CRITICAL CARE NURSES ASSOCIATION OF THE PHILIPPINES, INC.

8th Floor Medical Arts Building, Philippine Heart Center, East Avenue, Quezon City, Philippines
Tel. No. 925-2401 local 3823 Telefax No. (63-2) 426-4394
email address: ccnapi_nurses@[Link]
website: [Link]

GUIDELINES FOR CRITICAL CARE NURSING

1. INTRODUCTION

The health care industry all over the world has been undergoing great changes over the past two decades and the Philippines has been part of these
transformational events having great impact on the quality of nursing practice. There are new expectations in the way nurses and the nursing practices are to be
delivered particularly now that there are many challenges that besiege the present time as a consequence of the complexities of globalization.

In the Philippines, the Professional Regulation Commission – Board of Nursing (PRC-BON) is committed to provide need-driven, effective and efficient specialty
nursing care services of high standard and at international level within the obtainable resources. To respond to this mission and commitment, a PRC-BON
Working Group in Developing the Nursing Specialty Framework was formed sometime in 1996 to take on the task of setting the process-based framework and
guidelines for specialty nursing services. Working Group members comprise clinical nurse practitioners, nurse educators and nurse managers 1.

However, the expanding healthcare and nursing knowledge together with new and evolving healthcare sites, structures, and technologies all have contributed to
the need and desire for specialty nursing organizations like the Critical Care Nurses Association of the Philippines, Inc. (CCNAPI) to revisit the existing statement
of its Standards of Nursing Practice in order to provide clear and updated statements regarding the scopes of practice and standards of critical care nursing. This
will ensure continued understanding and acknowledgment of nursing’s varied specialty professional contributions in today’s healthcare environment.

Critical care nursing is that specialty within nursing that deals specifically with human responses to life-threatening problems 2. These problems deal dynamically
with human responses to actual or potential life-threatening illnesses.

The framework of critical care nursing is a complex, challenging area of nursing practice which utilizes the nursing process applying assessment, diagnosis,
outcome identification, planning, implementation, and evaluation. The critical care nursing practice is based on a scientific body of knowledge and incorporates
the professional competencies specific to critical care nursing practice and is focused on restorative, curative, rehabilitative, maintainable, or palliative care,
based on identified patient need3. It upholds multi and interdisciplinary disciplinary collaboration in initiating interventions to restore stability, prevent
complications, achieve and maintain optimal patient responses. The critical care nursing profession requires a clear description of the attributes, guidelines and
nursing practice standards in guiding the critical care nursing practice to fulfill this purpose.

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The critical care nursing competencies statements developed in 2005 are aligned with the PRC-BON statement of the 11 Core Competencies for Entry Level for
Safe and Quality Nursing Care. The CCNAPI Core Competencies of a Critical Care Nurse are stated according to the levels of expected behavior defining the
actual knowledge, skills and abilities in the practice of critical care by a nursing professional. These statements cover expected behavior of a Nurse Clinician I,
Nurse Clinician II and Nurse Specialist that will serve as the basis for assessing competence in critical care practice.
In the CCNAPI Standards of Practice, there is no statement that covers the goals, scope of practice and procedural standards in the care of the critically ill.
Hence, these are important aspects that should be covered in this working paper.

The focus of care for the critically ill patient is holistic. However, to organize statement in this paper physiological focus will be categorized under bodily
functional systems such as pulmonary system, cardiovascular system, renal system, neurological system and other system.

The specific objectives of developing this paper are:

1.1 To identify Critical Care Nursing Service characteristics and contributions of nurses to patient care in the specialty.

1.2 To develop specific competencies required for the delivery of nursing care in the critical care.

1.3 To provide a framework for evaluation of nursing practice within the specialty of critical care.

1.4 To provide a basis for the assessment of staff development needs in the critical care nursing.

1.5 To guide the development of collaborative relationship with other members of the health care team.

This process-based framework not only describes the critical care nursing services in Philippines, but also assists critical care nurses to have a better
understanding of what is expected of them from the organization and the public perspectives.

2. PHILOSOPHY OF CRITICAL CARE NURSING

Critical care nursing reflects a holistic approach in caring of patients. It places great emphasis on caring the bio-psycho-social-spiritual nature of human beings
and their responses to illnesses rather than the disease process. It helps to maintain the individual patient’s identity and dignity. The caring focus includes
preventive care, risk factor modification and education to decrease future patient admission to acute care facilities.

The Critical Care Nurses of the Philippines, Inc. (CCNAPI) believes that as an organization of critical care nurses, it is conscious of its responsibility for the
promotion of man’s health and welfare for national development, and has the desire to give support for professional and personal growth and development.
CCNAPI has organized itself into a national association committed to the ideals of service to the people, equality, justice and social progress.

In the Critical Care Units, each patient is viewed as a unique individual with dignity and worth. The critically ill patient should receive comfort and privacy in a
highly technological environment. In collaboration with other health care team members, critical care nurses provide high level of patient care which includes
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patient and family education, health promotion and rehabilitation. To achieve this holistic care process, participation by the patient and his/her family is always
emphasized. At the forefront of critical care science and technology, critical care nurses maintain professional competence based on a broad base of knowledge
and experience through continuous education and evidence-based research.

With advances in sophisticated biomedical technology and knowledge, critical care nurses are able to continuously monitor and observe patients for
physiological changes to confront problems proactively and to assist patients to achieve and maintain an optimum level of functioning or a peaceful death.

In other words, this nursing philosophy of the CCNAPI is accomplished by looking after critically ill patient in an environment with specially trained nurses,
appropriate equipment, adequate medical supplies and auxiliary health care personnel.

3. GOALS OF CRITICAL CARE NURSING

Critical or intensive care is a complex specialty developed to serve the diverse health care need of patients (and their families) with actual or potential life
threatening conditions3. It is therefore important that a clear statement of what critical care nursing wish to achieve and provide should be articulated.

Goals of critical care nursing include the following:

To promote optimal delivery of safe and quality care to the critically ill patients and their families by providing highly individualized care so that the
physiological dysfunction as well as the psychological stress in the ICU are under control

To care for the critically ill patients with a holistic approach, considering the patient’s biological, psychological, cultural and spiritual dimensions
regardless of diagnosis or clinical setting.

To use appropriate and up-to-date knowledge, caring attitude and clinical skills, supported by advanced technology for prevention, early detection and
treatment of complications in order to facilitate recovery.

To provide palliative care to the critically ill patients in situations where their health status is progressing to unavoidable death, and to help the patients
and families to go through the painful sufferings.

On the whole, critical care nursing should be patient-centered, safe, effective, and efficient. The nursing interventions are expected to be delivered in a timely
and equitable manner.

4. SCOPE CRITICAL CARE NURSING

The scope of critical care nursing is defined by the dynamic interaction of the critically ill patient, the critical care nurse and the critical care environment in order
to bring about optimal patient outcomes through nursing proficiency within an environment conducive to the provision of this highly specialized care 4.
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Constant intensive assessment, timely critical care interventions and continuous evaluation of management through multidisciplinary efforts are required to
restore stability, prevent complications and achieve optimal health. Palliative care should be instituted to alleviate pain and sufferings of the patient and family
in situations where death is imminent.

Critical Care Nurses are registered nurses, who are trained and qualified to practice critical care nursing. They possess the standard critical care nursing
competencies in assuming specialized and expanded roles in caring for the critically ill patients and their family. Likewise, the critical care nurse is personally
responsible and committed to continues learning and updating of knowledge and skills. The critical care nurses carry out interventions and collaborates patient
care activities to address life-threatening situations that will meet patient’s biological, psychological, cultural and spiritual needs.

