It is also the role of a critical care nurse to ensure that if the patient is transferred from one hospital to another or from one unit to another, bacterial cultures are taken upon admission into ICU in order to exclude any infectious diseases or infections that may need attention and distinguish between the hospital acquired infections and community acquired ones. There has been a significant increase in the hospital-acquired infections in the ICUs because of the prolonged stay in ICUs, improper use of antibiotics and increased multiple invasive procedures (Michell, 2010). Healthcare workers’ failure to adhere to hospital infection control policies and the multiple invasive procedures in these units contribute to hospital-aquired infections. When patients are admitted to ICU, they should be screened for infections like Methicillin Resistant Staphylococcus aureus (MRSA), vancomycin- resistant enterococcus (VRE) and other infections prevalent in other wards or facilities transferring patients to ICU (Weinstein & Bonten, 2002)
Poor hand washing technique has been implicated by several studies as the major source of hospital infections as it assists transmission of infections from the patient to healthcare worker and vice-versa and also from patient to patient (Weinstein & Bonten, 2002; du Plessis & Monkoe, 2010). In a study conducted by du Plessis and Monkoe (2010), in one major teaching hospital in South Africa, it was found that compliance with hand hygiene protocol was as low as 50% and that the hands of the adult ICU healthcare workers were the most colonized with pathogenic micro-organisms, 59%, compared with 21% for paediatric ICU and 19.67% for the neonatal ICU. The risk of patients in direct contact with these healthcare workers for acquiring an infection is therefore very high.
Apart from infection prevention and control, the critical care nurse is responsible for ensuring patient’s comfort and maintaining dignity. The scope of practice of critical care nurses explains that this role requires skilled professionals that will carefully study the condition of an individual patient and prioritize accordingly. The scope also takes in to account the fact that ensuring physical comfort, rest and sleep may be difficult to achieve in ICU setting but it encourages nurses to reduce the noise levels, communicate with the
24 patients in order to reduce anxiety and increase tolerance of the uncomfortable interventions (Scribante et al. 1995).
Positioning of the critically ill patient should be individualized as it can both ensure comfort and prevent complications and development of pressure sores. Bed sore development reflects inadequate skin assessment, care and evaluation in nursing as they can be prevented by the use of evidence-base guidelines. This is according to Estilo, Angeles, Perez, Hernandez and Valdez, (2012) who state that the skin is often not given the same attention in ICU as other organs that are considered as vital organs.
According to VanGilder, Amlung, Harrison and Meyer, (2009), facility acquired pressure ulcers are mostly prevalent in adult intensive care units with the highest percentage (12.1%) being in medical ICU. This means that critical care nurses should assess patients for the development of pressure ulcers, study all patients’ risk factors by means of scales and implement effective measures to reduce this from happening. According to Cox (2011), risk factors that the critical nurse should bear in mind include; patient’s immobility, nutritional status, incontinence (both faecal and urinary), age, length of ICU stay, sensory perception, APACHE score, vasopressors administered, blood pressure and other co-morbid conditions such as diabetes mellitus.
Two hourly turning or repositioning of the critically ill patient who cannot turn by himself has been recommended as a strategy to prevent the development of pressure sores since it relieves pressure from the dependent parts (Cox, 2011; Siddiqui, Behrendt, Lafluerand & Craft, 2013). Positioning is also important for postural drainage, mobilization of secretions, preventing ventilator-associated pneumonia, improving oxygenation and patient comfort (Goldhill D., Badacsonyi, Goldhill A. & Waldmann, 2008).
However, these interventions should take in to account the condition of individual patients. For example, it will not be beneficial or safe to position a patient with acute respiratory distress syndrome (ARDS) in the prone position if he or she has an open abdominal or thoracic cavity post-operatively (Murray & Patterson, 2002).Other interventions for avoiding pressure sores include elevating and supporting the heels, monitoring and caring for the incontinent patients, use of an evaluation scale, using skin barriers, evaluating the
25 skin in contact with assistive devices and ensuring optimal nutrition and hydration (Siddiqui et al. 2013).
Intake and output balance is very important in critically ill patients. Since the critical care nurse is responsible for maintenance of elimination by the patient, he or she should monitor the patient’s intake and output including the ability to pass stools. The Scope of Practice allows nurses to intervene accordingly to ensure elimination by the patient and adequate hydration (Scribante et al. 1995). Once abnormalities are noted and interventions are in place, adequate and accurate recording should be carried out.
Logically, if something is not recorded in the patient’s hospital file, it is not considered as done or it never happened. According to the scope of practice of critical care nurses, patient’s records are the most important professional and legal tools of communication between the healthcare professionals in the unit. Clear, accurate and complete record keeping is essential for delivery of safe and effective care to patients (Griffiths, Debbage & Smith, 2007). For example, if the nurse administers the prescribed medication but forgets to record in the correct charts, another nurse taking over the same patient may think that it was never given and administer it again putting the patient at risk of drug overdose.