Critical care nursing

In short

Critical care nursing is the specialised care of patients with actual or potential life-threatening single or multi-organ failure, delivered in an ICU, HDU, emergency department or during transport, with continuous monitoring and rapid intervention. The nurse's work is continuous assessment, interpretation of monitored data (ECG, ABG, haemodynamics, ventilator parameters), titration of life-support therapy on protocol, prevention of device-related infection, and support of the family. It is examined in Medical-Surgical Nursing II of the B.Sc Nursing (INC) curriculum, in M.Sc entrance and NORCET/AIIMS/JIPMER/PGIMER/ESIC/state staff-nurse papers, and tested in every ICU interview along with a BLS/ACLS demonstration. Employers recruit ICU-ready freshers heavily — AIIMS and PGIMER, Apollo, Fortis, Manipal, Narayana Health, Medanta, Aster, Amrita, CMC Vellore — and most require a 6-week to 6-month critical care orientation plus BLS certification.

Explained

Scope, levels of care and the ICU team

• Definition: nursing of the critically ill — physiologically unstable patients needing continuous surveillance and titrated organ support. Critical illness implies a threat to one or more vital functions.
• Levels of care (as used in Indian ICU guidelines, ISCCM): Level I — basic, non-invasive monitoring plus oxygen (small hospital HDU). Level II — ability to ventilate short-term, manage single-organ failure, resident doctor on site. Level III — full multi-organ support, 24-hour intensivist, dialysis/CRRT, tertiary referral.
• Types of units: MICU, SICU, CCU/CTVS ICU, neuro ICU, NICU, PICU, burns ICU, trauma/emergency ICU, respiratory ICU, isolation/negative-pressure ICU, HDU, step-down.
• Staffing: ISCCM and NABH recommend a nurse-to-patient ratio of 1:1 for ventilated/unstable patients and 1:2 for others; INC norms for teaching hospitals likewise place ICU above ward ratios. Exact figures differ between ISCCM guidance, NABH edition and state rules — quote the principle and name the source.
• Team: intensivist, critical care nurse, respiratory therapist, physiotherapist, clinical pharmacist, dietitian, microbiologist/infection-control nurse. The nurse is the only continuously present member, so trend detection is a nursing function.
• Admission priority (Society of Critical Care Medicine model): Priority 1 — unstable, needing therapy only ICU can give; Priority 2 — stable but needing intensive monitoring; Priority 3 — critically ill with reduced likelihood of recovery, ICU for limited therapy; Priority 4 — generally not appropriate for ICU.
• Equipment the nurse must check each shift: multiparameter monitor, ventilator with circuit and HME, infusion and syringe pumps, defibrillator with pads and charge, suction, Ambu bag with mask and PEEP valve, crash cart, ABG syringes, warming device, difficult-airway trolley.

Systematic assessment and scoring

• Primary survey ABCDE: Airway (patency, secretions, tube position), Breathing (rate, SpO₂, effort, auscultation, chest movement), Circulation (pulse, BP, CRT, urine output, lactate), Disability (GCS, pupils, blood sugar), Exposure (temperature, bleeding, wounds, lines).
• Glasgow Coma Scale: Eye 4 + Verbal 5 + Motor 6, total 3-15. GCS ≤ 8 = coma, intubate. Record components (E3V4M5) not just the total; a ventilated patient's verbal score is recorded as 1T or marked non-testable. FOUR score (eye, motor, brainstem, respiration — 0-16 each 0-4) is used where verbal testing is impossible.
• Pupils: size, equality, reaction. Unilateral fixed dilated pupil suggests uncal herniation — an emergency. Cushing's reflex (rising BP, bradycardia, irregular respiration) means rising ICP.
• Sedation and pain: RASS (Richmond Agitation-Sedation Scale) +4 combative to −5 unarousable; target 0 to −2 for most ventilated patients. CPOT or Behavioural Pain Scale for pain in non-verbal patients. CAM-ICU screens delirium every shift.
• Severity scores: APACHE II (0-71; age, 12 physiological variables, chronic health) predicts hospital mortality. SOFA (6 organ systems, 0-4 each, 0-24) tracks organ dysfunction; qSOFA (RR ≥ 22, altered mentation, SBP ≤ 100 — any 2) screens sepsis outside ICU. SAPS II, MODS, NEWS/MEWS for ward deterioration, Braden for pressure risk, Morse for falls, RIFLE/AKIN/KDIGO for AKI.
• Daily nursing targets: MAP, urine output ≥ 0.5 mL/kg/h, SpO₂ target, lactate clearance, fluid balance, CBG range, sedation level, bowel and feed tolerance.

