neuro icu set-up

1. NEURO INTENSIVE CARE
UNIT
Presented To Presented By
Ms. Tarika Sharma Ms. Amandeep Kaur
Nursing Tutor Msc Nsg. 2nd
Yr
Nsg. Foundation Deptt. 1915703

2. INTENSIVE CARE UNIT
 Intensive care unit is a hospital unit specially
designed to care for people who have sustained or
are at risk of sustaining acutely life threatening
single or multiple organ system failure due to
disease or injury, and who are hemodynamically
unstable and require prolonged minute therapy.

3. NEURO INTENSIVE CARE
UNIT
 “Neuro-critical care or neuro-intensive care
is a branch of medicine that emerged in the
1980s and deals with life-threatening
diseases of the nervous system, which are
those that involve the brain, spinal cord and
nerves.”

4. NEURO HDU
 “High Dependency Unit (HDUs) Some hospitals
have High Dependency Units (HDUs), also called
step-down, progressive and intermediate care units.
HDUs are wards for people who need more
intensive observation, treatment and nursing care
than is possible in a general ward but slightly less
than that given in intensive care.”

5. NEURO STROKE ICU
 “An intensive care unit (ICU) is a specially
trained area of the hospital providing patients with
personalized care from a team of experts. The
patients in the Neuro ICU suffer from severe brain
injuries, stroke or brain tumors and many are post-
op from a neurosurgical procedure”.

6. Policy Guideline
 A policy guideline to be developed for planning an
ICU by the hospital by framing a committee.
It includes:-
 Medical superintendent
 Surgeon/ neuro surgeon
 HODs Anaesthesia.
 Architect/designer
 Nursing superintendent
 Physician Paediatrician

7. DECISION MAKING
The planning committee will take the following
decisions:-
 Critical care need of the hospital
 Type and size of ICU
 Appointment of ICU in charge
 Appointment of ICU matron
 Planning, designing and physical facilities
 Guidelines, policies and procedures in ICU.

8. PHYSICAL PLANNING
 Location
 Size
 Physical facilities
 Designing
 Environmental planning

9. PRE-REQUISITE
 Training of nursing and medical staff
 Procurement of beds and equipments
 Developing protocols for monitoring and life
support techniques
 Training of supporting staff
 Commissioning and opening

10. LOCATION
 Should be centrally located with easy access
to emergency and other wards, OT and OPD.
 Easily approachable.
 Away from general hospital traffic.
 Restricted entry.

11. SIZE
 Size of ICU depends on the type of services
provided.
 In super specialty hospital 10% of total beds
 In general hospital 2% of hospital beds.
 Optimum size is 14 beds and minimum 4
beds.
 If no. of beds required is more than 14 beds,
two ICUs be opened. Ideal ICU is 10 beded.

12. DESIGNING OF ICU
There are some principles of designing:-
 All patients can be closely observed
 Ample space around bed for free movements
 Piped gas supply
 Adequate light and electric fixtures.

13. LAY OUT DESIGNING
 Circular placement of beds with central
nursing station
 Rectangular with central monitor system
 Semi circular with monitoring station at the
front.
 The lay out design depends on the
availability of space.

14. PHYSICAL FACILITIES
 Patient area
 Auxillary area
 Entrance
 Ancillary area

15. ENTRANCE TO ICU
 Broad corridor
 Entrance double door swinging ‘5’ to ‘6’ width
 Toilet
 Reception counter
 Telephone
 Visitors lounge 2sq feet
 Snack bar

16. PATIENT CARE AREA
 Bed space
 Nursing monitoring station
 Call bell system
 Equipments
 Hand washing
 Wall fixers

17. BED SPACE
 Sufficient space is required for each bed for free
movement and keeping ventilator, monitoring
system and other equipments.
 They are required for each bed 100-120 sq ft in
open ICU 140-180 sq ft in cubicle.
 Minimum 15 sq ft clear area.
 Head wall space 1-2 ft.

