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Fundamentals of Critical Care A Textbook for Nursing and Healthcare Students In Fundamentals of Critical Care , a team of clinicians and health educators deliver an accessible, timely, and evidence-based introduction to the role of nurses and healthcare practitioners in critical care. The book explores fundamental concepts in critical care and their implications for practice. Each chapter outlines essential knowledge necessary to understand key concepts and includes high quality, full-colour artwork to enhance learning and recall. Readers are also provided with clinical scenarios, practice questions, and red and orange flags to indicate physiological and psychological alerts respectively. Covering a range of common and specialised disease processes and treatments requiring critical care, the book provides: A thorough introduction to the critical care unit, including philosophies of care, ways of working, humanisation, and outreach Comprehensive exploration of organisational influences, including political, local, national, and international influences Practical discussion of legal, ethical, and professional issues, as well as evidence-based approaches to critical care In-depth examination of nursing care assessment tools, nursing communication, cognition, pharmacology, and more Perfect for nursing students and trainee nursing associates, Fundamentals of Critical Care: A Textbook for Nursing and Healthcare Students will also earn a place in the libraries of healthcare students in physiotherapy, paramedicine, medicine, and those returning to practice. All content reviewed by students for students. If you would like to be one of our student reviewers, go to to find out more. To receive automatic updates on Wiley books and journals, join our email list. Sign up today at

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Fundamentals of Critical Care A Textbook for Nursing and Healthcare Students In Fundamentals of Critical Care , a team of clinicians and health educators deliver an accessible, timely, and evidence-based introduction to the role of nurses and healthcare practitioners in critical care. The book explores fundamental concepts in critical care and their implications for practice. Each chapter outlines essential knowledge necessary to understand key concepts and includes high quality, full-colour artwork to enhance learning and recall. Readers are also provided with clinical scenarios, practice questions, and red and orange flags to indicate physiological and psychological alerts respectively. Covering a range of common and specialised disease processes and treatments requiring critical care, the book provides: A thorough introduction to the critical care unit, including philosophies of care, ways of working, humanisation, and outreach Comprehensive exploration of organisational influences, including political, local, national, and international influences Practical discussion of legal, ethical, and professional issues, as well as evidence-based approaches to critical care In-depth examination of nursing care assessment tools, nursing communication, cognition, pharmacology, and more Perfect for nursing students and trainee nursing associates, Fundamentals of Critical Care: A Textbook for Nursing and Healthcare Students will also earn a place in the libraries of healthcare students in physiotherapy, paramedicine, medicine, and those returning to practice. All content reviewed by students for students. If you would like to be one of our student reviewers, go to to find out more. To receive automatic updates on Wiley books and journals, join our email list. Sign up today at

Author Biography

Ian Peate OBE FRCN is Senior Lecturer, Roehampton University; Visiting Professor of Nursing, St George's University of London and Kingston University London; Visiting Professor, Northumbria University; Visiting Senior Clinical Fellow, University of Hertfordshire, and Editor-in-Chief of the British Journal of Nursing. Barry Hill is the Director of Education (Employability) for Nursing, Midwifery and Health at Northumbria University. His academic practice includes teaching and learning as well as research which impacts on undergraduate, postgraduate and CPD programmes. He specialises in clinical education relating to acute and critical care, and advanced level practice.

