of distress to
the physiology they represent and identify the
individual’s position on the continuum of
function, from health and compensation to
pathophysiology and disease.
For example, if an anxious middle-aged woman
presented for a checkup and was found to be
overweight, with a blood pressure of 130/85 mm
Hg, the nurse would counsel her with respect to
diet, stress management, and activity. The nurse
would also encourage weight loss and discuss the
woman’s intake of salt (which affects fluid balance)
and caffeine (which provides a stimulant effect). The
patient and the nurse would identify both individual
and environmental stressors and discuss strategies
to decrease the lifestyle stress, with the ultimate
goal being to create a healthy lifestyle and prevent
hypertension and
THANKS