The critical care environment constantly supports the interaction between the critically ill patients, their family and the critical care nurses to achieve desired
patient outcomes. It entails readily available and accessible emergency equipment, sufficient supplies and effective supporting system to ensure quality patient
care as well as staff safety and productivity.

5. ROLES OF THE CRITICAL CARE NURSES

In response to changes and expansion within and outside the healthcare environment, critical care nurses have broadened their roles at both practice and
advanced practice levels. Competencies of critical care nurses are honed and developed to achieve their roles as a practitioner, manager / leader and researcher.

5.1 Practitioner Role

ICU nurses execute their practice roles 24-hours a day to provide high quality care to the critically ill patient.

5.1.1 Care Provider

a. Direct patient care
1. Detects and interprets indicators that signify the varying conditions of the critically ill with the assistance of advanced technology
and knowledge.
2. Plans and initiates nursing process to its full capacity in a need-driven and proactive manner.
3. Acts promptly and judiciously to prevent or halt deterioration when conditions warrant.
4. Co-ordinates with other healthcare providers in the provision of optimal care to achieve the best possible outcomes.
b. Indirect patient care – Care of the Family
1. Understands family needs and provide information to allay fears and anxieties.
2. Assists family to cope with the life-threatening situation and/or patient’s impending death.

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 5.1.2 Extended Roles as critical care nurses

Critical care nurses have roles beyond their professional boundary. With proper training and established guidelines, algorithms, and protocols that
are continuously reviewed and updated, critical care nurses also perform procedures and therapies that are otherwise done by doctors. Such
procedures and therapies are:

a. Sampling and analyzing arterial blood gases;

b. Weaning patients off ventilations;
c. Adjusting intravenous analgesia / sedations;
d. Performing and interpreting ECGs;
e. Titrating intravenous and central line medicated infusion and nutrition support; and
f. Initiating defibrillation to patient with ventricular fibrillation or lethal ventricular tachycardia.
g. Removal of pacer wire, femoral sheaths and chest tubes
h. Other procedures deemed necessary by their respective institution under a clinical protocol.

5.1.3 Educator
a. Provides health education to patient and family to promote understanding and acceptance of the disease process and to facilitate recovery.

b. Participates in the training and coaching of novice healthcare team members to achieve cohesiveness in the delivery of patient care.

5.1.4. Patient Advocate

a. Acts in the best interest of the patient.
b. Monitors and safeguards the quality of care which the patient receives.

5.2. Management and Leadership Role

The critical care nurse in her management and leadership role will be able to render the following
responsibilities:
a. Perform management and leadership skills in providing safe and quality care
b. Accountability for safe critical care nursing practice
c. Delivery of effective health programs and services to critically-ill patients in the acute setting
d. Management of the critical care nursing unit or acute care setting
e. Take lead and supervision among nursing support staff
f. Utilize appropriate mechanism for collaboration, networking, linkage –building and referrals.

5.3. Researcher Role

The critical care nurse in her researcher role will be able to render the following responsibilities:
a. Engage self in nursing or other health –related research with or under supervision of an experienced researcher.
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 b. Utilize guidelines in the evaluation of research study or report
c. Apply the research process in improving patient care infusing concepts of quality improvement and in partnership with other team-players

Advanced Practice Level

This is the future direction in the Philippines and to be benched marked with other countries. For now, a thorough study of Advanced Practice Nursing in critical care
will be pursued to align with the BON initiative on specialization framework.

The current healthcare environment demands intensive care nurses to have advanced knowledge and skills to provide the highest possible level of care to the
critically ill patients.

5.1.4 Expanded Roles

a. Nurse Specialist / Clinical Nurse Specialist

Typically, the education and preparation of the critical care nurse practitioner is provided by the respective hospital or institution without advanced
educational preparation beyond that of the basic baccalaureate degree. Advanced educational preparation refers to the care nursing training
program run by the university or Institute offering Advanced Nursing Studies or other recognized critical care program both local and overseas.
A registered nurse, who is a nursing degree holder, should have more than more than years of uninterrupted practice experience in the
critical care field and has attained advanced education and expertise in caring patients with critical problems can function as a critical care nurse
specialist. He /She is also eligible to be accredited by the PRC- Board of Nursing as a Clinical Nurse Specialist. The Hospital Authority supports this
accreditation.

The critical care nurse specialist is responsible for building up nursing competencies in the ICU entity. He / She contributes to continuous
improvement in critical care nursing through staff and clients education and uphold quality nursing guidelines and patient care through clinical
research and refinement of ICU standards.

b. Advanced Practice Nurse

Advanced Practice Nurse (APN) in the critical care unit takes lead in developing practices to meet changing clinical needs and to facilitate patient
care processes across professional and organizational boundaries. He /She should have the recommended number of post registration nursing
experience, which are spent in the critical care field, exhibiting in-depth professional knowledge and skills. An APN (Critical Care) is a holder of a)
clinical master degree in a clinical nursing specialty (Medical-Surgical) such as Critical Care Nursing OR b) master degree in nursing or related
discipline / management together with recognized critical care training qualification(s). The Advanced Practice Nurse executes the nursing team
leader’s responsibilities as designated in the position of APN (NO) or APN (Ward/Unit Management).

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 c. Outcomes Manager
Outcome management has been introduced into the healthcare system to ensure achievement of quality and cost-effectiveness in the delivery
of patient care. Some critical care units have adopted clinical pathways (e.g., Critical Pathways, Protocols, Algorithms and Orders) in the
management of specific diseases such as Acute Myocardial Infarction and Cardio-thoracic Surgeries. Qualified nurse experts are involved in the
development and implementation of patient outcomes management.

5.2 Challenges that critical nurses will face:

The challenging needs from the critical care nursing service and its environments demand the nurses:

5.2.1 To develop, foster and maintain a level of knowledge about the norms, values, beliefs, patterns of ill health and care needs of the people;
5.2.2 To analyze and evaluate specialist skills and criticize their evolving roles;
5.2.3 To review current studies and researches and to examine contextual issues thus enabling evaluation and synthesis of new knowledge, traditional
techniques, religious and cultural influences to be applied in nursing practice, particularly, evidence-based nursing practice; and
5.2.4 To exercise professional judgments expected of them in the critical care clinical setting.

6. TRAINING OF NURSES FOR CRITICAL CARE SERVICES

The institution / hospital should provide training opportunities to ensure staff competencies. This will enable the nurses working in the critical care units to cope
with the complexities and demands of the changing needs of the critically ill patients. The following training activities should be supported in order to maintain
a high standard of care:

6.1 Orientation program / Preceptorship and mentoring program

New recruits to the critical care shall attend an orientation program and be given the opportunities to work under supervision. Experienced staff in the
unit should be readily available for consultation.

6.2 In-service training program

a. Unit / hospital based training courses / workshop / seminar at hospital level
b. On-the-job training and bedside supervision

6.3 Critical Care Nursing Program (Post-Graduate specialty program)

a. Post-graduate Course in Critical Care Nursing / Cardiac Special Care Nursing / Cardiac Intensive Care Nursing shall be reviewed, evaluated and
endorsed to PRC-BON by the CRITICAL CARE NURSES ASSOCIATION OF THE PHILIPPINES, INC for accreditation
i. Advanced Critical Care Nursing (ACCN) Provider Course
b. It is recommended that the WFCCN policy statement of education shall be used as a framework for designing a critical care program. (Please see
declaration of Madrid, 2005)

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 6.4 Continuing Nursing Education
a. CCNAPI recommends that all practicing CCN shall ensure that they continuously update their
knowledge, skills and behavior through active participation in related critical care nursing education.
This shall include but not limited to the following adult and pediatric concepts on:
a. Advanced Cardiac Life Support
b. Basic Critical Care Course (BCCC)
c. Cardiac Assessment
d. Neurological Assessment
e. Respiratory Assessment
f. Continuous Renal Replacement Therapy
g. Advanced Pharmacology
h. Advanced Intravenous Therapy
i. Others as may be deemed necessary to enhance critical care practice

7. LEVELS & CATEGORIES OF CRITICAL CARE PROVISIONS WITHIN PHILIPPINES

With respect to the physical set-up and supporting facilities of critical care units in the Philippines, the Department of Health (DOH) Standards requires the critical
care units / intensive care unit to be a self-contained area, with the provisions for resources that will support critical care practice. Currently, the DOH is
reviewing these standards to come-up with updated requirement.