Table of Contents

Contributors xix Preface xxv Acknowledgements xxvii How to use your textbook xxix About the companion website xxxi Chapter 1 The critical care unit 1
Vikki Park Introduction 2 Levels of care 2 The critical care environment 2 Critical care patients 3 Level 1 care 4 Level 2 care 4 Level 3 care 4 Critical care competence 5 The interprofessional team 6 Communication 7 Ways of working 7 Understanding philosophies of care 8 Humanising critical care 8 Surviving critical care 9 Death in critical care 9 Resilience 9 Nursing considerations and recommendations for practice 11 Future challenges 11 Conclusion 11 References 12 Chapter 2 Organisational influences 14
Vikki Park Introduction 15 The four UK nations 15 Legislation 15 Professional Statutory Regulatory Bodies (PSRBs) 15 Shared decision making 16 Capacity for shared decision making 16 Confidentiality 17 Decisions relating to end-of-life care 17 Risk management 18 International influences 18 National influences 18 UK government organisations 18 Networks 19 National guidelines 20 Quality assurance 20 Local policies 21 Nursing considerations and recommendations for practice 21 Conclusion 21 References 22 Chapter 3 Legal and ethical issues 24
Leonie Armstrong, Tracey Carrott, and Jacqueline Newby Introduction 25 Confidentiality 25 End-of-life care and best interest decisions 26 Ethical themes 27 Mental Capacity Act 27 Organ donation 29 Consent (authorisation in Scotland) for organ donation 30 First person consent 31 First person opt-in 31 First person opt-out 31 Appointed/nominated representative (not Scotland) 31 Deemed consent 31 The ethics of deemed consent 32 Consent from a person in the highest-ranking relationship 32 Cadaveric organ donation 33 The organ donation process 33 Post organ retrieval 34 Organ allocation 34 Conclusion 35 References 35 Chapter 4 Professional issues in critical care 37
Aurora Medonica Introduction 38 Opportunities for learning 38 NMC Code in critical care units: journey to independent, safe practice 38 The core principles 39 UK National Competency Framework: critical care 41 Development of critical thinking in healthcare 42 The prioritising process 42 Support systems: the student 44 Conclusion 44 References 45 Chapter 5 Using an evidence-based approach 46
Sadie Diamond-Fox and Alexandra Gatehouse Introduction 47 What is evidence-based practice (EBP)? 47 Step 1: formulating a clinical question – the PICO method 48 Step 2: locating the evidence/research: performing a systematic literature review 48 Step 3: critical appraisal and the hierarchy of evidence 49 Step 4: extracting the most relevant and useful results 51 Step 5: implementing research into practice 52 Quality healthcare in critical care 53 Clinical audit and quality improvement 53 Research and development in critical care 55 Conclusion 56 References 56 Chapter 6 Nursing care 58
Sarah Crowe and Fiona McLeod Introduction 59 Standards of care 59 Physical care 63 Mobility 66 Critical care bundles 67 Conclusion 67 References 68 Chapter 7 Skin integrity 70
Victoria Clemett Introduction 71 Anatomy and physiology of the skin 71 Impact of ageing on skin and tissue integrity 71 Pressure ulcers 71 Nursing assessment 75 Prevention of pressure ulcers 76 Management of pressure ulcers 79 Wound healing 79 Patient factors that affect wound healing 79 Nursing assessment 79 Recognising wound infection 81 Management of non-healing wounds 83 Conclusion 83 References 84 Chapter 8 Shock 86
Barry Hill Introduction 87 Shock 87 Hypovolaemic shock 87 Blood analysis 88 Multiple organ dysfunction syndrome 89 Staging of hypovolaemic shock 89 Principles of managing hypovolaemic shock 90 Fluid resuscitation 91 Training and education for Registered Nurses 91 Cardiogenic shock 91 Obstructive shock 93 Altered pathophysiology 93 Tension pneumothorax 94 Cardiac tamponade 94 Pulmonary embolism (PE) 94 Distributive shock 95 Conclusion 96 References 97 Chapter 9 Communication 98
Paul Jebb Introduction 99 Communicating effectively with patients 100 Communicating during a pandemic 100 Communication with families 102 Conclusion 103 References 103 Chapter 10 Electronic health records 105