Respiratory support and mechanical ventilation

• Oxygen delivery: nasal prongs (1-6 L/min, FiO₂ ~24-44%), simple mask (5-10 L/min, 40-60%), venturi mask (fixed FiO₂), non-rebreathing mask with reservoir (10-15 L/min, up to ~90%), high-flow nasal cannula (up to 60 L/min, heated humidified), NIV — CPAP (one pressure) and BiPAP (IPAP/EPAP).
• Indications for intubation and ventilation: apnoea or impending arrest, GCS ≤ 8/inability to protect airway, refractory hypoxaemia, hypercapnic respiratory failure with acidosis, severe work of breathing, airway burns or obstruction.
• Modes: A/C volume control (set tidal volume), pressure control (set pressure, variable volume), SIMV (mandatory breaths synchronised with spontaneous), PSV (pressure support, patient-triggered — weaning mode), CPAP, PRVC and dual modes.
• Settings the nurse documents and understands: tidal volume (lung-protective 6-8 mL/kg predicted body weight, 4-6 mL/kg in ARDS), rate, FiO₂ (wean to lowest keeping SpO₂ ≥ 92%, or 88-92% in chronic CO₂ retainers), PEEP (usual 5 cm H₂O, higher in ARDS), I:E ratio, trigger sensitivity, plateau pressure target < 30 cm H₂O, driving pressure < 15.
• Alarms — nurse's first response is to look at the patient, then DOPE: Displacement of tube, Obstruction (secretions, kink, biting), Pneumothorax, Equipment failure. Disconnect and bag with 100% oxygen if unsure. High-pressure alarm = secretions, bronchospasm, biting, pneumothorax, falling compliance. Low-pressure alarm = leak, disconnection, cuff deflation, extubation.
• VAP prevention bundle: head-up 30-45°, daily sedation interruption and readiness-to-wean assessment, oral care with chlorhexidine 0.12-0.2% 6-12 hourly, subglottic suction where available, cuff pressure 20-30 cm H₂O, closed suction, change circuit only when soiled, DVT and stress-ulcer prophylaxis, early enteral feeding.
• Endotracheal tube care: confirm placement by capnography (gold standard) plus bilateral air entry and chest X-ray (tip 2-4 cm above carina); secure and record the cm mark at the lip; suction only when indicated (not routinely), pre-oxygenate, catheter < half the tube lumen, suction < 15 seconds, pressure 80-120 mm Hg.
• Weaning and extubation: criteria — cause resolving, awake and cooperative, FiO₂ ≤ 0.4 with PEEP ≤ 5, haemodynamically stable off high-dose vasopressors, adequate cough, RSBI (f/Vt) < 105. Spontaneous breathing trial 30-120 minutes; after extubation watch for stridor, hoarseness and re-intubation need. Tracheostomy considered when ventilation is prolonged (commonly ~10-14 days, individualised).
• ARDS (Berlin definition): acute onset within 1 week, bilateral infiltrates, not cardiogenic, PaO₂/FiO₂ ≤ 300 — mild 201-300, moderate 101-200, severe ≤ 100. Nursing: low tidal volume, prone positioning 12-16 h/day (team of 5, airway at the head, pressure-point care), conservative fluids, neuromuscular blockade monitoring.

