Advance Class: Day 1 of Knowledge (Critical Care Nursing)

ADVANCE CLASS: DAY 1 of knowledge and experience through continuous education and evidence-based research....

ADVANCE CLASS: DAY 1 of knowledge and experience through continuous education and evidence-based research. OUTLINE With advances in sophisticated biomedical 1. Foundation Concepts technology and knowledge, critical care nurses are a. Definition of Terms able to continuously monitor and observe patients b. Scope of Critical Care Practice for physiological changes to confront problems c. Advocacy: Access to Social Care Services proactively and to assist patients to achieve and d. Critical Care Body of Knowledge maintain an optimum level of functioning or a peaceful death. 2. Nursing Process in the Critical Care Unit Note: a. Assessment Brain injury patient - reverse Trendelenburg to b. Analysis/Nursing prevent increased ICP and there will be lesser c. Diagnosis blood supply in the brain and there will be no added d. Planning injury e. Implementation of Care of Clients Presence of carbon dioxide in body it will dilate the f. Client Education cerebral vessel; increase blood supply g. Evaluation of the Outcome of Care 3 components: brain, csf and blood, if 3 will h. Reporting and Documentation of Care increase then ICP will increase III. ACUTELY ILL PATIENTS A. [ABC] ACUTE BIOLOGIC CRISIS patients who developed a disease/ illness with an abrupt onset and, usually, a short course. I. CRITICAL CARE UNIT Note: a place in the hospital where the most seriously ill o Ex: infections, trauma, fracture, bleeding patients are cared for by specially trained staff It has the highest density of healthcare providers per IV. CRITICALLY ILL PATIENTS square foot in the hospital. patients who are at high risk for actual or potential It is also defined by high technology and complex life-threatening health problems care. Those who are more critically ill require more ICU patients are the sickest patients. They are those intensive and vigilant nursing care. with the most severe disease of one or more organ- Note: systems. o Ex: stroke Patients who require any of the following are best o After discharge, educate family and relatives in cared for in an ICU setting: case of recurrence o frequent monitoring; o special monitoring devices; cardiac monitors, V. HEMODYNAMIC MONITORING mechanical ventilator o special medications and technology to support a mainstay in the care of critically ill patients and sustain normal bodily functions; monitor involves using invasive and non-invasive side effects methods to provide information about pump effectiveness, vascular capacity, blood volume and II. CRITICAL CARE NURSE tissue perfusion In collaboration with other health care team members, The precise data obtained from hemodynamic critical care nurses provide a high level of patient care monitoring helps to identify the type and severity of which includes patient and family education, health shock (cardiogenic, hypovolemic (no fluid in body), promotion and rehabilitation. In collaboration with distributive, or obstructive). others and the family When paired with clinical evaluation, hemodynamic At the forefront of critical care science and monitoring is helpful in guiding the administration of technology, critical care nurses maintain fluids, in selecting and titrating vasoactive drugs, professional competence based on a broad base and in deciding when mechanical support might be necessary to treat refractory shock. BSN 4H 1  NCM 218 Concept: ABC It allows for evaluation of the effectiveness of Support the decisions of the patient or patient’s treatment in real time. designated surrogate or transfer care to an equally qualified critical care nurse. Note: Intercede for patients who cannot speak for o Complex; no simple IV used themselves in situations that require immediate o Swan Ganz Pulmonary Artery Catheter attention. Animation: Swan Ganz Pulmonary Artery Monitor and safeguard the quality of care that the Catheter Animation by Cal Shipley, M.D. patient receives. Act as a liaison between the patient and the VI. INVASIVE MANAGEMENT patient’s family and other health care professionals. VII. POLYPHARMACY MANAGEMENT regular use of at least five medications b. Expanded-Role Nursing Position common in older adults and younger at-risk interacts with critical care patients, families, and populations and increases the risk of adverse the health care team. medical outcomes Nurse case managers work closely with the care Simultaneous use of drugs providers to ensure appropriate, timely care and services and to promote continuity of care from B. SCOPE OF CRITICAL CARE PRACTICE one setting to another. Other nurse clinicians, such as patient educators, I. DEVELOPMENT OF CRITICAL CARE NURSING cardiac rehabilitation specialists, physician office PRACTICE, EDUCATION AND PROFESSIONAL nurses, and infection control specialists, also ACTIVITIES IN THE PHILIPPINES contribute to the care. The scope is defined by the dynamic interaction The specific types of expanded-role nursing of the: positions are determined by patient needs and individual organizational resources. c. Advanced Practice Nurses Advanced practice nurses (APNs) have met educational and clinical requirements beyond the basic nursing educational requirements for all nurses. The most commonly seen APNs in the critical care areas are the clinical nurse specialist (CNS) Constant intensive assessment, timely critical and the nurse practitioner (NP) or acute care care interventions and continuous evaluation of nurse practitioner (ACNP). ; nurses that are management through multidisciplinary efforts are acting alone required to restore stability, prevent APNs have a broad depth of knowledge and complications and achieve optimal health expertise in their specialty area and manage Palliative care should be instituted to alleviate complex clinical and systems issues; they can pain and sufferings of the patient and family in alter problems in patient (physiologic, system like situations where death is imminent. cardiac and liver) The organizational system and existing II. CRITICAL CARE NURSING ROLES resources of an institution determine what roles a. Critical Care Nurse Role Responsibilities may be needed and how the roles function; Respect and support the right of the patient or regulated actions patient’s designated surrogate to autonomy and NPs and ACNPs manage direct clinical care of a informed decision making. group of patients and have various levels of Intervene when the best interest of the patient is prescriptive authority, depending on the state and in question. practice area in which they work. Help the patient obtain necessary care. They also provide care consistency, interact with Respect the values, beliefs, and rights of the families, plan for patient discharge, and provide patient. teaching to patients, families, and other members Provide education and support help to the patient of the health care team. or patient’s designated surrogate to make (Source: CCN diagnosis and mgt by Urden. UNIT decisions 1 CHAPTER 1) Represent the patient in accordance with the patient’s choices. III. ICU NURSE AS A PATIENT’S ADVOCATE BSN 4H 2  NCM 218 Concept: ABC Acts in the best interest of the patient. should be incorporated into medical orders Monitors and safeguards the quality of care which upon admission to the hospital or skilled the patient receives. nursing