Timothy Kuhn Introduction 106 Digitisation within healthcare 106 Understand your responsibilities and the law in relation to record keeping 107 Intensive Care Society Guidelines 107 Understanding the different types of EHRs in critical care and how they are used 108 Understanding what patient data is available within the critical care unit and how this is recorded in an electronic health record 109 Understanding how EHRs are used in critical care audit and research 110 Understanding the benefits and barriers to EHRs 112 Conclusion 113 References 113 Chapter 11 Pharmacology 115
Sadie Diamond-Fox and Alexandra Gatehouse Introduction 116 Principles of pharmacology and pharmacotherapy 116 The processes of drug therapy 116 Medication safety in critical care 119 Drugs and dialysis 120 Core drugs utilised within critical care 120 Respiratory drugs 120 Cardiovascular drugs 122 Haematological drugs 126 Renal drugs 126 Fluids and electrolytes 127 Gastrointestinal drugs 128 Insulin 129 H2-histamine antagonists and proton pump inhibitors (PPIs) 129 Anti-emetics 129 Laxatives and anti-diarrhoeal drugs 130 Neurological drugs 130 Analgesics 130 Opioids 130 Non-opioid analgesics 130 Epidural and regional anaesthesia 130 Sedatives and anxiolytics 131 Muscle relaxants 131 Anticonvulsants 132 Antideliriogenics 132 Immunomodulatory drugs 132 Antibacterial agents 132 Antifungals 133 Antiviral drugs 134 Corticosteroids 134 Immunoglobulins 134 Toxicology 134 Conclusion 135 References 135 Chapter 12 Anaesthesia and sedation 138
Lorraine Mutrie and Iain Carstairs Introduction 139 Indications for sedation and anaesthesia 139 Anaesthetic and sedative medications 142 Sedative drugs 142 Neuromuscular blocking agents and reversal agents 143 Sedation management 145 Conclusion 147 References 148 Chapter 13 Medicines management and drug calculations 150
Jan Guerin Introduction 151 Purpose of pharmacological interventions in the critically ill adult patient 152 Legal and professional issues 152 Collaborative multidisciplinary team working 154 Medication errors 154 Overview of routes and methods of administering medications in CCU 155 Rights of medication administration 158 Managing and reporting a medication error 159 Anaphylaxis 160 Pathophysiology and clinical manifestations of DIA 160 Management for DIA 160 Medication calculation formulae 160 Displacement 165 Conclusion 165 References 166 Chapter 14 Neurological critical care 167
Samantha O'Driscoll Introduction 168 Neurological anatomy and physiology 168 Central nervous system 169 Neurological assessment 174 Signs and symptoms of increasing ICP 179 Primary and secondary brain injury 180 Management of raised ICP 180 Nursing care 181 Transfer 182 Conclusion 184 References 184 Chapter 15 Cognition 186
Barry Hill and Sadie Diamond-Fox Introduction 187 Cognitive impairment 187 Causes of cognitive impairment 187 Signs of cognitive impairment 188 Delirium 188 Risk factors 190 Management of delirium 191 Sleep 193 Assessment of sleep in ICU 193 Conclusion 195 References 195 Chapter 16 Respiratory care: intubation and mechanical ventilation 197
Barry Hill and Lorraine Mutrie Introduction 198 Respiratory failure 198 Hypoventilation 198 Ventilation/perfusion (V/Q) mismatch 199 Work of breathing 199 Arterial blood gases (ABGs) 200 Non-invasive ventilation (NIV) 201 Continuous positive airway pressure (CPAP) 204 High flow nasal oxygen 204 Intubation 204 Mechanical ventilation 206 Artificial ventilation 207 Minute ventilation (Vm) 207 Fraction of inspired oxygen 207 Positive end-expiratory pressure (PEEP) 207 Volume control 207 Pressure control 207 Inspiratory:Expiratory (I:E) ratio 208 Inverse ratio 208 Synchronisation 208 Humidification 208 Benefits of mechanical ventilation 208 Risks of mechanical ventilation 208 Ventilator care bundles 209 Prone positioning 209 Prone positioning in COVID-19 209 Weaning from mechanical ventilation 210 Conclusion 210 References 211 Chapter 17 Lung function in critical care 213