18. Con…
 Space between two beds 5-8ft.
 The cubicles must have glass partitions or
transparent curtains for clear observation
from monitoring station.

19. BED HEAD FIXTURE AND
CALL BELL SYSTEM
 High intensity spot light connected to generator.
 Wall panel and call bell buttons near the bed
 Sufficient electric sockets for plugging.
 Wall suction tubes and piped oxygen supply.
 Small wash basin.
 No extension wire to be used.
 Equipments with CV stabilizer / USP

20. EQUIPMENTS
 Ventilators, fluids stands
 Defibrillator, pulse
oxymeter
 Monitor and monitor
procedure trolley
 Infusion pump, crush cart
trolley with emergency
equipments and
medicines.

21. NURSING STATION
 Central monitoring
system
 Counter, case records
and essential drugs.
 Complete visibility of
all patients.
 Two way
communication paging
as well as intercom.

22. AUXILLARY AREA
 Medication and nursing area
 Nursing changing room
 Doctors duty room
 Dressing room
 Store
 Equipment maintenance
 Isolation room
 Clean and dirty utility room
 Pantry

23. ISOLATION AREA
The working area is equal to total bed area and separated by
clean corridor from patient area. This area has 14sq. yards
area comprises of:-
 Washing, utility area
 Securable cabinets for staff rooms
 Clean supply room
 Work room with separate sink
 Toilet, dirty utility
 X-ray viewing, Special examination, procedure
 24hours laboratory, pharmacy, radiology

24. ANCILLARY AREA
 Office space and record room
 Staff lounge, toilet
 Telephone facility
 Staff rest room
 Janitor’s room/cleaner
 ICU matron’s office

25. MEDICAL ENVIRONMENT
Air condition:-
 ICU must be air conditioned
 Temperature maintained at 25o
to 27o
c and 40-50%
humidity.
 Plenty of sunlight, large windows.
Ventilation:-
 6/8 air changes
 Filter less than 10micron
 Positive pressure flow from patient area to outside

26. Con…
 Lighting:-
 Varying degree of illuminations for patient area,
working area
 Soothing and glare free
 Provision of dimmer lights
 Noise:-
 To be noise free
 Soft and light music
 Noise absorbable material
 Walls reflection free, light color

27. STAFFING REQUIREMENT AS
PER SHIFT
Nursing:-
 Ideally 1:1ratio during day and 1:2ratio during
night
 Broadly 4-5 nurses per bed including reliever
 One ANS for administration.
Medical staff:-
 One physician for per 5beds
 Consultant ICU-1/shift
 Senior resident -2/shift
 Junior resident-2/shift

28.  Technical staff:-
 Respiratory therapist-1/shift
 Physiotherapist-1/shift
 ICU Technician-1/shift
 Lab. Technician-1/shift
 OT Assistant-1
 Safety officer-1
 Ancillary Staff:-
 Receptionist-1
 Ward boys-4
 Stretcher bearer-2
 Sweeper-2

29. ADMISSION AND
TREATMENT POLICY
 ICU is a place for critically ill patients in need of
constant monitoring , life support and requiring
specialized treatment and trained nursing care.
 The ICU care is based on its three levels:-
 Level-1:- monitoring, observation and short time
ventilation.
 Level-2:- monitoring, observation and long time
ventilation.
 Level-3:- intensive care, invasive procedures,
continuous consultant support.

30. Admission criteria:-
 There should be fixed admission criteria for
admission.
 Priority to be given to the patients, who have
fair chances of reversible condition or
chances of improvement.

31. Treatment policy:-
 Responsibility lies with the incharge of unit admitting the
case.
 No direct admission to ICU but transferred from units.
 A vacant bed is allocated in original ward for patient
return.
 Admission only on recommendations of ICU direct
subjected to available of beds.
 20% of beds to be kept vacant for emergency admission.
 Continuity of treatment is the per view of ICU in charge in
consultation with unit in charge.

32. POLICIES & PROCEDURES
 Standard treatment protocol should be followed.
 Silence to be observed.
 All new admission/ discharge to be informed to the
ICU in charge.
 All new admission/ discharge to be registered.