facility. Note: POLST forms are more easily read than an Messenger of the patient, they also evaluate advance directive in that the format is one of checkboxes with specific directions. a. END OF LIFE CARE d. ADVANCE CARE PLANNING The primary purpose of admission of patients Planning for decisions to be made at a later to a critical care unit is to provide aggressive, date if one is deemed incompetent is a difficult life-saving treatment. The death of a patient is process, but this knowledge helps the family generally regarded as a failure.;place pt in ICU members left to make the treatment decisions. bc you want to give the best med and care to Communication of the patient’s wishes the pt between primary care providers and Because the culture emphasizes saving lives, intensivists is critical. If patients have stated the language that describes the end of life desires, they should be communicated when employs negative terms, such as “forgoing life- patients are transferred out of the critical care sustaining treatments,” “do not resuscitate unit. If the patient has not specified his or her (DNR),” and “withdrawal of life support.” preferences, that information also is important ;provide the comfortable situation before letting and should be communicated to new health the pt die like positioning, easing pain care providers; the level of care patients desire Sometimes the phrase withdrawal of care is should be offered as appropriate. used, which can cause families to think there Families and care providers should be informed will be no comfort measures or assistance if patients decline aggressive care, so their provided after a decision is made to discontinue families will not be left with difficult decisions in mechanical ventilation and other life-sustaining emergency situations. treatments. In reality, treatment options are usually IV. PALLIATIVE CARE FOR CRITICALLY ILL explained in rapid technical language, followed Patients who are identified as being near the end of by a frightening question, “Do you want us to life require aggressive care for their symptom keep going?” or “Tell us what you want us to management, provided by a team of health do.” professionals.;near the end of life requires This heavy burden placed on loved ones aggressive care means they must choose between treatment The most relevant clinical goal is to palliate these options, one of which may result in loss of their unpleasant situations by assessing for them and loved one. implementing appropriate interventions. Critical care nurses are often the i ers of medical information and how it applies to personal preferences and values. a. PAIN MANAGEMENT The ability to respond realistically in Many critical care patients are not conscious, accordance with the listener’s values and assessment of pain and other symptoms culture is a learned skill. becomes more difficult. Fortunately, many resources are available to Gélinas and colleagues recommended using further develop the necessary skills to better signs of body movements, neuromuscular signs, support patients and families through a critical facial expressions, or responses to physical care unit admission to discharge. examination for pain assessment in patients with altered consciousness. b. ADVANCE DIRECTIVES o Nonopioid medications - first-line approach A.k.a. a living will, or a health care power of (e.g Acetaminophen) attorney intended to ensure that patients o followed by adding an opioid for additional received the care they desired at end of life, analgesia when relief is not obtained. their enactment has been less than desired Because opioids provide sedation, anxiolysis, and analgesia, they are c. PHYSICIAN ORDERS FOR LIFE SUSTAINING particularly beneficial in the ventilated TREATMENT (POLST) patient. POLST forms are medical orders that are o Morphine - medication of choice, and there honored across all treatment settings and are is no upper limit in dosing. → Should be especially important to emergency responders ordered; antidote Naloxone/Narcan in the community o In non ventilated patients - sedation may completed by the patient and physician in the cause respiratory depression, and presence of a serious chronic illness and BSN 4H 3  NCM 218 Concept: ABC nonopioids or specific anesthetic agents may 2-3 liters only then increase be more appropriate. o In the sedated ventilated patient, especially d. NAUSEA AND VOMITING those receiving neuromuscular blocking common and should be treated with antiemetics. medications, there is no systematic, reliable The cause of nausea and vomiting may be method to determine presence or degree of intestinal obstruction. pain. Treatment for decompression may be o The absence of the usual clinical indicators of uncomfortable in dying patients, and its use pain, such as grimacing or guarding, makes should be weighed using a benefit-to-burden it a challenge to determine whether pain is ratio. present. Note: o Titration of intravenous infusions to achieve Antiemetic - domperidone (motilium) maximum effect with minimum sedation is an Gastric Decompression Video: inexact science. https://www.youtube.com/watch?v=4lXFWo o Sedation/ agitation scales are one method of 9kRx4 monitoring the effectiveness of medications but are not performed continuously with frequent titration, such as during surgery. e. FEVER AND INFECTION o Potential pain sources include prone necessitate assessment of the benefits of position, endotracheal tube, wounds, and continuing antibiotics so as not to prolong the immobility, and should necessitate dying process. preventive analgesia administration. Management of the fever with antipyretics may be o Critical care nurses should assume pain is appropriate for the patient’s comfort, but other present in the immobile patient and methods such as ice or hypothermia blankets administer routine analgesics to prevent should be balanced against the amount of suffering. distress the patient may experience. f. EDEMA b. SYMPTOM MANAGEMENT may cause discomfort, and diuretics may be Campbell, in her book chapter titled “Usual Care effective if kidney function is intact. Requirements for the Patient Who Is Near Dialysis is not warranted at the end of life. Death,” listed the following symptoms as The use of fluids may contribute to the edema necessary parts of the assessment: when kidney function is impaired, and the body is o dyspnea, nausea and vomiting, edema and slowing its functions. pulmonary edema, anxiety (restlessness) and delirium, metabolic derangements, skin g. ANXIETY integrity (bed sores), and anemia and should be assessed verbally, if possible, or by hemorrhage. changes in vital signs or restlessness. Note: Benzodiazepines, especially midazolam with its Black, tarry stool - sign of ulcer/bleeding rapid onset and short half-life, are frequently used. Minimizing noxious sounds and playing a c. DYSPNEA patient’s favorite music may help to soothe Best managed with close evaluation of the patient anxiety. and the use of opioids, sedatives, and nonpharmacologic interventions (oxygen, h. DELIRIUM positioning, and increased ambient air flow). commonly observed in the critically ill and in Morphine - can give IV (2-4 mg) or IM (5-10 mg) those approaching death. then PRN every 5 mins. Reduces anxiety and Haloperidol is recommended as useful, and muscle tension and increases pulmonary restraints should be avoided. vasodilatation but is not effective when