Circulatory failure, shock and haemodynamic monitoring

• Shock: inadequate tissue perfusion and oxygen delivery. Hypovolaemic (haemorrhage, dehydration, burns), cardiogenic (MI, arrhythmia, cardiomyopathy), obstructive (tension pneumothorax, tamponade, massive PE), distributive (septic, anaphylactic, neurogenic). Stages: initial → compensatory (tachycardia, narrow pulse pressure, cool skin, restlessness, oliguria) → progressive → refractory.
• Warm vs cold shock: septic/distributive shock gives warm extremities, bounding pulse and wide pulse pressure early; cardiogenic and hypovolaemic shock give cold, clammy, mottled skin and prolonged capillary refill.
• Sepsis (Sepsis-3): life-threatening organ dysfunction from dysregulated host response to infection — SOFA rise ≥ 2. Septic shock: sepsis with vasopressors needed to keep MAP ≥ 65 mm Hg plus lactate > 2 mmol/L despite fluids. Hour-1 bundle: measure lactate, blood cultures before antibiotics, broad-spectrum antibiotics, 30 mL/kg crystalloid for hypotension or lactate ≥ 4, vasopressors to MAP ≥ 65.
• Monitoring: invasive arterial line (continuous BP, ABG sampling; level transducer at the phlebostatic axis — 4th intercostal space, mid-axillary line; zero to atmosphere; Allen's test before radial cannulation). CVP 2-8 mm Hg (≈ 3-10 cm H₂O) reflects right-sided filling — a trend, not a reliable fluid-responsiveness measure. ScvO₂ ≥ 70%. Pulmonary artery catheter gives PAP, PCWP 4-12 mm Hg, cardiac output by thermodilution; largely replaced by echo, pulse-contour cardiac output and passive leg raise/stroke-volume variation.
• Vasoactive drugs (nursing essentials): noradrenaline — first-line vasopressor in septic shock, central line, extravasation causes necrosis (antidote phentolamine). Adrenaline — anaphylaxis 0.5 mg IM and cardiac arrest 1 mg IV. Dopamine — dose-dependent. Dobutamine — inotrope, may drop BP. Vasopressin — adjunct. Nitroglycerin/nitroprusside — vasodilators, light-protected lines. All on dedicated infusion pumps, double-checked, concentration and rate written on the pump, never bolused, never stopped abruptly.
• Arrhythmias and arrest: recognise VF/pulseless VT (shockable — defibrillate 150-200 J biphasic / 360 J monophasic), asystole and PEA (non-shockable — CPR plus adrenaline 1 mg every 3-5 min). High-quality CPR: depth 5-6 cm, rate 100-120/min, ratio 30:2 until advanced airway, then continuous compressions with 10 breaths/min, minimal interruptions, change compressor every 2 minutes. Cardioversion is synchronised (unstable SVT, AF, VT with pulse); defibrillation is unsynchronised. Reversible causes — 4H4T: hypoxia, hypovolaemia, hypo/hyperkalaemia-metabolic, hypothermia; thrombosis (coronary/pulmonary), tension pneumothorax, tamponade, toxins.

Neurological, renal, metabolic and multi-system care

• Raised ICP: normal 5-15 mm Hg; CPP = MAP − ICP, target ≥ 60 mm Hg. Nursing: head-up 30°, head and neck neutral, avoid hip flexion and neck constriction, cluster care to limit stimulation, pre-oxygenate before suction, prevent straining/coughing/fever, maintain normocapnia, osmotherapy (mannitol 20%, hypertonic saline) as prescribed with serum osmolality and sodium monitoring.
• Status epilepticus, stroke, Guillain-Barré, myasthenic crisis, brain death evaluation — nursing roles are airway protection, serial neuro observation, documentation and family communication. Brain-stem death certification and organ donation in India are governed by the Transplantation of Human Organs and Tissues Act, 1994 (amended 2011) with its Rules, requiring a board of specified medical experts and two examinations; the nurse's role is documentation, maintaining the donor's physiology and referral to the transplant coordinator — she does not certify death.
• Acute kidney injury: staged by KDIGO on creatinine rise and urine output; nursing — hourly output, strict intake-output, avoid nephrotoxics, dose adjustment, dialysis/CRRT (SLED, CVVHDF) circuit and anticoagulation monitoring, watch for disequilibrium, hypotension, filter clotting, hypothermia and electrolyte shifts.
• Electrolyte and glycaemic control: hyperkalaemia (peaked T waves → calcium gluconate, insulin-dextrose, salbutamol, dialysis), hypokalaemia (never IV push; peripheral ≤ 10 mEq/h, concentrated only centrally), hyponatraemia (correct slowly to avoid osmotic demyelination), hypoglycaemia protocol, DKA care. Target blood glucose commonly 140-180 mg/dL in ICU; tight control increases hypoglycaemia.
• Nutrition: enteral within 24-48 hours if the gut works; check tube position, head-up, gastric residual as per unit policy, watch refeeding syndrome; parenteral when enteral fails. Prophylaxis: DVT (LMWH or mechanical), stress ulcer (PPI/H2 blocker) for high-risk patients only.
• Infection prevention bundles: hand hygiene (WHO 5 moments), CLABSI bundle (maximal barrier precautions, chlorhexidine 2% skin prep, subclavian/preferred site choice, daily review of line need, scrub the hub), CAUTI bundle (insert only when indicated, closed system, bag below bladder and off the floor, no routine change, remove early), antimicrobial stewardship, isolation for MDROs, biomedical waste segregation under the Bio-Medical Waste Management Rules, 2016 (as amended) — yellow, red, white (translucent, sharps) and blue categories.
• ICU complications and syndromes: ICU-acquired weakness, delirium, pressure injury, ventilator-induced lung injury, ICU psychosis, post-intensive-care syndrome, alarm fatigue, sleep deprivation. ABCDEF bundle: Assess/treat pain, Both SBT and sedation interruption, Choice of analgesia and sedation, Delirium monitoring, Early mobility, Family engagement.
• Legal, ethical and documentation: informed consent, documentation as legal evidence, DNR/limitation of therapy decisions (no specific statute; the Supreme Court in Common Cause (2018), clarified in 2023, permits passive euthanasia and advance medical directives under laid-down safeguards — procedure has been simplified, so quote the principle, not a fixed format), patient rights under the Charter of Patients' Rights (NHRC/Ministry of Health), scope of practice under the Indian Nursing Council Act, 1947 and state council registration, National Patient Safety Implementation Framework, NABH accreditation standards, incident and sentinel-event reporting, handover using SBAR (Situation, Background, Assessment, Recommendation).