33. STAFF STANDING
ORDERS
 Joint round at the time of shift change and proper
handing/taking.
 Instructions and maintenance of intake/output chart.
 Cleaning and maintenance of equipments.
 Checking and replacement of essential drugs.
 Proper maintenance of records.
 Daily round of physician and incharge ICU
combine to take decision for change in treatment.

34. DISCHARGE POLICY
 Decision to discharge is taken in consultation with unit
in charge.
 Patient who have recovered, stable and does not
required artificial ventilation can be shifted to
intermediate care unit or high dependency unit area.
 Patients who are not progressing and chances of
recovery is remote to be discharged for allotting bed to
patient having fair chance of recovery when demand is
acute.
 When there is no demand patient kept in ICU till death.

35. QUALITY ASSURANCE IN
ICU
 To maintain high standard by hygiene and
cleanliness.
 To prevent hospital acquired infection.
 Proper treatment and disposal of bio-medical waste.
 Daily maintenance and checking of vital
equipments.
 Priority on patient comfort and home feeling.
 Exit interview of patient and relatives to improve
standard and quality of care.

36. In Service Education
 A program of instruction or training provided by an
agency or institution for its employees.
 The program is held in the institution or agency and
is intended to increase the skills and competence of
the employees in a specific area.
 Inservice education may be a part of any program
of staff development.

37. TYPE OF TRAINING AND EDUCATION
PROGRAMS FOR ICU NURSES
 In-House training Programs
 College-Based training Programs
 Distance Education
 Simulation training
 Training through E-Learning

38. In-House training Programs

39. College-Based training
Programs

40. Distance Education

41. Simulation training

42. Training through E-Learning

43. PSYCHOSOCIALASPECTS
OF NEURO ICU

44. ICU Psychosis
 ICU psychosis is a disorder in which
patients in an intensive care unit (ICU) or a
similar setting experience a cluster of serious
psychiatric symptoms.
 ICU psychosis is also known as- ICU
syndrome.

45. ICU Psychosis
 Acc. to Hackett et al (1968) 30 % to 70 % of
patients in intensive care units develop this
syndrome.
 The patient’s personality and psychological make-
up are predisposing factors in developing an ICU
psychosis.
 A person suffering from depression pre-operatively,
for example, still be depressed post-operatively and
similarly, an anxious person who has a myocardial
infarct will retain his anxiety.

46. ICU Psychosis
Other predisposing factors are:-
 the length of time under anaesthesia (8 to 10 hours)
 on the cardiopulmonary bypass machine.
 The type of illness can also play a role — it is
easier to cope with a cholecystectomy or an asthma
attack than with a colostomy.

47. ICU Psychosis
 The signs and symptoms of the syndrome are mild
at first, presenting with sleeplessness and
restlessness.
 The patient then becomes disorientated, frightened
and often starts interfering with his treatment.
 This may be followed by perceptual distortions and
illusions — seeing and hearing things that are not
there

48. CAUSES OF PSYCHOLOGICAL
PROBLEMS IN PATIENTS
 Various factors in the intensive care unit itself can
contribute to the psychological breakdown of
patients and staff.
 1. Fear and anxiety,
 2.The unit,
 3. Communication,
 4. Security,
 5. Visitors.

49. 1. Fear and anxiety
 The first factor which may cause the ICU
syndrome is the patient’s fear and anxiety.
These two are related and are the most
frequently occurring manifestations of stress.
Most patients are afraid — afraid of the new
environment, new people, his illness and its
prognosis, in short, afraid of the unknown.

50. 2.The unit
 The unit environment, is unpleasant. The
lights are usually on 24 hours a day, there is
constant noise and the patients lie fairly close
together. This results in the patient getting
very little rest and sleep and becoming
exhausted.

51. 3. Communication
 Patients in the intensive care unit are
submitted to both sensory overstimulation
and sensory deprivation — overstimulation
by noise, light and new things, but
deprivation through the lack of touch, spoken
word and reassurance.