inhaled. In a review of the available literature, Kehl Antidote: Naloxone/Narcan concluded that despite the recommendations of Benzodiazepines - may be used in patients who most study authors to use neuroleptic are not able to take opioids or for whom the medications as a treatment for restlessness, respiratory effects are minimal. several studies demonstrated the effectiveness Benzodiazepines and opioids - should be of other medications, such as benzodiazepines titrated to effect. (notably midazolam and lorazepam) or Treatment efforts should be aimed at the patient’s phenothiazines, alone or in combination. expression of dyspnea rather than at respiratory rates or oxygen levels. V. METABOLIC DERANGEMENT Note: BSN 4H 4  NCM 218 Concept: ABC Treatments for metabolic derangements, skin C. ADVOCACY: ACCESS TO SOCIAL CARE problems, anemia, and hemorrhage should be SERVICES tempered with concerns for the patient’s comfort. Philippine Health Insurance Corporation (PHIC) Only interventions promoting comfort should be Department of Health (DOH) performed Department of Social Welfare and Patients do not necessarily feel better “when the Development (DSWD) laboratory values are right.” Philippine Amusement and Gaming Corporation (PAGCOR) VI. PROVIDING COMFORT Philippine Sweepstakes Charity Office (PCSO) The nursing interventions at end of life should Philippine Health Insurance Corporation (PHIC) focus on the provision of comfort care as an Department of Health (DOH) active, desirable, and important service. Unnecessary checks of vital signs, laboratory DEPARTMENT OF SOCIAL WELFARE AND work, and any treatment that does not promote DEVELOPMENT (DSWD) comfort should be avoided. Programs: Positioning the patient who is actively dying has a. Assistance to Individuals in Crisis Situation as its purpose only comfort, not the schedule to (AICS) promote skin integrity. AICS is part of the DSWD’s protective Coordinating this care with the many members of services for the poor, marginalized and the critical care team is important to ensure vulnerable/ disadvantaged individuals. consistency across disciplines and across shifts. medical assistance: assistance to help When symptom management is not successful in shoulder hospitalization expenses, purchase ensuring comfort, the services of the pain team or of medicines, and other treatment and other the palliative care service may be required. medical expenses. cases with chronic illnesses may be provided with PhilHealth VII. NEAR-DEATH AWARENESS insurance coverage, in coordination with the Two hospice nurses have described a DOH. they will no longer be entitled to in- phenomenon of near-death awareness. patient financial assistance, except by The same behaviors may be seen in conscious philhealth. critical care patients near death. b. Lingap at Gabay Para sa may sakit/ Lingap sa Masa: Having an awareness of the phenomenon enables more careful assessment of behaviors envisioned as the program that will that may be interpreted as delirium, acid-base implement the president’s directive to imbalance, or other metabolic derangements. provide free medicines, prosthetics, medical and assistive devices, medical supplies, These behaviors include communicating with medical implants, laboratory/ diagnostic/ someone who is not alive, preparing for travel, radiology procedure, chemotherapy and describing a place they can see, or even knowing dialysis, medical assistance to indigents and when death will occur. to needy government workers. The amount Family members may find these behaviors of 1 Billion Pesos has been committed to the disturbing but find comfort in understanding the program to be sourced from the president’s phenomenon and in sharing these experiences socio-civic projects fund of the president. with their loved one. c. Philippine Amusement and Gaming Corporation (PAGCOR) VIII. FAMILY MEETINGS PAGCOR supports the promotion of key Although family meetings should be held within health-related programs of the government 72 hours of an admission, they are frequently by providing financial assistance to state-run held to formulate a decision to withdraw life hospitals. support. Apart from that, PAGCOR also donated Lilly and colleagues found that an earlier meeting P350 million funding to Southern Philippines led to shorter critical care unit stays for patients Medical Center (SPMC) for the procurement who eventually died and allowed them earlier of Linear Accelerator Machine, an apparatus access to palliative care. used for cancer treatment, aside from These results held up in a 4-year evaluation of chemotherapy. SPMC also received P184 this intervention, and they found that they were million from PAGCOR in 2018, for the providing advanced life support to patients with purchase of medical equipment that will the potential to survive and an earlier withdrawal cater to women and newborn’s sensitive when ineffective. health conditions. (Source: CCN diagnosis and mgt by Urden. UNIT o Aside from helping state-run hospitals, 1 CHAPTER 11) PAGCOR continues to help less- privileged citizens through providing BSN 4H 5  NCM 218 Concept: ABC financial support. In 2020, the agency committed to provide need-driven, effective and granted financial medical assistance to efficient specialty nursing care services of high individuals/ beneficiaries amounting to standard and at international level within the P20.37 million and financial grants to obtainable resources. Local Government Units, Non- To respond to this mission and commitment, a government organizations, and other PRC-BON Working Group in Developing the government agencies and individual Nursing Specialty Framework was formed beneficiaries amounting to P30.45 sometime in 1996 to take on the task of setting the million. process-based framework and guidelines for d. Philippine Sweepstakes Charity Office specialty nursing services. (PCSO) Working Group members comprise clinical nurse It is the program for the provision of practitioners, nurse educators and nurse assistance to male and female individuals managers. with health-related problems seeking financial help, which is embedded on the premise of augmenting their funds, in NURSING PROCESS IN THE CRITICAL CARE UNIT partnership with government and private hospitals, health facilities, medicine retailers and other partners. 