Key points

• Critical care nursing - continuous assessment and titrated organ support for patients with life-threatening instability.
• Level III ICU - full multi-organ support with 24-hour intensivist; Level I gives only basic monitoring and oxygen.
• ICU nurse ratio - 1:1 for ventilated/unstable and 1:2 otherwise, per ISCCM/NABH guidance.
• GCS - E4+V5+M6 = 3 to 15; ≤ 8 means coma and need for airway protection; record components, V as 1T if intubated.
• RASS target - 0 to −2 for most ventilated patients; CAM-ICU each shift for delirium.
• SOFA/qSOFA - SOFA rise ≥ 2 defines sepsis organ dysfunction; qSOFA (RR ≥ 22, altered mentation, SBP ≤ 100) is a ward screen.
• Lung-protective ventilation - 6-8 mL/kg predicted body weight (4-6 in ARDS), plateau pressure < 30 cm H₂O.
• DOPE - the four causes of sudden ventilator trouble: displacement, obstruction, pneumothorax, equipment.
• Cuff pressure - keep 20-30 cm H₂O: lower leaks and aspirates, higher causes tracheal ischaemia.
• VAP bundle - head-up 30-45°, oral chlorhexidine, sedation break with daily weaning assessment, closed suction.
• Phlebostatic axis - 4th intercostal space at mid-axillary line; transducer zeroed there or arterial/CVP readings are false.
• Septic shock - vasopressors needed for MAP ≥ 65 plus lactate > 2 despite fluid; Hour-1 bundle of five actions.
• Noradrenaline - first-line vasopressor, central line only, extravasation causes tissue necrosis.
• Shockable rhythms - VF and pulseless VT only; asystole and PEA get CPR and adrenaline, never a shock.
• Cardioversion vs defibrillation - synchronised for unstable rhythms with a pulse; unsynchronised in pulseless arrest.
• CPP = MAP − ICP - keep ≥ 60 mm Hg; nurse by head-up 30°, neutral neck, clustered care, normocapnia.
• 4H4T - reversible causes of arrest the nurse helps identify and correct during resuscitation.
• ICU glucose target - commonly 140-180 mg/dL; tighter control risks hypoglycaemia.

Formulas and examples

Example 1 — MAP and CPP. A head-injury patient has BP 100/60 mm Hg and ICP 22 mm Hg.

• MAP = (100 + 2 × 60)/3 = (100 + 120)/3 = 220/3 = 73.3 mm Hg.
• CPP = 73.3 − 22 = 51.3 mm Hg — below the 60 mm Hg target.
• Action: report at once; head-up 30° with neutral neck, ensure no venous obstruction, treat fever and pain, expect osmotherapy and a higher MAP target (vasopressor) on orders.