52. 4. Security
 The patient is quite defenceless — he is too
sick to defend himself physically and can
often not defend himself verbally either. He
realises that he is totally vulnerable and thus
regresses to childlike behaviour in order to
overcome his feelings of helplessness.

53. 5. Visitors
 Patients are allowed to have visitors for short
periods. This is, however, a controversial
point — visitors are important for the
patient’s wellbeing, but at the same time they
may have a negative influence.

54. FACTORS AFFECTING THE
STAFF
 Most nurses have at some stage of their career felt
stagnant, bitter, disillusioned and have seen no
future.
 They have done their work, but have put no feeling
into it. This often happens when nurses eventually
realize that things are not as they had expected them
to be — their ideals are not congruent with the
reality.
 This apathetic state of the staff is not only
detrimental to the patients but also to the person
herself and other staff.

55.  To reach a situation where the work is more or less
in line with the beliefs of the staff, the co-operation
of the nursing service is necessary — including
adequate and functioning equipment, enough staff
and good pay.
 The nurses want to be treated with respect and there
must be mechanisms of discussing problems of
medical incompetence with the doctors.

56. Factors including:-
 Nature of the work,
 Communication,
 Group pressure,
 Aspects of patient care,
 Visitors.

57. Team Approach
 “Team-based health care is the provision of health
services to individuals, families, and/or their
communities by at least two health providers who
work collaboratively with patients and their
caregivers-to the extent preferred by each patient-to
accomplish shared goals within and across settings
to achieve coordinated, high-quality care.”

58. Functions
 Ensuring that the patient and family are at the center of the
team requires careful planning and execution.
 Targeting of team-based care-matching resources to patient
and family needs-is essential to maximize value.
 Building bridges to ongoing activities related to team-based
care is critical to ensure efficiency.
 Defining a coordinated research agenda for team-based care
is necessary to achieve continuously improving, high-value
team-based health care.

59. DRUGS
USED
IN NEURO ICU

60. Antidotes & other substances
used in poisoning
 Charcoal activated powder 450g
 Atropine Sulphate 1mg/ml inj. (1ml)
 Anti-snake venom serum dry powder inj.
 Naloxone 0.4mg/ml inj.
 Pralidoxime 1g inj.

61. General anaesthetics & oxygen
 Halothane inhalation 250ml.
 Isofluranel inhalation 250ml
 Nitrous Oxide inhalation.
 Sevoflurane Solution Inhalation 250ml
 Oxygen inhalation
 Propofol 1% Injection

62. Local anaesthetics
 Bupivacaine 0.5% plain inj. (20ml)
 Lignocaine 2% inj. (30ml) with preservative
 Lignocaine 2% + adrenaline 1 in 200,000 inj.
 Lignocaine HCl 10% spray

63. Analgesics, Antipyretics,
NSAIDs & Drugs
 Paracetamol 150mg/ml inj (2ml)
 Ibuprofen 400mg tab.
 Diclofenac Sodium 25mg/ml inj. (3ml)
 Diclofenac 100mg suppositories
 Mefenamic acid 500mg tab.
 Allopurinol 100mg tab.
 Morphine 15mg/ml inj. (1ml)

64. Anti-allergies & Drugs used in
anaphylaxis
 Promethazine hydrochloride 25mg/ml inj.
(2ml)
 Promethazine hydrochloride 25mg/ml inj.
(2ml)
 Cetirizine 10mg tab.