1. ASSESSMENT Requests Covered: According to The Joint Commission, education o Confinement provided should be appropriate to the patient’s o Chemotherapy condition and should address the patient’s o Dialysis (Hemo/ PD/ Erythropoietin) identified learning needs. o Medicines (Hemophilia and Post- The assessment is an important first step to transplant) providing need-targeted patient and family education. D. CRITICAL CARE BODY OF KNOWLEDGE It begins on admission and continues until the patient is discharged. A. CRITICAL CARE COMPETENCIES A formal, comprehensive, initial education The competence of critical care nurses together assessment produces valuable information; with established nursing standards and the however, it can take the nurse hours to complete. identified core competencies for registered The nurse must focus the initial and subsequent nurses will result in excellence in critical care education assessments on identifying gaps in nursing practice. knowledge related to the patient’s current health- This three-pronged holistic framework ensures altering situation. quality performance through an adherence to Learning needs can be defined as gaps between nursing standards, the application of what the learner knows and what the learner needs competencies, and the integration of appropriate to know, such as survival skills, coping skills, and nursing model/s into the care delivery process. ability to make a care decision. To achieve safe and quality client-centered care, Identification of actual and perceived learning nurses working in the critical care units are needs directs the health care team to provide need- envisioned to adopt not only the stated core targeted education. competencies of registered nurses but also the Need targeted or need-to-know education is specific competencies stipulated in the following directed at helping the learner to become familiar eleven major key responsibility areas: with the current situation. Safe and Quality Nursing Care (CCNAPI page Educational needs of the patient and family can be 10) categorized as: I. Management of Resources I o information only (environment, visitation hours, II.Legal Responsibilities get questions answered); III.Ethico-Moral Responsibilities o informed decision making (treatment plan, IV.Collaboration and Teamwork informed consent); or V.Personal and Professional Development o self-management (recognition of problems and VI.Communication how to respond) VII.Health Education Patient education to be included in the education VIII.Quality Improvement plan should address the plan of care, health IX.Research practices and safety, safe and effective use of X.Record Management medications, nutrition interventions, safe and effective use of medical equipment or supplies, B. PROFESSIONAL ORGANIZATIONS pain, and habilitation or rehabilitation needs. Learning needs may change from day to day, shift In the Philippines, the Professional Regulation to shift, or minute to minute. Educational needs are Commission – Board of Nursing (PRC-BON) is BSN 4H 6  NCM 218 Concept: ABC influenced by how the patient, or the family perceives or interprets the critical illness. Perceptions of experiences vary from person to A. SUBJECTIVE DATA person, even if two people are involved in the same Information that is provided verbally by the patient event. is called subjective data. Symptoms are subjective This intense internal feeling affects the desire to data. Subjective data are often placed in quotes, learn and understanding of the current situation. such as “I have a headache” or “I feel out of breath.” Satisfaction with the learning encounter is often You must listen carefully to the patient and judged to be positive if the nurse meets the understand that only the patient truly knows how he expected learning needs of the patient and family. or she feels. Congruency between nurse-identified needs and When collecting subjective data, begin with the patient-identified needs brings about more positive patient’s main concern. Focus on the reason the learning experiences and encourages the learner to patient is seeking health care. The question, “What seek further information. The nurse must actively happened that made you decide to come to the listen, maintain eye contact, seek clarification, and hospital (clinic, office)?” can be helpful. pay attention to verbal and nonverbal cues from the Once the patient has identified the main concern, patient and the family to gather relevant information further questioning can elicit more pertinent concerning perceived learning needs. The nurse information. Use the letters of the “WHAT’S UP?” should seek to first understand the learning need questioning format to remember questions to ask from the patient’s point of view and then seek to be the patient (Box 1.1 What’s Up? Guide to Symptom understood. Assessment). Asking the right questions can help Strategic questioning provides an avenue for the you obtain better data with which to make the best nurse to determine whether the patient or family decisions. has any misconceptions about the environment, Next, obtain a patient history. This is done by asking their illness, self-management skills, or the the patient and family questions about the patient’s medication schedule. past and present health problems, including Health care providers use the term noncompliant to specific questions about each body system, family describe a patient or family members who do not health problems, and risk factors for health modify behaviors to meet the demands of the problems. The patient’s medical record may also be prescribed treatment regimen, such as following the consulted for background history information. rules of a low-fat diet or medication dosing. In addition to assessment related to physiological However, the problem behind noncompliance may functioning, ask the patient about personal habits not be a conscious desire to defy the treatment plan that relate to health, such as exercise, diet, and the but instead be a misunderstanding of the presence of stressors, per institutional assessment importance of the medication or how to take the guidelines. Finally, assess the patient’s family role, medication. support systems, and cultural and spiritual beliefs. The technique of asking open-ended questions (“Can you tell me what you know about your medication?”) can elicit more information about the B. OBJECTIVE DATA patient’s knowledge base than asking closed- ended questions (“You know this is your water pill, Objective data are pieces of factual information right?”). Open-ended questions provide the nurse obtained through physical assessment and an opportunity to assess actual knowledge gaps diagnostic tests and are observable or knowable rather than assume knowledge by obtaining a yes- through the five senses. Objective data are or-no response. sometimes called signs. These types of questions also assist the patient and Note that these are all observable or measurable by family to tell their story of the illness and a nurse and do not require explanation by the communicate their perceptions of the experience, patient. allowing the adult learner to feel respected and Objective data are gathered through physical involved in the treatment process. assessment. Inspection, palpation, percussion, and Questions that elicit a yes-or-no response close off auscultation techniques are used to collect communication and do not provide an interactive objective data (Fig. 1.2). Give special attention to teaching learning session. areas that the patient has identified as potential Generally, with practice and effort, it can be problems. determined what educational information is needed C. PHYSICAL ASSESSMENT in a brief period without much disruption in the routine care of the patient. Patients and families are multidimensional. Even D. DIAGNOSTIC STUDIES/ PROCEDURES with good questioning skills, the nurse cannot assess many aspects of the learner during the initial contact or even during the hospital stay. BSN 4H 7  NCM 218 Concept: ABC 2. ANALYSIS/NURSING DIAGNOSIS a. Planning for health Promotion Once data has been collected, the LPN/LVN b. Planning for health restoration and maintenance assists the RN to compare the findings with what is considered “normal.” 