Rana Din and Joyce Smith Introduction 214 Anatomy and physiology 214 Composition of air 215 Alveolar gas 215 Expired air 216 Lung volumes 216 Pulmonary ventilation 216 External respiration 217 Ventilation/Perfusion 217 Transport of gases 217 Internal respiration 218 Assessment of lung function 220 Normal breath sounds (vesicular) 221 Absent Sounds 221 Wheeze 222 Crackles 222 The work of breathing 222 Compliance 222 Resistance 222 Emphysema 222 Asthma 223 Obstructive sleep apnoea 224 Prone positioning 224 Conclusion 225 References 226 Chapter 18 Cardiac physiology 227
Paul Sinnott Introduction 228 Functions of the cardiovascular system 228 Anatomy of the heart and great vessels 228 Pericardium 229 Layers of the heart 229 Chambers of the heart 230 Valves of the heart 230 Coronary circulation 232 Cardiac conduction system 235 The cardiac cycle 236 Cardiac output and blood pressure 237 Regulation of heart rate 238 Stroke volume 239 The regulation of blood pressure 240 The microcirculation 242 Capillary exchange 243 Effects of ventilation on the cardiovascular system 245 Conclusion 245 References 246 Chapter 19 Cardiovascular critical care 247
Alice Shaw and Paul Sinnott Introduction 248 Cardiovascular assessment 248 Heart rate and rhythm 248 Atrial ectopic beats 249 Ventricular ectopic beats 253 Blood pressure 254 Invasive blood pressure monitoring 255 Central venous catheters (CVCs) and central venous pressure (CVP) 256 Markers of organ and tissue perfusion 258 Neurological status 258 Urine output 258 Blood results 259 Advanced haemodynamic monitoring 260 Cardiac pacing 262 Nursing considerations and recommendations for practice 263 Conclusion 263 References 263 Chapter 20 Fluids and electrolytes in critically ill patients 265
Barry Hill Introduction 266 The role of the critical care nurse 266 Intravenous fluids 266 Crystalloids versus colloids critical care 267 Fluid management 268 Third spacing 269 Assessment and monitoring 269 Training and education 271 Electrolyte replacement therapy 271 Management of hyperkalaemia 272 Oral sodium and water 272 Oral rehydration therapy (ORT) 272 Oral bicarbonate 273 Parenteral preparations for fluid and electrolyte imbalance 273 Plasma and plasma substitutes 276 Plasma substitutes 276 Fluid overload 276 The four Ds of fluid management 276 Hyponatraemia 277 Hypernatraemia 277 Hypokalaemia 277 Hyperkalaemia 277 Hypophosphataemia 278 Hypocalcaemia 278 Hypomagnesaemia 278 Conclusion 279 References 279 Chapter 21 Critical care emergencies 280
Alexandra Gatehouse and Sadie Diamond-Fox Introduction 281 A – Airway 282 B – Breathing 290 C – Circulation/Cardiovascular 291 D – Disability 298 E – Everything else (exposure, endocrine, electrolytes and environmental) 301 Care of the patient post return of spontaneous circulation (ROSC) 307 Critical care emergencies and human factors 307 Debriefing 309 Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) 309 Conclusion 310 References 310 Chapter 22 Gastrointestinal critical care 313
Anna Riley, Joe Box, and Aileen Aherne Introduction 314 Anatomy and physiology 314 GI monitoring and investigation in the critically ill 317 Imaging and endoscopy 318 Bowel charts and abnormal GI motility 320 The acute abdomen in critical care 322 Common surgical procedures cared for in critical care 325 Post-operative monitoring 325 Abdominal surgical drains 326 Anaesthetics 326 Post-operative complications 326 Wound dehiscence 327 GI pharmacology 327 Conclusion 328 References 328 Chapter 23 Nutrition in critical care 330
Barry Hill and Lorraine Mutrie Introduction 331 Pathophysiology 331 Fight or flight 332 Resistance 332 Exhaustion 332 Nutritional screening and assessment 333 Indirect calorimetry (IC) 333 Routes of administration 334 Nursing considerations and recommendations for practice 336 Care of people with feeding tubes 336 Glycaemic control 337 Refeeding syndrome 338 Discontinuing feed 339 Nutritional guidance 339 Conclusion 340 References 341 Chapter 24 Renal critical care 343
Alexandra Gatehouse and Sadie Diamond-Fox Introduction 344 Anatomy and physiology of the renal tract 344 Vascular supply 344 Renin-angiotensin-aldosterone system (RASS) 344 The nephrons 345 Control of plasma osmolality 346 Electrolyte balance 346 Acid-base balance 352 Renal failure 352 Acute kidney injury 353 Classification of AKI 353 Pathophysiology 353 Organ cross-talk 354 Risk factors for AKI 355 Clinical features and examination 355 Investigations 355 Specific disorders associated with AKI 357 Drug-induced renal damage 357 Management of AKI 359 Clinical features and examination 361 Management 361 Chronic kidney disease 362 Management 362 Diabetic nephropathy 362 Continuous renal replacement therapy (CRRT) 364 Dosing of CRRT 364 Anticoagulation 364 Drug dosing and RRT 367 Kidney transplantation – critical care considerations 367 Conclusion 368 References 368 Chapter 25 Endocrine critical care 370
Geraldine Fitzgerald O'Connor and Emma Long Introduction 371 Thyroid and parathyroid glands 371 Disorders of the thyroid gland 371 Thyroid crisis 372 Parathyroid glands 372 Disorders of the parathyroid glands 372 Hypocalcaemia 373 Pituitary gland 373 Disorders of the pituitary gland 373 Diabetes insipidus 374 Pathophysiology 375 Hyperglycaemia in the critically ill 376 Diabetic emergencies 376 Pathophysiology 380 Conclusion 383 References 384 Chapter 26 Haematological and immunological critical care 385
Barry Hill, Gerri Mortimore, and Pamela Arasen Introduction 386 Normal physiology 386 Blood components 386 Haematopoiesis 387 Disorders of erythrocytes 387 B12 vitamin deficiency 387 Sickle cell anaemia 388 Genetic haemochromatosis 389 Haemostasis 390 Lymphoma 390 Disseminated intravascular coagulation 393 Thrombocytopenia 394 Neutropenia and sepsis 394 Vasculitis 396 Blood transfusions in adults 397 Blood sample collections 398 Blood groups 398 Compatibility 399 Indications for blood transfusions 399 Platelets 400 Fresh frozen plasma (FFP) 400 Cryoprecipitate 400 Granulocytes 400 Procedural safety 400 Pre-procedure and sampling 400 Administration of the blood product 400 Post-procedural care 401 Traceability 401 Patient information 402 Alternatives to blood transfusions 403 Summary of SaBTO recommendations on consent 403 Conclusion 408 References 408 Chapter 27 Musculoskeletal considerations in critical care 411
Clare L. Wade and Helen Sanger Introduction 412 Trauma 412 Management of traumatic injury 413 Intensive care unit-acquired weakness 415 Assessment of musculoskeletal impairment or injury 418 Management of musculoskeletal injury and impairment 419 Conclusion 424 References 424 Chapter 28 Burn care within a critical care setting 426
Nicole Lee Introduction 427 Classification of burn wound depths 427 Pathological considerations 429 Burn size estimation 430 An ABCDE approach to burn care 432 Breathing 433 Cardiovascular 433 Disability (neurological assessment) 434 Exposure (and everything else) 434 Psychological support 434 Acknowledgement 436 References 436 Chapter 29 Maternal critical care 438
Wendy Pollock Introduction 439 Epidemiology 439 Adapted physiology 439 Recognising clinical deterioration 441 Nursing considerations and recommendations for practice 442 Conclusion 448 References 449 Chapter 30 Critical care transfers 451
Kirstin Geer, Mark Cannan, and Stuart Cox Inter-hospital and intra-hospital patient transfers 452 Transfer of the critically ill adult 452 Critical care bed and repatriation 456 The risks of critical care transfer 457 Preparation for transfer 458 ABCDE process during critical care transfer 458 Conclusion 469 References 469 Chapter 31 Rehabilitation after critical illness 470
Helen Sanger and Clare L. Wade Introduction 471 The impact of critical illness – what do we mean by morbidity? 471 Describing physical functioning and morbidity 472 Models of post-critical care morbidity 473 Assessment 473 Goals 475 Key timepoints in RaCI 477 Treatment 478 National guidelines and standards 480 Conclusion 481 References 481 Chapter 32 Dying and death 484
Helen Merlane and Leonie Armstrong Introduction 485 End-of-life care 485 Palliative care 486 Dying 486 Recognising Dying 486 Advance care planning 488 Involve and support 489 Nursing the dying patient 489 The critical care environment 489 Symptom management 490 End-of-life care discharges from a critical care setting 491 Care after death 494 Conclusion 495 References 495 Index 497

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