65. Anti-migraine drugs
 Ergotamine Tartrate 1mg + Caffeine 100mg
tab.

66. Other drugs
 Clobazam 5mg tablet
 Diazepam 5mg/ml inj. (2ml)
 Phenobarbital 200mg/ml inj.
 Piracetam 400mg cap
 Levodopa 250mg + Carbidopa 25mg tab.
 Albendazole 400mg tab.
 Nitroglycerin 5mg/ml inj (5ml)

67. Care of the Patient
With a Neurological
Disorder

68. Anatomy and Physiology
 Central nervous system
(CNS)
 Brain
 Spinal cord
 Peripheral nervous
system
 Somatic (voluntary)
 Autonomic
(involuntary)

69. Anatomy and Physiology
 Neurons
 Transmitter cells
 Carry messages to and
from brain and spinal
cord
 Glial cells
 Support and protect
neurons
 Produce cerebral spinal
fluid

70. Anatomy and Physiology
 CNS: brain
 Cerebrum – lobe functions
 Diencephalon – thalamus, hypothalamus
 Cerebellum – balance, coordination
 Brain stem – midbrain, pons, medulla oblongata

71. Anatomy and Physiology
 PNS: Somatic (voluntary)
 31 pairs of spinal nerves
 12 pair of cranial nerves

72. Neurological Assessment
 History
 Headaches
 Loss of function
 Visual acuity
 Seizures
 Numbness
 Pain
 Personality change
 Mood swing
 Fatigue

73. Neuro Assessment
 Mental Status
 Orientation
 Mood and behavior
 General knowledge
 Short term memory
 Long term memory

74. Neuro Assessment
 Level of consciousness
 Glasgow Coma Scale
 Eye opening
 Verbal response
 Motor response

75. Neuro Assessment
 Language and Speech
 Aphasia
 Sensory
 Expressive
 Global

76. Cranial Nerves
 I. Olfactory
 II. Optic
 III. Oculomotor
 IV. Trochlear
 V. Trigeminal
 VI. Abducens
 VII. Facial
 VIII. Acoustic
 IX. Glossopharyngeal
 X. Vagus
 XI. Spinal Accessory
 XII. Hypoglossal

77. Neurological Problems
 Headache
 Vascular – migraine, cluster, hypertensive
 Tension – stress
 Traction-inflammatory – infection, occlusion
vessels

78. Increased Intracranial Pressure
(IIP)
 Occurs slowly or rapidly
 May lead to brain stem herniation and death

79. Nursing Care of the Patient
With IIP
 Elevate HOB
 Neck in neutral
position
 Avoid flexion of hips,
waist and neck
 Hypothermia blanket
 Restrict fluids
 Foley
 Suctioning
 O2

80. Seizures
 Disorderly neuron discharges in brain
 Different types affect body differently
 Involuntary movement usually

81. Seizures
 Generalized:
 Tonic-clonic –
grand mal
 Absence - Petit mal
 Myoclonic
 Atonic or akinetic
 Localized: (Focal)
 Partial (Jacksonian)
 Psychomotor

82. Seizures: Nursing Care
 Continue medicines
 Medical alert ID
 Avoid alcohol, avoid driving, get adequate rest
 If on Dilantin, instruct on oral hygiene.
 Prevent aspiration (airway)
 Turn side; loosen clothing around neck

83. Seizures: Nursing Care
 Protect
 Lower to the floor; pad side rails; pillow under
head; don’t restrain
 No bite block or padded tongue blade
 Allow for post-ictal rest
 Document everything

84. Degenerative Neuro Diseases
 Multiple Sclerosis
 Parkinson’s Disease
 Alzheimer’s Disease
 Myasthenia Gravis
 Huntington’s Disease
(chorea)

85. Multiple Sclerosis
 Common degenerative
neurological disease.
 Myelin sheath is
destroyed.
 Symptoms vary.
 Relapsing/remitting.
 Usually ages 20-40.

86. Multiple Sclerosis - Symptoms
 Shakiness, difficulty walking
 Fatigue, muscle weakness
 Numbness, tingling
 Tinnitus
 Visual problems
 Difficulty chewing and speaking

87. Symptoms con…
 Ataxia
 Changes in behavior & emotions
 Nystagmus
 Spasticity, tremors, dysphagia, facial palsy,
speech impaired, fatigue
 Incontinence
 Impaired judgment

88. Multiple Sclerosis-Nursing
Interventions
 Nutrition
 Skin Care
 Activity
 Control of environment
 Emotional support
 Patient teaching

89. Parkinson’s Disease
 Unknown cause
 Lack of dopamine.
 Parkinsonism: encephalitis, toxic chemicals,
drugs.

90. Parkinson’s
 Symptoms include:
 Muscular tremors and rigidity
 Emotional instability
 Judgment defects
 Heat intolerance
 Mask-like facial appearance
 Dysphagia and drooling

91. Parkinson’s – Nursing Care
 Prevent injury (fall or aspiration)
 Prevent urinary retention and constipation
 Patient teaching about medication
 Patient and family support

92. Alzheimer’s
 Unknown cause, but genetic link
 Very common; risk increases with age
 Brain changes:
 plaques
 tangled neurons
 blood vessel degeneration
 chemical changes

93. Alzheimer’s - Symptoms
 1st– memory lapses, difficult word finding,
decreased attention span
 2nd – increased memory problems,
disoriented to time, loses things,
confabulates
 3rd – total disorientation, apraxia, wanders
 4th – severe impairment

94. Alzheimer’s – Medical
Management
 Medication to treat symptoms
 Memory
 Agitation
 Supplements
 Folic Acid & Vitamin B12
 Low fat diet
 NSAIDS

95. Alzheimer’s – Nursing Care
 2 key points for all care:
 Prevent overstimulation
 Provide structured, orderly environment
 Other concerns
 Communication
 Family support and education

96. Cerebrovascular Accident
(CVA)
 Ischemia of brain tissue
 Hemorrhage
 Thrombus
 Embolus
 3rd
leading cause of death in the US
 All ages, but usually elderly

97. CVA-Nursing Care
 Assess LOC
 IV, NG, Foley, Vent.
 Nutrition
 Encourage perform ADLs
 Bladder and bowel training
 ROM
 Teaching and emotional support

98. Meningitis
 Acute infection of the meninges
 Viral or bacterial
 Severe headache, irritable, fever, delirium,
N/V, neck stiffness
 Kernig’s sign
 Brudzinski’s sign

99. Meningitis-Medical
Management
 Diagnosed by LP
 Medications
 Respiratory isolation
 Cool, dark quiet room
 Maintain hydration
 Prevent injury

100. Acquired Immunodeficiency
Syndrome - AIDS
 AIDS dementia complex
 Infection of CNS
 Dementia
 Treatment depends on infection
 Treat symptoms, maintain safety

101. ANY QUESTION?

102. RESEARCH INPUT
 TITLE:-
TRAINING PROGRAMS CARRIED FOR NURSES
WORKING IN INTENSIVE CARE UNIT
 OBJECTIVE :
 To study training programs carried for nurses
working in intensive care unit.

103. RESULT
 An ICU is a consolidated area of a hospital
where patients with acutely life-threatening
illnesses or injuries receive around the clock
specialized medical and nursing care.
 Intensive care medicine/ Quality of patient
care in ICU is the result of close cooperation
among doctors, nurses, and allied health care
professionals.

104. CONCLUSION
 The intensive care unit is equipped and staffed to
provide patients treatment.
 In-house orientation is the most commonly used
method to prepare nurses for practice in critical care
area.
 An efficient process of communication has to be
organized between the medical and nursing staff of
the ICU.
 Tasks and responsibilities have to be clearly
defined.

105. SUMMARY
 Neuro intensive care unit
 Neuro hdu
 Neuro stroke icu
 Policy guidelines fo
neuro icu
 Physical set-up
 Staffing requirements
 Policies
 Procedures
 In service education
programmes
 Team approach
 Nursing care of patients
with neuro disorders.

106. CONCLUSION
 Patients are admitted to an intensive care unit after
experiencing a significant illness or injury.
 ICU nurses need in-house hospital-based training
programs to provide quality of patient care and
treatment.
 College-based training programs will help in
enhancing knowledge and new skills important in
ICU section.

107. References
BOOK:-
 The clinical practice of NEUROLOGICAL AND
NEUROSURGICAL NURSING. Seventh edition.
By Joanne V. Hickey.P-312-332.
INTERNET:-
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