4. IMPLEMENTATION OF CARE OF CLIENTS Data are then grouped, or clustered, into sets of a. Independent Nursing Care related information that identify problems. Physiologic Care According to the North American Nursing Psychosocial Care Diagnosis Association (NANDA), a nursing Spiritual Care diagnosis is a clinical judgment about individual, b. Interdependent Care family, or community response to actual or Pharmacological Therapeutics potential health problems or life processes. Complementary and Alternative Therapies Nursing diagnoses are standardized labels that Nutritional and Diet Therapy make an identified problem understandable to all Surgical Interventions nurses. Nursing diagnoses are the foundation Immunologic Therapy used to select interventions to achieve a desired outcome. A list of NANDA-approved nursing diagnoses can 5. CLIENT EDUCATION be found in Appendix A of this book. Patient education is a process that includes the Nursing actions are either independent or purposeful delivery of health-related information to collaborative. Independent nursing actions can be promote changes in behavior that will optimize initiated by the nurse. health practices and assist the individual in attaining new skills for living. The bedside nurse must incorporate the abundant educational needs of the patient or family into the 3. PLANNING education plan and be aware of the requirements Education must be ongoing, interactive, and of regulatory agencies and the legalities of consistent with the patient’s plan of care and documenting the teaching learning encounter. education level. Studies have documented that quality education The nurse must analyze information gathered from shortens hospital length of stay, reduces the assessment to prioritize the educational needs readmission rates, and improves self-care of the patient and family. management skills. Complications associated with The nursing diagnosis for deficient knowledge and the physiologic stress response may be prevented accompanying interventions can be applied to any if the patient or family perceives the education situation. encounter as positive. Positive encounters The nurse must also consider the patient’s decrease the stress response, relieve anxiety, physical and emotional status when setting promote individual growth and development, and education priorities. Ability, willingness, and increase patient and family satisfaction. readiness to learn are factors that impair The following are examples of positive outcomes acceptance of new information and add to the associated with a structured teaching-learning complexity of teaching-learning encounters. process. These factors should be recognized by the nurse o Clarification of patients’ understanding and before implementation of teaching. perceptions of their chronic illness and care The written teaching plan should identify the decisions learning need, goals or expected outcome of the o Improved health outcomes relative to self- teaching-learning encounter, interventions to meet management techniques, such as symptom that outcome, and appropriate teaching strategies. management Research and accepted national guidelines or o Promotion of informed decision making and standards can be used to assist the practitioner in control over the situation developing an evidence-based plan for education. o Diminished emotional stress associated with o Examples of organizations that offer education an unfamiliar environment and unknown standards are the American Association of prognosis Critical Care Nurses, American Heart o Improved adaptation to stressful situations Association Guidelines for Practice, and the o Improved satisfaction with the care received Society of Critical Care Medicine. o Improved relationship with the health care o It can be used in daily practice and can be team found in two books: Nursing Interventions o Promotion of self-concept Classification (NIC) and Nursing Outcomes Classification (NOC). These evidence-based 6. EVALUATION OF THE OUTCOME OF CARE interventions and outcomes assist the nurse in Evaluation is the final component in the patient providing consistent outcomes and and family education process. interventions from nurse to nurse, shift to shift, The intent of evaluation is to determine the and discipline to discipline. effectiveness of the educational interventions. BSN 4H 8  NCM 218 Concept: ABC The nurse must use his or her clinical judgment Indicators such as blood cholesterol levels, blood and knowledge of adult-learning principles to pressure, heart rate, blood sugars, and weight can determine how well the learner has met the lead the practitioner to the conclusion that the expected outcomes and objectives. patient and family may be having difficulties The evaluation process is continual and assesses understanding or following through with the the entire teaching-learning interaction, including identified plan of care. the level of learner interest in the session, Adults generally want to comply with new willingness to learn the content, and level of expectations but often cannot for various reasons, participation during the encounter. such as a lack of money for medications or an Evaluation should be completed at the end of each inability to understand what is expected of them. teaching-learning encounter. These barriers must be explored and included in This allows the nurse to immediately present the education plan. positive and constructive feedback to the patient Observation and return demonstration is the and family, as well as revise the education plan to evaluation of choice for the skills-learning domain. accommodate ongoing learning needs. For the patient and family members to be It is also important to assess the response to “checked off” on a particular skill, they should be teaching and determine whether follow-up able to perform it independently, using the nurse education is required. only as a resource for questions. Endotracheal Techniques such as verbalization of information, suctioning, placing condom catheters, and return demonstration, and physiologic performing dressing changes are examples of measurement are common evaluation methods to common tasks that patients and families may be determine the effectiveness of a teaching-learning asked to learn. Because of the increasingly encounter. complex care that patients require at home after Evaluation of knowledge retention can be discharge, these skills may be the entire focus of completed by verbally questioning the learner. teaching before discharge. Not every teaching This method is known as teach-back. Teach-back moment is a success, and the nurse need not feel is an interactive process that assists the nurse in guilty or like a failure when the learner has not determining whether the learner has retained the achieved the desired objective. Revisiting and information taught. The nurse may ask the patient revising the goals and objectives during the if he or she is able to list signs and symptoms of teaching learning session may be necessary to heart failure. Verbal questioning should occur meet the ever-changing needs of the patient or immediately after the teaching event and family. throughout the hospitalization to assess knowledge retention. For example, the physician 7. REPORTING AND DOCUMENTATION OF CARE orders a new medication for the patient today, and members of the health care team, patients and the nurse educates that patient on the effects and families, and regulatory agencies. side effects; the next day, the nurse may assess The nurse should recognize that informal teaching retention by asking the patient if he or she at the bedside is education. remembers the