Sometime in 2003, the Philippine Society of Critical Care Medicine (PSCCM), Society of Pediatric Critical Care Medicine (SPCCM) and the CCNAPI stratified into
different levels and categories the care provisions in critical care practice to make it similar to its counterparts overseas with the goal of having effective
utilization and organization of resources. Hence, as a guide, CCNAPI will incorporate these standards into this guideline.

7.1 Levels of Care provision

The role of a particular critical care unit will vary, depending on staffing, facilities and support services as well as the type and number of patients it has to
manage. Taking into account the guidelines of the Society of Critical Care Medicine, the critical care service provision in Philippines can be classified into
3 levels:

Level 1
Should be capable of providing immediate resuscitation for the critically ill and short term cardio-respiratory support because the patients are at risk
of deterioration;
Has a major role in monitoring and preventing complications in “at risk” medical and surgical patients;
Must be capable of providing mechanical ventilation and simple invasive cardiovascular monitoring;
Has a formal organization of medical staff and at least one registered medical officer available to the unit at all times;

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 A certain number of nurses including the nurse in-charge of the unit should possess post-registration qualification in critical care or in the related
clinical specialties; and
Has a nurse: patient ratio of 1:1 for all critically ill patients.

Level 2
Should be capable of providing a high standard of general criitcal care for patients who are stepping down from higher levels of care or requiring
single organ support/support post-operatively;
Capable of providing sustainable support for mechanical ventilation, renal replacement therapy, invasive hemodynamic monitoring and equipment
for critically ill patients of various specialties such as medicine, surgery, trauma, neurosurgery, vascular surgery;
Has a designated medical director with appropriate intensive care qualification and a duty specialist available exclusively to the unit at all times;
The nurse in-charge and a significant number of nursing staff in the unit have critical care certification; and
A nurse: patient ratio is 1:1 for all critically ill patients.

Level 3
Is a tertiary referral unit, capable of managing all aspects of critical care medicine (This does not only include the management of patients requiring
advanced respiratory support but also patients with multi-organ failure);
Has a medical director with specialist critical / intensive care qualification and a duty specialist available exclusively to the unit and medical staff with
an appropriate level of experience present in the unit at all times;
A nurse in-charge and the majority of nursing staff have intensive care certification; and
A nurse: patient ratio is at least 1:1 for all patients at all times.

7.2 Categories of Critical Care Unit

The Critical Care Unit can be categorized according to patients’ age group or medical specialties.
a. Age group
i. Neonatal
ii. Pediatric
iii. Adult
b. Specialty
In the existing environment, majority of the Critical Care Units in the Philippines provide service for patients of various specialties. They are labeled
as General ICUs. In certain hospitals, the critical care unit / service is dedicated to the following specific groups:
i. Medical
ii. Surgical
iii. Cardio-thoracic
iv. Cardiac
v. Respiratory

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vi. Neurosurgical

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 vii. Trauma

7.3 System operation of Critical Care Units

The operation of critical care units can be classified into Open System and Closed System.
a. Open System
The admitting and other attending doctors dictate management, change management or perform procedures without consultation or communication
with a Critical Care Specialist. A Critical Care Specialist may be available for advice or be consulted to provide interventional skills (optional). No one
designated person assumes the “gatekeeper” role.
b. Closed System
Management is coordinated by a qualified Critical Care Specialist. The critical / intensive care specialist has clinical and administrative responsibility.
There is a multi-disciplinary team of specially trained critical care staff. The “intensivist” is the final common pathway for all medical decision-making
including the decision to admit or discharge.
Irrespective of the ICU “System” Operation, i.e. open system or closed system, or a mixture of the two, there should be a designated group of registered nurses
under a unique management to provide highly specialized care to the critically ill patients. The nurse in-charge and the majority of nursing staff in each unit
should have the relevant qualification in the specialty of the respective Unit.

7.4 Critical Care Nursing Workforce

The CCNAPI will adopt the Position Statement of the World Federation of Critical Care Nurses on the Provisions of Critical Care Nursing Workforce also called the
Declaration of Buenos Aires ratified in the full council meeting last August 27, 2011 at the Sheraton Hotel, Buenos Aires, Argentina.

The declaration presents guidelines universally accepted by critical care professionals, which may be adapted to meet the critical care nursing workforce and system
requirements of a particular country or jurisdiction. The declaration states the specific central principles governing the provision and provides for specific
recommended critical care nursing workforce requirement. The complete declaration is attached as Annex to this guideline.

8. COMPETENCIES FOR CRITICAL CARE NURSES

The competence of critical care nurses together with established nursing standards and the identified core competencies for registered nurses will result to
excellence in critical care nursing practice. This three pronged holistic framework ensures quality performance through an adherence to nursing standards, the
application of competencies, and the integration of appropriate nursing model/s into the care delivery process.

To achieve safe and quality client-centered care, nurses working in the critical care units are envisioned to adopt not only the stated core competencies of registered
nurses but also the specific competencies stipulated in the following eleven major key responsibility areas:

8.1 Safe and Quality Nursing Care

8.2 Management of Resources
8.3 Legal Responsibilities
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 8.4 Ethico-Moral Responsibilities
8.5 Collaboration and Teamwork
8.6 Personal and Professional Development
8.7 Communication
8.8 Health Education
8.9 Quality Improvement
8.10 Research
8.11 Record Management