Example 2 — tidal volume for ARDS. Male, height 170 cm, actual weight 85 kg.

• PBW = 50 + 0.91 × (170 − 152.4) = 50 + 0.91 × 17.6 = 50 + 16.0 = 66.0 kg.
• ARDS Vt at 6 mL/kg = 6 × 66.0 = 396 mL (set ~395-400 mL).
• Note the error avoided: using 85 kg would give 510 mL — about 29% more volume and a real risk of volutrauma. Always use predicted, never actual, body weight.
• Minute ventilation at RR 22 = 0.396 × 22 ≈ 8.7 L/min.

Example 3 — noradrenaline infusion rate. Order: 0.1 µg/kg/min for a 60 kg patient. Bag: 4 mg noradrenaline in 50 mL.

• Concentration = 4,000 µg / 50 mL = 80 µg/mL.
• Dose per minute = 0.1 × 60 = 6 µg/min → per hour = 360 µg/h.
• Rate = 360 / 80 = 4.5 mL/h.
• If the dose is raised to 0.2 µg/kg/min, rate doubles to 9 mL/h. Central line, dedicated lumen, pump only.

Example 4 — ABG interpretation. pH 7.22, PaCO₂ 62 mm Hg, HCO₃⁻ 25 mEq/L, PaO₂ 58 mm Hg on FiO₂ 0.40, Na⁺ 138, Cl⁻ 103.

• pH < 7.35 → acidaemia. PaCO₂ 62 (high) matches the acidosis → respiratory acidosis; HCO₃⁻ 25 is near normal → uncompensated/acute.
• P/F ratio = 58 / 0.40 = 145 → moderate ARDS range (101-200) by oxygenation criterion.
• Anion gap = 138 − (103 + 25) = 10 mEq/L — normal, so no added metabolic acidosis.
• Action: type II (hypercapnic) respiratory failure with hypoxaemia — escalate for NIV or intubation, position, suction, inform the intensivist.

Example 5 — urine output and fluid responsiveness. A 70 kg septic patient passes 90 mL in 3 hours; MAP 62 mm Hg, lactate 4.2 mmol/L.

• Output = 90 / (70 × 3) = 90/210 = 0.43 mL/kg/h → oliguric (< 0.5).
• Fluid bolus 30 mL/kg = 30 × 70 = 2,100 mL crystalloid per the sepsis bundle.
• Targets after bolus: MAP ≥ 65 mm Hg, output ≥ 0.5 mL/kg/h (≥ 35 mL/h here), falling lactate; if MAP stays < 65, vasopressor is indicated — fluids alone are not the answer.

ABG in four steps (write these in the exam)
1. pH      < 7.35 acidosis | > 7.45 alkalosis | 7.35-7.45 normal/compensated
2. PaCO₂   > 45 respiratory cause | < 35 respiratory compensation (normal 35-45)
3. HCO₃⁻   < 22 metabolic cause | > 26 metabolic compensation (normal 22-26)
4. Match the abnormal value to pH = primary disorder; the other = compensation
   Then oxygenation: PaO₂ 80-100 mm Hg, SaO₂ > 94%, P/F ratio for ARDS

Where it is used

• Tertiary and corporate ICUs: AIIMS, PGIMER, JIPMER, CMC Vellore, SGPGI and the Apollo, Fortis, Manipal, Max, Medanta, Narayana, Aster and Amrita groups recruit B.Sc graduates as ICU staff nurses after a structured critical care orientation and BLS/ACLS certification.
• Specialty units and procedures: CTVS and cardiac ICUs (post-CABG, IABP, pacing), neuro ICU, transplant ICU, burns ICU, dialysis and CRRT units, cath lab and emergency department resuscitation bays.
• Emergency and transport care: 108/102 ambulance services, hospital code-blue and rapid-response teams, inter-hospital and air transfers, disaster and mass-casualty triage, ICU-on-wheels.
• Quality, safety and infection control roles: NABH coordinator, infection-control nurse tracking VAP, CLABSI and CAUTI rates per 1,000 device-days, clinical audit and bundle compliance.
• Higher study and specialist practice: M.Sc (Medical-Surgical Nursing, critical care speciality), Nurse Practitioner in Critical Care (NPCC) — a 2-year INC residency-based programme — plus post-basic diplomas in critical care, teaching and clinical instructor roles.
• Overseas and allied employment: Gulf and UK/Ireland ICU recruitment (HAAD/DHA/MOH/Prometric, NMC OSCE), clinical research coordination in ICU trials, medical-device and monitoring application specialists with ventilator and monitor companies.

Interview questions

• Q: What is the first thing you do when a ventilator alarms? A: Look at the patient, not the machine — check chest rise, SpO₂, colour and tube position; if the patient is in distress, disconnect and bag with 100% oxygen while running through DOPE.
• Q: Why is tidal volume set on predicted and not actual body weight? A: Lung size depends on height and sex, not on fat mass; using actual weight in an obese patient gives an excessive volume and causes volutrauma.
• Q: Which rhythms do you defibrillate? A: Only ventricular fibrillation and pulseless ventricular tachycardia; asystole and PEA are treated with high-quality CPR and adrenaline.
• Q: Difference between cardioversion and defibrillation? A: Cardioversion is a synchronised, usually lower-energy shock timed to the R wave for unstable rhythms with a pulse; defibrillation is unsynchronised and used in pulseless arrest.
• Q: A septic patient's MAP is 58 after 30 mL/kg of fluid. What next? A: Report immediately and prepare a noradrenaline infusion through a central line with a pump — further fluid alone will not restore perfusion in vasoplegic shock.
• Q: How do you position a patient with raised ICP, and why? A: Head-up about 30° with head and neck neutral and no hip flexion, to aid cerebral venous drainage without lowering cerebral perfusion pressure.
• Q: What endotracheal cuff pressure do you maintain and why? A: 20-30 cm H₂O — below this the patient leaks and aspirates, above it mucosal capillary flow is compromised and tracheal ischaemia or stenosis follows.
• Q: How is a central line infection prevented? A: Hand hygiene and maximal barrier precautions at insertion, 2% chlorhexidine skin prep, appropriate site, sterile dressing, scrub the hub, and daily review to remove the line as soon as it is not needed.
• Q: What does CAM-ICU assess and how often? A: It screens for ICU delirium — acute fluctuating change, inattention, altered consciousness and disorganised thinking — and should be done at least once a shift.
• Q: Interpret pH 7.30, PaCO₂ 30, HCO₃⁻ 15. A: Metabolic acidosis with partial respiratory compensation — the low bicarbonate matches the low pH and the low PaCO₂ is the compensatory response; look for shock, DKA or renal failure.
• Q: Your patient is for extubation. What do you check? A: Underlying cause resolved, awake and obeying commands, FiO₂ ≤ 0.4 with PEEP ≤ 5, stable haemodynamics, good cough and cuff-leak, a passed spontaneous breathing trial, with suction, oxygen and re-intubation equipment ready.
• Q: Can a nurse certify brain death in India? A: No — under the Transplantation of Human Organs and Tissues Act, 1994 (amended 2011) a specified board of medical experts does, after two examinations; the nurse documents, maintains the patient's physiology and involves the transplant coordinator.

Common mistakes

• Treating the monitor instead of the patient — silencing alarms, or recording a saturation or arterial pressure without checking the probe, the transducer level and the patient's clinical state.
• Using actual body weight for tidal volume, or forgetting to re-zero and re-level the arterial/CVP transducer at the phlebostatic axis after repositioning — both give wrong numbers that drive wrong decisions.
• Giving a total GCS without components, or scoring verbal response in an intubated patient instead of recording 1T/non-testable.
• Routine deep suctioning on a schedule, without pre-oxygenation, with too large a catheter or for too long — causes hypoxia, arrhythmia and mucosal trauma.
• Shocking asystole or PEA in exam answers and mock codes, confusing synchronised cardioversion with defibrillation, or giving adrenaline doses for anaphylaxis (0.5 mg IM) and arrest (1 mg IV) the wrong way round.
• Pushing potassium as a bolus or running concentrated potassium peripherally, and running vasopressors by gravity or in a peripheral line instead of a pump and central access.
• Charting fluid balance without the obvious losses — drains, nasogastric aspirate, insensible loss in fever — then reporting a "balanced" patient who is actually hypovolaemic.

Related topics

• Cardiovascular nursing · Respiratory nursing · Emergency and disaster nursing · Advanced nursing procedures and infection control · Pharmacology of emergency and vasoactive drugs · Nursing management and quality standards (NABH, patient safety).