reason for taking the new It is important to record any information given to the medication. Common items that patients and patient on formal documents approved for use by families are asked to verbalize are reportable each health care institution. signs and symptoms, how to manage symptoms at In most institutions, formal education records are home, when to take medication, how often the used to document education rendered by medication should be taken, and who to call for practitioners of any discipline involved in the care of questions or concerns. a particular patient and family. Changes in attitude, beliefs, or lifestyle are often These forms are communication tools used to difficult to evaluate, because learners can say they indicate progress in the teaching-learning process have changed their attitude when actually they from shift to shift, day to day, and discipline to have not. In this learning domain, the nurse must discipline. use his or her detective skills to assess whether Documentation should include education from the individual has accepted the prescribed admission to discharge on topics ranging from treatment plan and modified behavior accordingly. orientation to the environment to acquisition of self- Sometimes, the best way to evaluate a change in management skills for home care. attitude is by observation and verbal questioning. An example is a patient who has been asked to comply with a low-cholesterol diet; a food diary the What Should Be Documented? patient has kept as requested provides some o The complexity of information, demand evidence about what the patient has eaten. A by governing agencies, lawsuits, and the wealth of information can also be obtained from sheer volume of patients in and out of a the family concerning the patient’s exhibited unit are driving nurses to provide quality changes. BSN 4H 9  NCM 218 Concept: ABC documentation of the education encounter. o Documentation of the teaching-learning process is multifaceted. o The documentation form should “tell the story” of the education encounter from assessment to evaluation. o Documentation of the education assessment should include learning preferences; factors that impair ability, readiness, and willingness to learn; and actual or perceived learning needs. o Information should be recorded on the interaction, material taught, supplemental materials distributed, response to the education, achievement of outcome, and any follow-up education or resources needed. What Should Be Documented? o The complexity of information, demand by governing agencies, lawsuits, and the sheer volume of patients in and out of a unit are driving nurses to provide quality documentation of the education encounter. o Documentation of the teaching-learning process is multifaceted. o The documentation form should “tell the story” of the education encounter from assessment to evaluation. o Documentation of the education assessment should include learning preferences; factors that impair ability, readiness, and willingness to learn; and actual or perceived learning needs. o Information should be recorded on the interaction, material taught, supplemental materials distributed, response to the education, achievement of outcome, and any follow-up education or resources needed. BSN 4H 10  SKILLS LAB: DAY 2 Aggravating factors Smoking history OUTLINE Environmental exposure 1. Responses to alterations/problems and its Past medical history pathophysiologic basis in life-threatening Family history conditions, acutely ill/multi-organ problems, high Current medications acuity, and emergency situation Vaccines A. Physical Assessment Older Adults: risk for respiratory disease B. Past Health History noticeable changes C. Family History D. Lifestyle Patterns  Orthopnea 2. Common diagnostic assessment - difficulty breathing while lying down A. Non Invasive - Place pillow-- for severe form of orthopnea B. Invasive  Coughing - When did it start? - Is it productive? RESPONSE TO ALTERATIONS/PROBLEMS - What is the color? - If the cough is chronic, nag change ba PHYSICAL ASSESSMENT recently? Subjective Data - What makes the cough better? o Current Health Status - What makes it worse? ▪ Focus on the client’s presenting problem - What medications are you taking? ▪ Explore the onset, location, duration, character, aggravating, alleviating factors Note: When Patient Produces Septum radiation (if relevant)  Ask him to estimate the amount produced in ▪ Ask about smoking history, environmental teaspoons or some other common exposure, past medical and family history, measurements and current medications (Bickley, 2012;  At what time of day do you cough most often? Mansen & Gabiola, 2015). ▪ Because older adults are at increased risk  What‘s the color and consistency of the sputum?  If sputum is a chronic problem, has it changed for respiratory disease due to loss of recently? If so, how? elasticity and decreased ventilation of the lower lobes, specifically inquire about: o Fatigue, weight change, dyspnea on  Wheezing exertion, flu and pneumonia vaccine - More common in asthma status, and change in number of pillows - What time of the day does wheezing occur? used at night (Hogstel & Curry, 2005). - What makes you wheeze? Note: - Do you wheeze loudly enough for others  Alleviating factors - (Depends on the situation, if pt to hear it? will lie down, it is more severe. Can also be relieved - What helps stop your wheezing? with walking)  What will you ask? Note: Common or concerning symptoms (cough, 1 teaspoon - 5 ml orthopnea, chest pain 1 tablespoon = 15 ml Associated symptoms 1 cc = 1 ml Duration 1 oz = 30 ml Location Severity  Chest Pain Setting - Coming from the heart? Time of day - GERD can produce chest pain also known Alleviating factors as heartburn - Chest pain is sharp, knife-like → MI signs BSN 4H 1  NCM 218 Concept: ABC - Perform ECG to determine the electrical activity of the heart (ex. MI) PAST HEALTH HISTORY  Identification of previous health problems  Childhood illness  Immunization (if your pt is not given complete vaxx, maybe they’ll grow up unhealthy)  Smoking history  Alcohol history (excessive) FAMILY HISTORY  Ask the patient if anyone in his family has had cancer, diabetes, sickle cell anemia, heart disease, or a chronic illness, such as asthma or emphysema.  Chest Symmetry Be sure to determine whether the patient lives with - Both sides of the chest should be equal at anyone who has an infectious disease, such as rest and expand equally as the patient inhales. influenza or tuberculosis (TB) The diameter of the chest from front to back should be about half the width of the chest Note:  Costal Angle  Any infection is not hereditary - The angle between the ribs and the sternum  Mantoux test: 10 mm induration (+), 38°C), which is often high, and sometimes No vaccine or specific treatment is currently associated with chills and rigor. available, although several MERS-CoV specific ✓ It may also be accompanied by other symptoms vaccines and treatments are in development. including headache, malaise, and muscle pain. Treatment is supportive and based on the patient's ✓ At the onset of illness, some cases have mild clinical condition. respiratory symptoms. As a general precaution, anyone visiting farms, ✓ Typically, rash and neurologic or gastrointestinal markets, barns, or other places where dromedary findings are absent, although a few patients have camels and other animals are