Key Responsibility Areas Responsibilities / Tasks Competent Behavior Clusters

I. Safe Quality Nursing Care 1. Conducting nursing assessment The critical care nurse:
Description: The critical care a. obtains comprehensive patient information
(ICU) nurse performs patient health from a holistic perspective with the aid of
assessment accurately, advanced technologies and physical
continuously, comprehensively and examination techniques, paying particular
systematically. The critical care attention to the psychosocial impact of the
nurse prioritizes the health needs of critical care environment on patients and
the patient from a holistic relatives
perspective. b. prioritizes the health needs of the patient
based on the assessment data and
communicates these information to the
right people in a timely right manner
c. collects patient’s data in a systematic,
objective and continuous manner from
clinical observation and monitor devices
d. ensures pertinent data are clearly
documented and accessible to all health
care team members
2. Formulating care plans The critical care nurse:
Description: The critical care a. utilizes collected data to establish a list
nurse develops individualized, actual and potential patient
holistic and patient-centered care problems/needs
plans that document nursing b. collaborates with the patient, if applicable,
diagnoses / identifies patient’s family and other health care team
problems in relation to patient’s members in identifying problems/needs
needs. and planning of appropriate nursing actions
accordingly
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 c. establishes and records the priority of
problem/needs according to the actual
danger or potential threats to the patient
d. formulates an individualized care plan with
continuous review to match both the needs
of patient and family
3. Implementing planned care The critical care Nurse:
Description: The critical care a. carries out planned patient care or
nurse implements planned care to immediate nursing actions in a safe,
achieve optimal health status of comprehensive, effective and humanistic
dignified death of the patient. manner according to patient’s response.
b. adopts evidence based practice in the care
of the critically ill patients where applicable
c. helps patient to survive comfortably and
ensures the end of life to be peaceful and
dignified
4. Evaluating patient’s health progress and The critical care nurse:
outcome a. maximizes clinical skills and monitoring
Description: The critical care devices to evaluate the care process and
nurse evaluates the outcomes of compares the patient’s response with
nursing care in an explicit, expected outcome
systematic and ongoing manner. b. identifies the cause for any significant
difference between the patient’s response
and the expected outcome
c. Identifies potential risk of patients, such as
but not limited to DVT, aspiration,
pressures, infection, fall risk, malnutrition /
starvation, patient abuse, iatrogenic
etiologies
d. revises the care plan to ensure patient
centered and quality of care to patient
e. implements appropriate and effective
nursing interventions to help patients and
significant others address hospice,
palliative and end-of-life care needs
5. Maintaining effective communication The critical care nurse:
Description: The critical care a. reports instantly key changes of patient’s
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 nurse communicates relevant, health condition in an emergency
accurate and comprehensive b. monitors and documents relevant
information, both verbal and information objectively and systematically
written, about the patient’s health c. maintains information in an accessible and
status to related health care team retrievable form
members and family members. d. conducts effective patients and family
teaching
6. Acting in emergency situations such as The critical care nurse:
rapid deterioration, life- threatening , a. demonstrates knowledge of ICU
unstable, and critical events emergencies such as medical emergencies,
Description: The critical care civil disasters and contingent plan for
nurse responds swiftly in a calm and hospital emergencies
proficient manner when faced with b. anticipates possible changes /
an unexpected or rapidly changing complications associated with particular
situation related to the patient or diseases and/or treatment procedures
environment. c. implements prompt and appropriate
resuscitative intervention
d. keeps the medical team informed of
patient’s deteriorating condition in a timely
manner
e. fulfills the specific team role during large-
scale crisis to provide safe, effective and
efficient care of the needy.
7. Demonstrating specific knowledge and A. Pulmonary care
skills in the critical care setting The critical care nurse:
Description: The critical care i. Has an understanding of the applied
nurse provides quality and effective respiratory physiology
care to patient in the following ii. Demonstrates nursing competencies in:
aspects:  Respiratory assessment
Pulmonary  Respiratory monitoring such as
Cardiovascular clinical observation, arterial
Neurological blood gases, SpO2, ETCO2
Renal  Airway management such
Gastrointestinal suctioning, chest
Endocrine physiotherapy, oral care, use
Peri-operative of airway gadgets and others
 Respiratory investigation and
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Trauma therapy such as bronchoscopy,
Burn tracheostomy, chest
Organ Transplantation physiotherapy
Control of Infection iii. Provides holistic care to patients in
Psychosocial and Spiritual the following conditions:
Care  Before and after thoracic
surgery
 With acute or chronic
respiratory disorders
 On ventilator support
 Being weaned from mechanical
ventilator
 On oxygen therapy
iv. Initiates and assists in the
emergency and resuscitative
procedures such as endotracheal
intubation, tracheostomy and
chest drain insertion
v. Educates and supervises patients
and families on home oxygen
therapy
B. Cardiovascular care
The critical care nurse:
i. Has an understanding of
the applied cardiac
physiology
ii. Demonstrates nursing
competencies in:
 Cardiovascular assessment
 Cardiovascular investigation
 Interpretation of
electrocardiogram
 Hemodynamic monitoring such
as non-invasive, arterial
pressure, pulmonary artery
pressure, CVP
 Administration of cardiac
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medication

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 iii. Provides holistic care to patients
with the following conditions:
 Before and after cardiac
surgery
 With cardiac arrhythmias
and heart block
 With cardiac disorders such
as myocardial infarction,
Acute Coronary Syndrome,
heart failure, shock
 On cardiovascular support
such as intra-aortic balloon
pump, ventricular assist
devices
iv. Initiates and assists in
cardiovascular resuscitation e.g.
cardiac pacing, cardioversion,
defibrillation, pericardiocentesis,
advanced cardiac life support
C. Neurological care
The critical care nurse:
i. Has an understanding of the
applied neurological physiology
ii. Demonstrates nursing
competencies in:
 Neurological assessment
 Neurological investigation
iii. Provides holistic care to patient:
 Before and after neurological
operation
 Suffering from neuro-medical
disorders
 On intracranial pressure
monitoring

D. Renal care
The critical care nurse:
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i. Has an understanding of the

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 applied renal physiology
ii. Demonstrates nursing
competencies in:
 Renal assessment
 Renal investigation
 Interpretation of blood
biochemistry
iii. Provides holistic care to patients
with renal failure by:
 Peritoneal dialysis
 Hemodialysis
 Continuous renal replacement
therapy (CRRT)
E. Gastrointestinal care
The critical care nurse:
i. Has an understanding of the
applied gastrointestinal physiology
ii. Provides holistic care to patient:
 With gastrointestinal disorder
such as acute pancreatitis,
hepatic failure
 Before and after
gastrointestinal operation
 With gastrointestinal
emergencies such as
gastrointestinal bleeding,
bleeding esophageal varices
 Undergoing different
procedures such as peritoneal
lavage
 Early access and early feeding using
appropriate gadgets
F. Endocrine care
The critical care nurse:
i. Has an understanding of the
applied endocrine physiology
ii. Provides holistic care to patients
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 with the following conditions:
 Diabetic emergencies such as
diabetic ketoacidosis,
hyperglycemia, hypoglycemia
 Thyroid storm
 Other
endocrine emergencies
G. Peri-operative care
The critical care nurse:
i. Equips oneself with knowledge
and skills for implementation
of safe, adequate evidence-
based care of clients during the
pre-, intra- and post operative
procedures
ii. Provides holistic care to patients
with the following conditions:
 Before and after different types
of operations
 With wounds and drains
iii. Demonstrates nursing
competencies in pain assessment
and pain management
H. Trauma care
The critical care nurse:
i. Has an understanding on the
mechanism of different types of
injury
ii. Demonstrates nursing
competencies in:
 Primary and
secondary assessment
 Stabilization, transfer and
transport of trauma patients
 Emergency and resuscitative
procedures
iii. Provides holistic care to patients
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 with different types of trauma
I. Burn care
The critical care nurse:
i. Has an understanding of the:
 Applied skin physiology
 Mechanism of injury associated
with burn and inhalation injury
ii. Demonstrates nursing
competencies in:
 Burn assessment
 Burn resuscitation such as
airway, breathing and
circulation
 Burn wound care
iii. Provides holistic care to patients
with burn
iv. Educates patient on long term skin
care
J. Organ transplantation care
The critical care nurse:
i. Demonstrates knowledge in brain
stem death test
ii. Identifies potential organ donor
iii. Provides holistic care to:
 Potential donor
 Perioperative transplant
patient
iv. Identifies potential risk associated
with organ transplant and takes
appropriate actions
K. Pain Management
The critical care nurse:
i. Applies evidence-based practices on
pain prevention
ii. Selects appropriate assessment and
intervention tools and techniques
in collaboration and consultation
21
with

22
 other team members (such as WHO
Pain Ladder or other similar
framework)
iii. Demonstrate management capabilities
of clients using pharmacological and
non-pharmacological interventions.
L. Prevention and Control of Infection
The critical care nurse:
i. Has an understanding of
the principles of prevention
of infection
ii. Complies with infection prevention
and control guidelines
iii. Demonstrates competency in
handling and preventing infection
iv. Monitors patient’s treatment
compliance and the related
outcome
v. Provides health education on
infection control to the
patients and relatives
M. Psychosocial and spiritual care
The critical care nurse:
i. Identifies the psychosocial and
spiritual needs of ICU patent
and his/her families
ii. Demonstrates nursing
competence in communication
and counseling skills
iii. Supports the family during the loss,
grieving and bereavement process
iv. Provides psychosocial care such
as music therapy, therapeutic
touch and relaxation therapy to
patient and his/her family
according to their needs
N. Miscellaneous
23
 The critical care nurse provides holistic care to
patients with the following problems:
 Drug overdose
 Hematological failure
 Obstetrical emergencies
 Pediatric emergencies
 Near drowning
 Thermal injuries – heat
stroke, hypothermia
II. Management of Resources 1. Managing within the organization The critical care nurse:
Description: The critical care a. Demonstrates specialty knowledge in
nurse understands the mission and managing within the organization
core values of the organization and b. Uses organizational core values and
facilitates the achievement of the objectives in line with daily work
organizational goals. c. Follows organizational policies, procedures
and protocols
d. Participates in organizational initiatives by
contributing constructive proposals for
improvement
e. Strengthens and develops critical care
delivery in pace with rapid advanced
technologies
f. Maximizes effective resource utilization
2. Empowering subordinates The critical care nurse:
Description: The critical care a. Motivates subordinates to achieve
nurse achieves targets through assignments and goals by providing them
subordinates using the processes with the rationale for performing the task;
and techniques associated with considering and accepting their suggestions
motivating, coaching, delegating when appropriate; and reinforcing good
and supervising. practice
b. Collaborates tasks and deploys
subordinates according to their capabilities
and job experiences, to allow immediate
delivery of critical care services in crisis
management
c. Encourages subordinates to participate in
specialty activities, and stimulates their
24
 innovation in critical care nursing
development
3. Assisting in maintaining a safe and The critical care nurse:
healthy working environment a. Creates a favorable working environment
Description: The critical care that maximizes the production of high
nurse carries out activities to assist quality critical care delivery
in maintaining a favorable working b. Establishes effective feedback loop
environment between health care teams, patients and
relatives
c. Contributes to the maintenance of
occupational health and safety, and
prevention of occupational hazard ensuring
positive practice environment.
d. Establishes effective linkages between inter
and intra departments and hospitals to
share updated specialty information and
different experiences, thus preparing the
organization to cope with continuous
external changes more efficiently
e. Reports any unfavorable environment
which may have a negative impact on the
patient’s physical, psychological and social
well being as well as the process of
rehabilitation.
III. Legal Responsibilities Fulfilling legal responsibilities and acting as The critical care nurse:
patients advocate a. Demonstrates awareness of the relevant
Description: The critical care ordinances and organizational regulations that
nurse functions in accordance have legal regulations such as Code of
with common law, ordinance and Professional Conduct for Nurses and the
regulations influencing nursing Philippines Nursing Law of 2002 (RA 9173).
practice. b. Acts on the all ethical principles and ensures
that no action or omission is detrimental to
the safety of patients.
c. Familiarizes with the legal procedures for
organ transplantation and be sensitive to organ
preservation management and family support.
d. Ensures that informed consent has been
25
 obtained prior to carrying out invasive and non-
invasive procedures and medical treatment,
particularly when patient or/and family does
not have complete information to make an
informed decision.
e. Facilitates delivery of comprehensive
explanation to patient/family if indicated to
empower them to make responsible choice.
f. Maintains legible, dated signed and accurate
nursing records to fulfill legal responsibilities.
g. Is aware of self-limitation and seeks advice and
supervision from senior if a delegated task or
responsibility is felt to be beyond current
training or ability, (e.g., informs seniors that
he/she has no experience and training in caring
patient undergoing continuous renal
replacement therapy).
h. Reports any unfavorable environment which
may have a negative impact on the patient’s
physical, psychological and social well being as
well as the process of rehabilitation.
IV. Ethico-Moral Practice Practicing ethico-moral standards of the The critical care nurse:
nursing profession. a. Has respect for patient / family rights including
Description: The critical care confidentiality
nurse demonstrates the appropriate b. Conducts intensive care nursing practice and
application of knowledge in nursing makes sound independent clinical judgment in
practice, which complies with the a way that can be ethically justified
code of professional conduct, c. Aware of the importance of open discussion
principles of autonomy, beneficence with others about his/her own views on ethical
and justice. She / He also accepts dilemmas
personal responsibility for one’s own d. Reports all perceived unethical incidents to
professional judgments and actions responsible person such as but not limited to,
as well as consequence of one’s responsible use of technology (clinical or
behavior administrative); use of communication devices
not related to clinical practice
e. Maintains professional decorum in dealings
with patient, family and co-workers.
26
V. Collaboration and Teamwork 1. Maintaining collaborative relationships The critical care nurse:
in the multi-disciplinary team a. Contributes in various clinical meetings to
Description: The critical care provide professional input in patient care
nurse maintains collaborative management such as case conference and
relationships within the ICU team. risk management meeting
This relationship contributes b. Values team members’ participation and
towards the achievement of smooth joint decision-making
and effective team performance in c. Seeks opportunities to participate in cross-
accomplishing common goals. functional, multi-disciplinary quality
improvement initiatives
2. Maintaining a cohesive nursing team The critical care nurse:
Description: The critical care a. Demonstrates knowledge of team concepts
nurse establishes and maintains (e.g., discuss the dynamic of teams,
harmonious working relationships participates in various stages of team
with nursing colleagues growth: forming, brainstorming, and
performing)
b. Demonstrates understanding of the
structure, functions and purposes of the
team
c. Demonstrates understanding of the role of
different team members and the agreed
goals
d. Takes initiatives to participate in team
discussion and to achieve team goals and
objectives
e. Shows willingness to share workload when
needed
f. Participates in various intensive care
related activities such as CQI projects,
research activities, infection prevention
and control survey
VI. Professional and Personal 1. Facilitating the development of nursing The critical care nurse:
Development knowledge in clinical setting a. Develops the necessary skills and initiates
Description: The critical care efforts to improve efficiency and
nurse takes initiative to support or effectiveness of service; seeks
conduct activities, which promote opportunities for further development
the advancement of nursing within the organization and contributes to
27
knowledge the training and development needs
b. Facilitates learners to achieve their training
and development needs
c. Conducts coaching and actively participates
in preceptorship and mentorhip
d. Assists in ward orientation/induction for
new nurses and alerts them to the
specific requirements in caring ICU
patients.
e. Assimilates the evidence-based research
findings to further improve clinical practice
f. Supports or participates in nursing research
g. Shares and disseminates evidence-based
findings
h. Shares clinical experience and knowledge
with colleagues
i. Applies theoretical knowledge to practice
j. Identifies areas for enhancement of nursing
knowledge such as counseling and
communication skills in all areas of critical
care practice including bereavement
process

28
2. Promoting the professional image of ICU The critical care nurse:
nurse a. Asserts professionally in the health care
Description: The critical care team
nurse acts in manner that maintains b. Shows concerns about the public
active ongoing involvement in interest regarding health promotion and
activities related to the nursing maintenance
profession such as ICU conference, c. Acts in the manner of a knowledgeable,
workshop and course; and competent, responsible, accountable and
promotes the professional image of caring professional with critical thinking to
nursing. achieve the aimed objective
d. Supports activities run by professional
organization such as micro-teaching and
sharing session of clinical experiences
e. Promotes spirit of professional
cohesiveness
f. Acts for the collective interest of the

29
 profession
g. Adopts continuous improvement in nursing
3. Evaluating own nursing practice and The critical care nurse:
knowledge to enhance personal skills a. Uses professionally acceptable standards or
Description: The critical care practice to assess self-performance
nurse assesses self-awareness of b. Demonstrates proficiency in providing care
his/her own professional to patients receiving different modes of
competence continuously and treatment in acute settings to achieve
independently; maintains up-to- intended outcomes and prevent or
date nursing knowledge to keep minimize adverse outcomes
abreast of nursing trends and c. Demonstrates awareness of individual
nursing standards in specialty strength and limitations and the
practice. importance of enhancing nursing
knowledge
d. Seeks additional information/opportunities
to polish personal skills and qualities e.g.
attending courses/seminars or reading
books on relevant subjects when unfamiliar
clinical situations with no precedents are
encountered
e. Develops own personal development plans
that include attending in-service ICU
courses, ICU scientific meetings, overseas
ICU conferences, tertiary educational
programs and reading ICU specialty
journals/literature, etc.
f. Shares up-to-date ICU nursing knowledge
and current practice with nursing
colleagues
VII. Communication Communicates with individual patient The ICU nurse:
and/or groups and with other members of a. Develops the necessary skills and initiates
the health care team efforts to improve efficiency and
Description: The critical care effectiveness of communication;
nurse takes initiative to b. Uses a range of appropriate
communicate with individual and / communication strategies which will have
or groups and with other members effective outcome such as but not limited
of the health team to facilitate care to Hand-off communication, use of SBAR
30
 and management of the patients on referral, use of ICU flow sheet .
c. Encourages the use of non-verbal /
alternative communication techniques
including information technologies where
appropriate to elicit appropriate
communication.
d. Responds rapidly and appropriately to
the needs of the critically ill patients,
their significant others and the members
of the health team

VIII. Health Education Provides appropriate health education The critical care nurse:
based on comprehensive learning needs of a. Assesses comprehensively the needs
the patient and family and learning barriers of critically-ill
Description: The critical care clients, family and their significant
nurse makes thorough assessment others
of the learning needs of the patient b. Provides refined health education plan
and family for the provision of which is individualized and comprehensive
health education to assist the based on the client’s needs
patient and family towards a c. Demonstrates ability to develop and use
productive life appropriate learning tools for health
education
d. Conducts health education to significant
others of the critically-ill clients with
emphasis on basic concepts of the disease
process
e. Facilitates the thorough understanding of
the critically ill client’s significant others
regarding the disease process and course of
management to enable them to participate
in the care process
f. Demonstrates ability to appraise outcome
of the health education
g. Integrates the helping and coaching role of
a nurse during expressed need of the client,
his family and significant others

31
IX. Quality Improvement Proactive in the implementation of The critical care nurse:
changes as a consequence of quality a. Demonstrates in-depth understanding and

32
 improvement initiatives facilitates the achievement of the
Description: The critical care organization’s mission, vision and goals
nurse demonstrates positive through quality improvement
attitudes towards change for b. Identifies areas for quality improvement
improvement initiatives
c. Establishes effective feedback loops
between the organizations, health teams,
patients and significant others pertaining to
quality improvement.
d. Facilitates the implementation of new
policies, changes in implementing rules and
regulations for quality improvement.
e. Utilizes available and existing data to
support quality improvement initiatives.
X. Research Supports a positive climate for research The critical care nurse:
within the practice setting a. Demonstrates active involvement in
Description: The critical care research activities
nurse maintains currency of b. Incorporates evidenced-base and research
knowledge and practice based on findings into nursing practice.
relevant research findings c. Identifies areas of practice for which
further research is indicated
d. Seeks continuously to improve professional
practice through research activities.
XI. Record Management Ensures that written information conforms The ICU nurse:
to legal and ethical framework a. Demonstrates ability to document
Description: The critical care information in a comprehensive and clear
nurse maintains accurate and manner within the legal and ethical
updated documentation of the care framework.
for the critically ill patients b. Protects and safe guards the document
conforming legal and ethical framework
and institutional policies.
c. Demonstrates effective and appropriate
methods of documenting information
d. Analyzes variances in the data recorded for
improvement of client care

33
9. STANDARDS OF CRITICAL CARE NURSING PRACTICE

Critical care specialty addresses the management and support of patients with severe or life-threatening illness. The goal of critical care nursing is to promote
optimal adaptation of critically ill patients and their families by providing highly individualized care, so that the critically ill patients adapt to their physiological
dysfunction as well as the psychological stress in the Critical Care Unit or Intensive Care Unit (ICU). In order to achieve this, standards should be developed to
serve as a guide for monitoring and enhancing the quality of intensive care nursing practice.

Care standards for critical care nursing provides measures for determining the quality of care delivered, and also serves as means for recognizing the
competencies of nurses in intensive care specialty.

Procedures standards for critical care nursing practice provide a step-by-step guideline in guiding nurses to carry out day-to-day nursing procedure in a most
appropriate manner.

The following 11 are Standards are intended to furnish nurses with direction in providing quality care and excellence in Critical Care Nursing.

1. The critical care nurse functions in accordance with legislation, common laws, organizational regulations and by-laws, which affect nursing practice.

2. The critical care nurse provides care to meet individual patient needs on a 24-hour basis.

3. The critical care nurse practices current critical care nursing competently.

4. The critical care nurse delivers nursing care in a way that can be ethically justified.

5. The critical care nurse demonstrates accountability for his/her professional judgment and actions.

6. The critical care nurse creates and maintains an environment which promotes safety and security of patients, visitors and staff.

7. The critical care nurse masters the use of all essential equipment, available services and supplies for immediate care of patients.

8. The critical care nurse protects patients from developing environmental induced infection.

9. The critical care nurse utilizes the nursing process in an explicit systematic manner to achieve the goals of care.

10. The critical care nurse carries out health education for promotion and maintenance of health.

11. The critical care nurse acts to enhance the professional development of self and others.

34
The Structure-Process-Outcome model is used. Emphasis is put on management systems, nursing activities and interactions between the nurse and the care
recipients, as well as the outcomes of nursing care provided.
9.1

Standard Statement 1

The critical care nurse functions in accordance with legislation, common laws, organizational regulations and by-laws, which affect nursing
practice.

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOME CRITERIA

1. A copy of the Code of Professional The critical care nurse: 1. Patient/Family states that his/her
Conduct for Nurses in the Philippines 1. Gains access to relevant ordinances rights are protected.
established by the PRC-BON is and organizational regulations. 2. Patient’s privacy is not violated.
available. 2. Maintains current nursing registration 3. Patient expresses satisfaction to the
2. A copy of the Philippine Nursing Law with the Professional Regulation quality treatment and service that
of 2002 (RA 9173) is available. Commission and membership to the he/she is lawfully entitled to.
3. A copy of the organizational accredited professional organization 4. Legible, dated, signed and
regulations, policies and procedures and CCNAPI. accurate nursing records are
are available. 3. Fulfills the duty of care in maintained.
4. A copy of the CCNAPI Guidelines accordance with the laws.
for Critical Care Nursing. 4. Practices in accordance with the
5. Other Laws such as but not limited to organizational regulations, by-laws,
the Patient’s Bill of Rights (PhilHealth) policies and procedures.
5. Practices in compliance with the
scope of nursing practice and the
equitable duty of confidence so as
to deliver nursing care in a way to
safeguard the rights, privacy, well
being and interests of every patient.
6. Ensures that informed consents
have been obtained prior to carrying
out nursing procedures and medical
treatment.
7. Maintains legible, dated, signed and
accurate nursing records to fulfill the legal
responsibilities.
35
9.2

Standard Statement 2

The critical care nurse provides care to meet individual patient needs on a 24-hour basis.

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOME CRITERIA

1. An explicit policy for selection of The critical care nurse: 1. There is documented evidence that
nursing staff is established. 1. Demonstrates knowledge and critically ill patients receive quality
2. A recognized manpower indicator to responsibility in line with policies and intensive nursing care in a continuous
calculate staffing level is used. procedures stipulated by the unit. manner.
3. Nurses with appropriate qualification 2. Participates in the development of 2. The staffing level is sufficient to meet
to practice intensive care nursing are staffing patterns with flexibility to give daily patient care requirements.
available at all times. optimum patient care on a 24-hour
4. A contingency plan is available. basis.
3. Practices intensive care nursing in a
continuous manner

9.3

Standard Statement 3

The critical care nurse practices current critical care nursing competently.

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOME CRITERIA

1. The critical care nurse possesses The critical care nurse: 1. The critical care nurse demonstrates
the knowledge required for the 1. Maintains standards of nursing competency according to his/her
care of the critically ill. practice and professional behavior experience and knowledge base.
2. The critical care nurse has knowledge determined by the organization 2. There is documented evidence that
and skills in assessing patient’s needs, requirements and Scope of care provided is individually assessed,
planning, implementing and Nursing Practice (RA 9173). planned, implemented and evaluated.
evaluating the care provided. 2. Demonstrates possession of
3. There is always a nursing expert psychomotor skills required for
available in the ICU. the care of the critically ill.
4. There is a mechanism in place to 3. Shares knowledge and expertise with

36
 provide continuing nursing education. others through teaching programs,
5. There is a system in place to monitor clinical supervision and research
the competency level of critical care activities.
nurses. 4. Demonstrates effective interpersonal
skills in communicating with patients
and families.

9.4
Standard Statement 4

The critical care nurse delivers nursing care in a way that can be ethically justified.

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOMECRITERIA

1. The information regarding patient's The critical care nurse: 1. Patient/Family states that his/her
rights and responsibilities is available 1. Complies with the Code of rights and dignity are protected.
for patients and families. Professional Conducts for Nurses in 2. Patient/Family states that he/she is
2. A mechanism for identification and Philippines as determined by the adequately informed and adequately
resolution of ethical issues related to Professional Regulation Commission. supported in decision making.
the care of the critically ill is 2. Provides care with respect for 3. All perceived unethical incidents are
established. patient’s dignity. recorded and reported.
3. A copy of the Code of Professional 3. Acts as patient advocate in terms
Conducts for Nurses in Philippines is of respecting patient’s rights and
available. interests.
4. Materials such as books, journals 4. Maintains confidentiality of
and training programs on nursing information as appropriate.
ethics are available. 5. Informs and supports patient in
his/her decision making regarding
his/her well-being.
6. Acknowledges honestly and limits
of personal knowledge and skills
and takes steps to remedy such
deficits.
7. Reports perceived unethical incidents
to the appropriate person.

37
9.5
Standard Statement 5

The critical care nurse demonstrates accountability for his/her professional judgment and actions.

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOMECRITERIA

1. The philosophy of critical care The critical care nurse: 1. The critical care nurse demonstrates
nursing is available. 1. Accepts responsibility to deliver safe ability to justify his/her own actions
2. The unit objectives to guide nursing nursing care to critically ill patients. and judgment.
activities are available. 2. Take responsibility to clarify unclear 2. No professional misconduct is
3. Policy and procedure manuals instruction and question reported.
approved by the hospital are inappropriate intervention.
available. 3. Practices within the guidelines and
4. A mechanism is available to protocols issued by hospitals and
ensure the eligibility of nursing professional organizations.
practice. 4. Audits nursing practice regularly.
5. An audit system to ensure 5. Makes sound and independent clinical
safe nursing practice is judgments based upon ongoing
established. monitoring of critically ill patients and
evidence-based practice.
6. Recognizes on level of competence
and limitation; and seeks appropriate
plan of self-development.

9.6
Standard Statement 6

The critical care nurse creates and maintains an environment which promotes safety and security of patients, visitors and staff.

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOMECRITERIA

1. Written policies and procedures exist The critical care nurse: 1. Accidents are minimized.
to minimize the risks of environmental 1. Implements agreed policies to 2. Hazardous incidents are documented

38
 hazards. minimize the risks of environmental and reported.
2. A policy exists to ensure staff knows hazards. Such policies and 3. A safe environment for patients,
the correct use of new equipment. procedures shall include the visitors and hospital staff is provided
3. Copies of Occupational Safety prevention of fire and bio-medical and maintained.
and Health Ordinance and hazards.
Regulation (OSHO & OSHR) are 2. Demonstrates knowledge of and
available. responsibility for implementation of
4. A copy of the guidelines on Manual all aspects of the fire and bio-medical
Handling Operations is in place. safety program.
5. An established mechanism exists for 3. Evaluates the effectiveness of
reporting and auditing incidents. preventive measures for controlling
6. The critical care nurse is cognizant and counteracting the hazards
of various rules and regulations periodically.
governing the use of medical 4. Ensures that the patient’s safety is
appliances for caring critically ill protected through the planning
patients. and design of the unit:
7. Resource persons are available to the Adequate space per patient bed,
intensive care staff at all times to with allowance for potential
provide service and advice on the equipment.
safe use of medical appliances. Adequate space for support areas.
Adequate electrical outlets.
Adequate illumination.
Adequate fire exits.
Windows, clocks, calendars
Sewage and sinks
Life-supporting systems, including
medical gases, suction outlets
and emergency power
availability.
Emergency call system.
Auxiliary lighting system
5. Reports any environmental situation
or defect, which is dangerous
to patient/visitors/hospital
staff.

39
9.7

Standard Statement 7

The critical care nurse masters the use of all essential equipment, available services and supplies for immediate care of patients.

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOMECRITERIA

1. An inventory of essential routine and The critical care nurse: 1. Harm to patient from equipment
emergency equipment is established 1. Participates in mandatory equipment failure is prevented.
and reviewed regularly. training ensuring safe, efficient and 2. Harm to patient from deficiencies of
2. Access to service provision is effective utilization. service and supply system is
stipulated. 2. Participates in establishing written prevented.
3. Emergency equipment, medication policies and procedures for ordering, 3. There is written document for all
and supplies are readily accessible. reordering, monitoring and replacing equipment being checked for proper
4. Policies and guidelines for acquisition, equipment, medication and supplies functioning on a regular basis.
preparation, utilization, cleaning and needed.
maintenance are available. 3. Reviews inventory of all equipment at
5. Policies for ordering, monitoring ad regular intervals and ensures
replacing equipment, medication and functionality through preventive
supplies for the intensive care unit maintenance program
are in place. 4. Ensures that all necessary equipment
and supplies are readily available at all
times, and in proper working order.
5. Is familiar with the available hospital
services, such as laboratory and
pharmacy services during emergency
situations.

40
9.8

Standard Statement 8

The critical care nurse protects patients from developing environmental induced infection.

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOMECRITERIA

1. Written infection control policies are The critical care nurse: 1. The outbreak of infection is
established. 1. Demonstrates knowledge of various controlled.
2. Immunization programs for all critical infectious conditions requiring 2. The infection rate in the intensive care
care nurses are provided when isolation and precaution. unit is reduced or stays low.
condition warrants. 2. Adheres to the defined policies, 3. Decreased infection incidents are
3. In-service programs regarding procedures and guidelines for reported and documented.
current infection control practice are control of infection.
provided. 3. Reviews and revises infection
4. Necessary protective devices are control policies and procedures
available for standard regularly.
precautions. 4. Works collaboratively with infection
5. Isolation facilities are provided to control nurses for controlling
cohort and contain infectious infection.
outbreak.
6. A standing working group composing
of staff of critical care unit and
infection control unit for controlling
infection is established.
7. An ongoing system for reporting,
reviewing and evaluating infection
incidents are established.

41
9.9
Standard Statement 9
The critical care nurse utilizes the nursing process in an explicit systematic manner to achieve the goals of care.

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOME CRITERIA

A. Performance of Health Assessment The critical care nurse: 1. Individualized patient assessment is
1. Guidelines for critical care nurse 1. Collects data on a continuous basis performed in an accurate,
to perform health assessment are starting from admission. continuous and systematic manner.
available. 2. Collects subjective and objective data 2. There is documented evidence that
2. An agreed conceptual model for to determine patient needs. patient’s physical, psycho-social and
guiding nursing practice is 3. Collects data in a systematic spiritual needs are identified.
available. manner to ensure completeness of 3. The intensive care nurse is
3. The Health Assessment form is assessment. cognizant of the current condition
available for documentation of patient 4. Uses appropriate physical of each patient under his/her care.
data. examination techniques to 4. Patient’s data are kept up-to-date.
4. Experienced staffs are available to gather data.
give advice on health assessment 5. Uses effective communication skills to
to less-experienced staff. obtain psycho-social subjective data
5. The critical care nurse possesses the from patient/family.
knowledge and skills in performing 6. Collects relevant data from previous
physical examination and psycho- patient record(s).
social assessment 7. Documents all relevant data in
the patient record.
8. Updates the database regularly and
whenever necessary.
9. Ensures pertinent data are accessible
to all health care team members.

B. Formulation nursing diagnoses/identifies The critical care nurse: There is documented evidence that nursing
patient problems in priority of patient’s 1. Utilizes collected data to establish a diagnoses are formulated. Patient problems
needs list of actual and potential patient are identified according to priority of needs.
1. References to guide formulating problems/needs.
nursing diagnoses/identifying patient 2. Collaborates with the patient, family
problems are available. and other health care team members
2. Guidelines for formulating nursing in identification of problems/needs.
diagnoses/identifying patient 3. Formulates appropriate nursing
42
 problems are established. diagnosis relevant to the patient’s
3. Experienced staffs are available to condition wherein the nurse has the
advise nurses in formulating nursing ability and experience to implement
diagnoses/identifying patient plan of care
problems. 4. Establishes the priority of
4. The critical care nurse possesses the problems/needs according to
knowledge and skills to make the actual/potential threats to
accurate nursing diagnoses to identify the patient.
patient problems. 5. Records prioritized nursing
diagnoses/patient problems in the
patient record.
6. Updates nursing diagnoses/patient
problems when patient’s condition
changes.

C. Planning for Collaboration of Care The critical care nurse: 1. Patient care reflects the identified
1. References and information on 1. Develops goals for each nursing patient problems/needs.
nursing care plans are available. diagnosis/patient problem. 2. The planned care reflects
2. Experienced staff advises novice 2. Plans appropriate nursing appropriate nursing interventions.
nurses in care planning when interventions in collaboration with the
appropriate. patient, family and other health care
3. The critical care nurse possesses team members whenever necessary.
knowledge and skills to devise an 3. Devises an individualized care plan.
individualized care plan pertinent 4. Communicates the plan with
to patient needs. those involved.
4. An agreed nursing care delivery model 5. Updates planned nursing actions in
and medical treatment protocol, accordance with changes in
algorithm is available. patient health status.
6. Provides coordinated continuity
of care.
7. Identifies activities through which
care will be evaluated.
8. Records the nursing care plan in
patient record.
D. Implementation of Planned Nursing Care The critical care nurse: 1. The agreed nursing care plan is
1. The critical care nurse possesses the 1. Utilizes accepted principles for nursing implemented.
knowledge and skills in implementing interventions according to the 2. A nursing intervention record for
43
 the agreed care plan. dynamic environment. individual patient is kept.
2. Standards of nursing care and 2. Implements care according 3. The identified goals for individual
practice are established. to standards and protocols. patient care are achieved
3. Experienced staffs are available to 3. Implements the planned care in
give advice on implementation of collaboration with the patient, family
care. and other health care team
4. Appropriate equipment for the members.
implementation of the agreed 4. Implements the planned care in
care plan is available. an organized and humanistic
5. A policy to ensure the continuity manner.
of patient care is in place. 5. Integrates current scientific
knowledge with technical
and psychomotor
competency.
6. Provides care in such a way as to
anticipate and to prevent
complications and life-threatening
situations.
7. Provides individualized and
continuous care to achieve identified
goals.
8. Documents interventions in
patient’s records.
9. Reviews and modifies interventions
based on patient’s progress.

44
E. Evaluation of Outcome of Nursing Care The critical care nurse: The implemented care is evaluated and
1. The critical care nurse possesses the 1. Collects data for evaluation within an documented.
knowledge and skills to evaluate the appropriate time interval after
implemented care. intervention.
2. Experienced staff advises nurses on 2. Compares the patient’s responses
the evaluation of delivered care are with expected outcomes.
available. 3. Determines the causes of significant
3. A policy is available to evaluate differences between the patient’s
patient’s responses to nursing care in responses and the expected
a continuous manner. outcomes.
4. Reviews and revises the plan of care
based on the evaluation.
5. Documents evaluation findings in
patient record.

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9.10

Standard Statement 10
The critical care nurse carries out health education for promotion and maintenance of health.

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOME CRITERIA

1. An education framework for intensive The critical care nurse: 1. Patient demonstrates a positive
care setting is established. 1. Modifies health teaching strategies attitude towards health promotion
2. An optimal learning environment is according to patients /family’s literacy and health maintenance.
created. level. 2. There is documented evidence that
3. A tool for assessing patient’s/family’s 2. Assesses patient’s/family’s learning patient/family understands the
needs is established. ability or any barriers to learning. health education material.
4. Plans for promoting and maintaining 3. Establishes good rapport with patient
health are devised. and family.
5. The critical care nurse possesses 4. Assists patient in setting short-term
competency in the provision of and long-term goals for the
health education. promotion and maintenance of
health.
5. Plans and implements individualized
health educational activities.
6. Provides educational information for
patient and family in promotion and
maintenance of health.
7. Facilities patient’s/family’s ability to
comply with the health education
provided.
8. Documents the teaching-learning
progress.
9. Evaluates the effectiveness of health
teaching and modifies the approach
if necessary.

46
9.11

Standard Statement 11
The critical care nurse acts to enhance the professional development of self and others.

STRUCTURE CRITERIA PROCESS CRITERIA OUTCOME CRITERIA

1. A system to offer nurses the The critical care nurse: 1. Patient receives quality nursing care
opportunity for continual professional 1. Sets and reviews objectives for based on current scientific knowledge
development is established. professional development at regular and research findings.
2. An objective performance appraisal intervals. 2. The critical care nurse completes
system is available. 2. Participates in continuing educational continuing nursing education
3. Professional journals and programs to update intensive care programs and demonstrates
textbooks related to critical care knowledge and skills. commitment in further professional
nursing are available. 3. Contributes to professional advancement.
4. A mechanism to facilitate career development through teaching 3. Expertise in intensive care nursing is
progression program is available. activities and clinical supervision. developed and respected by others.
4. Participates in conducting clinical
research and application of evidence-
based nursing practice.
5. Participates and promotes the
activities of professional nursing
organizations.
6. Demonstrates interest in pursuing
advanced critical care nursing
practice

47