present should reported diarrhea during the early febrile stage. practice general hygiene measures, including ✓ After 3-7 days, a lower respiratory phase begins regular hand washing before and after touching with the onset of a dry, non-productive cough or animals and avoiding contact with sick animals. dyspnea (shortness of breath) that may be The consumption of raw or undercooked animal accompanied by, or progress to, hypoxemia (Low products, including milk and meat, carries a high blood oxygen levels) risk of infection that can cause disease in humans. ✓ In 10-20% of cases, the respiratory illness is severe Animal products that are processed appropriately enough to require intubation and mechanical through cooking or pasteurization are safe for ventilation Chest radiographs may be normal consumption but should also be handled with care throughout the course of illness. though not for all to avoid cross contamination with uncooked foods. patients Camel meat and camel milk are nutritious products ✓ The white blood cell count is often decreased early that can continue to be consumed after in the disease, and many people have low platelet pasteurization, cooking or other heat treatments. counts at the peak of the disease Transmission of the virus has occurred in health care facilities in several countries, including MEDICAL-SURGICAL MANAGEMENT transmission from patients to health care providers There is no cure or vaccine for SARS and treatment and transmission between patients before MERS- should be supportive and based on the patient's CoV was diagnosed. It is not always possible to symptoms. identify patients with MERS-CoV early or without Controlling outbreaks relies on-containment testing because symptoms and other clinical measures including: features may be non-specific BSN4H 6  NCM 218 Concept: ABC prompt detection of cases through good Vasodilators such as calcium channel blockers or surveillance networks and including an early angiotensin converting enzyme (ACE) inhibitors warning system: may be used to reduce pulmonary artery pressure isolation of suspected of probably cases; tracing to Warfarin may be used to prevent clotting. identify both the source of the infection and contacts Epoprostenol (Flolan) is a vasodilator that may of those who are sick and may be at risk of reverse some of the vascular changes and prolong contracting the virus: quarantine of suspected survival, but has many serious side effects, and contacts for 10 days: must be continuously administered IV via an exit screening for outgoing passengers from areas implanted pump. with recent local transmission by asking questions Bosentan (Tracleer) is a new oral drug that blocks and temperature measurement. and disinfection of endothelin, a substance that causes blood vessels aircraft and cruise vessels having SARS cases on to constrict. Silfenadil (Viagra) is being tested for board using WHO guidelines possible use in PAH NURSING RESPONSIBILITIES NURSING RESPONSIBILITIES ◼ Personal preventive measures to prevent spread of ◼ Nursing care is collaborative and focuses primarily the virus include frequent hand washing using soap on patient assessment. or alcohol-based disinfectants. ◼ Fowler's or high-Fowler's position may help reduce ◼ For those with a high risk of contracting the disease, dyspnea, and rest and comfort measures are such as health care workers, use of personal helpful in treating fatigue and anxiety. protective equipment, including a mask, goggles and an apron is mandatory. PNEUMOTHORAX ◼ Whenever possible, household contacts should also Air or gas accumulates between the parietal and wear a mask. visceral pleurae, causing the lungs to collapse. Accumulation of atmospheric air in the pleural space, PULMONARY ARTERIAL HYPERTENSION which results in a rise in intra thoracic pressure and → “Hypertension of your pulmonary area” reduced vital capacity. ⚫ Primary pulmonary arterial hypertension (PAH) CLINICAL MANIFESTATION occurs when the arteries that carry deoxygenated ✓ SUDDEN PLEURITIC RAIN blood from the heart to the lungs become narrowed ✓ TACHYPNEA as a result of changes in the lining of smooth ✓ ANXIOUXS muscle of the vessels. ✓ DYSPNEA(AIR HUNGER) ⚫ The result is elevated pressure in the pulmonary ✓ USE OF ACCESSORY MUSCLE arteries, causing the right ventricle to work harder to ✓ CYANOSIS push blood in them. Eventually, the right ventricle ✓ TACHYCARDIA fails (cor pulmonale). ✓ PROFUSE DIAPHORESIS ⚫ The reason for these vascular changes is not ✓ ASYMMETRICAL CHEST WALL EXPANSION known. Primary PAH is more common in women between ages 20 and 40 and has a hereditary DIAGNOSTIC TEST: tendency. ❖ CHEST XRAY ❖ ABG CLINICAL MANIFESTATION ✓ Dyspnea MEDICAL-SURGICAL MANAGEMENT ✓ Fatigue THORACENTESIS ✓ Crackles CHEST TOBE DRAINAGE ✓ Decreased breath sounds THORACOTOMY ✓ Peripheral edema PAIN RELIEVER ✓ Distended jugular veins ✓ Angina may result from right ventricular ischemia CLASSIFICATION MEDICAL-SURGICAL MANAGEMENT No cure is available for pulmonary hypertension SIMPLE PNEUMOTHORAX except for lung or heart-lung transplant. A simple, or spontaneous, pneumothorax occurs In secondary pulmonary hypertension, the when air enters the pleural space through a underlying disorder is treated. breach of either the parietal or visceral pleura. Supportive care includes a low-sodium diet and Most commonly, this occurs as air enters the diuretics to reduce blood volume (and therefore pleural space through the rupture of a bleb or a pressure), oxygen, and cardiac monitoring. bronchopleural fistula TENSION PNEUMOTHORAX BSN4H 7  NCM 218 Concept: ABC - A tension pneumothorax occurs when air is ◼ Monitor vital signs for indications of shock of drawn into the pleural space from a lacerated increasing respiratory distress. lung or through a small opening or wound in the ◼ Administer oxygen as prescribed. chest wall. ◼ Place the client in a fowler’s position. ◼ Prepare for chest tube placement which will remain TRAUMATIC PNEUMOTHORAX in place until the lung has expanded fully. - A traumatic pneumothorax occurs when air ◼ If chest tube is in place, encourage the patient to escapes from a laceration in the lung itself and cough and breathe deeply at least once per hour to enters the pleural space or from a wound in the promote lung expansions. chest wall. It may result from blunt trauma (e.g., ◼ In the patient undergoing chest tube drainage, rib fractures), penetrating chest or abdominal watch for continuing air leakage (bubbling) in the trauma (e.g., stab wounds or gunshot wounds), water-seal chamber. This indicates the lung defect or diaphragmatic tears. has failed to close and may require surgery. ◼ Observe for increasing subcutaneous emphysema OPEN PNEUMOTHORAX by checking around the neck or at the tube insertion - If air can enter and escape through the opening site for crackling beneath the skin. In the pleural space, it considered an open ◼ If the patient is on a ventilator, be alert for any difficulty in breathing in time with the ventilator as pneumothorax you monitor its gauges for pressure increases. ◼ Change dressings around the chest tube insertion site as needed and as per your facility’s policy. ◼ Don’t reposition or dislodge the tube; If the tube does dislodge, immediately place a petroleum gauze dressing over the opening to prevent rapid lung collapse. ◼ Observe the chest tube site for leakage, and note the amount and color of drainage. HEMOTHORAX - The term hemothorax refers to the presence of blood in the pleural space.This can occur with or without accompanying pneumothorax (hemopneumothorax) and is often the result of traumatic injury CLOSE PNEUMOTHORAX - If air collects in the space and is unable to escape, a closed pneumothorax exists. NURSING RESPONSIBILITIES ◼ Apply a nonporous dressing over an open chest wound. BSN4H 8  ABC CONCEPT: DAY 4 - Damage is irreversible - >70% damage OUTLINE - ESRD I Tissue Perfusion - Only treatment is kidney II Cardiovascular Physical Assessment transplant A Subjective Data - Ongoing dialysis for survival B Objective Data III Cardiovascular Common Diagnostic Assessment Nursing care planning and management for A Electrocardiogram (ECG) ineffective tissue perfusion is directed at B Echocardiography ○ removing vasoconstricting factors IV Invasive Cardiovascular Diagnostic Assessment ○ improving peripheral blood flow A Cardiac Catheterization ○ reducing metabolic demands on the body B Central Venous Pressure (CVP) ○ patient‘s participation C Pulmonary Artery Pressure (PAP) ○ understanding the disease process and D Intra-Arterial BP Monitoring its treatment, and preventing V Common Nursing Diagnoses for Altered Tissue Perfusion complications. 08/16/22 CARDIOVASCULAR PHYSICAL ASSESSMENT Subjective Data CONDITIONS WITH ALTERED TISSUE PERFUSION ○ Chest pain TISSUE PERFUSION ○ Palpitations Tissue perfusion is the circulation of blood ○ Shortness of breath or dyspnea through the vascular bed of tissue, and it is crucial Assess for subcostal retractions for organ functions such as the formation of urine, ○ Assess for edema muscle contraction, and exchange of oxygen and ○ Include risk factors: carbon dioxide Family history Tissue perfusion is dependent on blood flow. → Personal history (if diagnosed Heart governs blood flow beforehand) The three major factors affecting blood flow are Diet the circulating volume, cardiac pump function, BMI (obese) and the vasomotor tone or peripheral vascular Alcohol resistance. Can cause What type of vessels supply the tissues? cardiomyopathy ○ Arteries Illicit drug use ○ Stomach - gastric artery (superior & Can cause increased inferior) heart rate leading to MI ○ Liver - hepatic artery Type 2 DM ○ Brain - cerebral artery ○ Kidney - renal artery ○ Heart - coronary artery ○ “OLDCART” Vein - carries deoxygenated blood ○ “ICE” → Impact on ADL, Coping Capillary beds for exchange of oxygen and Strategies, Emotional Response carbon dioxide Altered Tissue Perfusion can lead to: Temporary - minimal to no consequences Acute - destructive effect on patient - Reversible - Acute Renal Failure (ARF) is different from Chronic Renal Failure (CRF) because in ARF, it can be reversed Chronic - tissue organ damage or death BSN 4H 1  NCM 218 Concept: ABC 10 being most severe? Does the symptom affect normal daily activities? If so, how? A (Associated Do you have any other Factors) symptoms at this time that seem to be associated with this one? R (Relieving/ What makes the symptom aggravating better? factors) What makes it worse? Consider actions and situations T (Treatment) Have you tried any treatments? Have you tried anything else? CARDIOVASCULAR PHYSICAL ASSESSMENT Objective Data ○ Patient’s Vital Signs Systolic blood pressure increases with age. - If increased, look for clinical aspects/signs and symptoms (e.g. headache, dizziness, etc.) ○ Height and weight. OLDCART mnemonic to help ask appropriate Weight loss over months or questions when exploring a symptoms years can be a clue to advancing CVD O (Onset) Ask about the onset of symptoms An abrupt weight gain may be an Was onset sudden or gradual? indication of worsening heart Is it diminishing, staying the failure (d/t retention of fluids in same or intensifying? the body) What were you doing when the whereas abrupt weight loss may symptoms started? be an indication of over diuresis L (Location) Where in the body do symptoms occur? INSPECTION Does the symptom radiate to any ○ General appearance: thin, obese, level of parts of the body? If so, where? alertness, skin color, turgor, texture, ○ Arm, ears, neck → may be temperature, and diaphoresis. signs for impending MI In geriatrics: Temperature may be D (Duration How often does the symptoms lower than usual occur? Senile skin turgor How long does the symptoms ○ Observe mucous membranes for pallor last? and extremities for clubbing of fingers or ○ Does it persist? (If yes, bring cyanosis. to hospital for further Clubbing of fingers is caused by evaluation) chronic reduction of oxygen ○ sitting or lying flat C Ask the client to describe how observe pulsations (especially (Characteristic the symptom apical pulse), retractions, s) Does it feel as if an elephant is heaves,, thrills midclavicular line. sitting on your chest? ○ Examine extremities What does it feel like, look like or assess arterial or venous sound like? disorders and symmetry, Pain in MI is treated as…? ○ Noting skin color, hemosiderin staining, How would you rate the edema, lesions, scars, or clubbing, and symptoms on a scale of 1-10 with pattern and distribution of body hair BSN4A 2  NCM 218 Concept: ABC IAPP - abdomen Murmurs occur when there is turbulent IPPA - other parts of body blood flow caused by structural defects in ○ Note for jugular distention (this indicates the heart‘s chambers or valves. blood volume and pressure in the right (abnormality in regurgitation) side of the heart) Note the characteristics of the assessed Indicated for congestive heart murmurs have various characteristics, failure low, medium, and high-pitched. PALPATION NOTE: ○ Palpate over the precordium to find the Left Side Heart Failure - dyspnea apical impulse. Also note any thrills, Right Side Heart Failure (cor pulmonale) - edema heaves, or fine vibrations, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis pulses using the pads of the index and middle CARDIOVASCULAR COMMON DIAGNOSTIC fingers. All pulses should be regular in ASSESSMENT rhythm and equal in strength. Non-invasive Cardiovascular Diagnostic PMI (point of maximal impulse); Assessment assessed by palpation a. Echocardiogram (ECG or EKG) ○ Palpate the patient's legs and arms to - Precordial leads assess skin temperature, texture, turgor, b. Echocardiography and edema ○ Guide for Palpation Pray Pulmonic Always Aortic To Tricuspid Mary Mitral AV Fistula ○ Arteriovenous Fistula ○ Connection of artery & vein for dialysis Internal Jugular Catheter Insertion ○ Used in emergency dialysis cases Dextrocardia ○ Heart is on the right instead of left PERCUSSION ○ Percussion is not as useful as other methods of assessment in evaluating the cardiovascular system, but it may help locate the cardiac borders. AUSCULTATION ○ Listening for heart sounds. S1and S2 are normal heart sound. A third heart sound, S3, is commonly heard in patients with a high cardiac output and in children. It is called a ventricular gallop when it occurs in adults S3 (ventricular gallop) may be a cardinal sign of heart failure. S3 is best heard at the apex when the patient is lying on his left side. S4 is considered an adventitious sound and is called an atrial gallop (or presystolic gallop) Heard in pt with aortic stenosis, hypertension ○ Listening for Murmurs BSN4A 3  NCM 218 Concept: ABC ○ 15 LEAD ECG (12 leads only in SPH) Run the first 12 lead as always The following patients shall receive a 15-lead ECG: All patients requiring a 12 lead ECG Placement: