Introduction To Critical Care Nursing PDF

INTRODUCTION TO CRITICAL CARE NURSING o Nurses, pharmacists, and respiratory therapists are ICU based, but PROF. JHON PAUL FRANCISCO...

INTRODUCTION TO CRITICAL CARE NURSING o Nurses, pharmacists, and respiratory therapists are ICU based, but PROF. JHON PAUL FRANCISCO physicians may have other obligations o Higher mortality and morbidity rates Critical Care Nursing Critical Care Nurses Concerned with human responses to life- Licensed professional nurse who is responsible threatening problems, such as trauma, major for ensuring that acutely and critically ill surgery, or complications of illness (AACN) patients and their families receive optimal care. Human response can be a physiological or Certification psychological phenomenon o Validates knowledge of critical care Focus of the critical care nurse nursing, promotes professional o both the patient’s and family’s excellence, and helps nurses to responses to illness and involves maintain a current knowledge base. prevention as well as cure. o CCRN and PCCN administered by Critical care American Association of Critical Care o Direct delivery of medical care for a Nurses (AACN). critically ill or injured patient Competencies of Critical Care Nurses o To be considered critical, an illness or injury must acutely impair one or more AACN Synergy Model for Patient Care vital organ systems to such a degree 1. Clinical inquiry that there is a high probability of life o Critical care nurse should be engaged threatening deterioration in the “ongoing process of questioning and evaluating practice and providing Evolution of Critical Care informed practice.” Prior to 1950s –seriously ill patients are o EBP practice and quality improvement grouped together usually near the nurses’ o Demonstrated by providing care based station but not separated from other patients on the best available evidence rather and placed in critical units until 1950s than on tradition 1950 –patients with polio were cared for o Develop the mindset that questioning specialized units; use of mech vents and CPR practice is an issue of safety began 2. Clinical judgment 1960 –recovery rooms were established for o engage in “clinical reasoning which postoperative patients includes clinical decision-making, 1970 –critical care nursing evolved as a critical thinking, and a global grasp of specialty; since then critical care nursing the situation, coupled with nursing become more specialized (ex. Cardiovascular, skills acquired through a process of neurological, pediatric, etc.) integrating formal and experiential Critical care has expanded beyond the walls of knowledge.” traditional critical care units o able to collect and interpret basic data o ED, PACU, stepdown unit/telemetry and then follow pathways and unit, intermediate and progressive care algorithms when providing care units o able to use past experience, recognize Electronic ICU (eICU) patterns of patient problems, and “see o Patients are monitored remotely by the big picture” that will help him to critical care nurses and physician anticipate untoward events and develop interventions Critical Care Unit 3. Caring practices Closed ICU o Caring behaviors as “nursing activities o Patient care is provided by dedicated that create a compassionate, ICU team that includes an intensivist / supportive, and therapeutic critical care physician environment for patients and staff, o Lower mortality and morbidity rates with the aim of promoting comfort and Open ICU preventing unnecessary suffering.”  o to anticipate patient/ family changes Critical Care Nurses Association of the and needs, varying caring approach to Philippines (CCNAPI) meet their needs. Qualification of Members: 4. Advocacy and Moral Agency 1. Any registered nurse who has attended at o “The nurse promotes, advocates for, least 20 Credit Education Units of CCNAPI and protects the rights, health, and for the current year or have at least 3 safety of the patient” months working experience in MS or Critical o Defines advocacy as ‘respecting and Care Unit as certified by the immediate supporting the basic rights and beliefs superior or head nurse. of the critically ill patient.’ ** 2. Resident of the Philippines o An expert nurse advocates from the 3. Member of PNA family/patient perspective, whether it 4. With Current PRC license as a Registered is similar to or different from her own; Nurse empowers the patient and family to 5. With good standing in the community speak for or represent themselves; and achieves mutuality in relationships American Association of Critical Care Nurses 5. Systems thinking (AACN) o Defined as “managing the existing Society of Critical Care Medicine (SCCM) environmental and system resources for the benefit of patients and their families.” o Nurse should know how the system works and explains it to the patient and family, or who helps the patient and family obtain what they need 6. Facilitator of Learning o Nurses should be able to facilitate both informal and formal learning for patients, families, and members of the healthcare team o Expert nurses can “creatively modify or develop patient/family educational programs and integrate family/patient education throughout the delivery of care.” 7. Response to Diversity o Defined as “sensitivity to recognize, Quality and Safety Emphasis appreciate, and incorporate diversity into the provision of care.” Reduce medical errors and promote an o Patient-centered care; culturally environment that facilitates safe practices competent care; consider spiritual and personal values and tailor delivery of care to incorporate these values 8. Collaboration o Defined as “working with others in a way that promotes each person’s contributions toward achieving optimal and realistic patient/family goals.” o Expert nurse might facilitate the active involvement and contributions of others in meetings and role model leadership and accountability during the meetings. Professional Organizations  Collaboration EVIDENCE BASED PRACTICE Multiprofessional bedside rounds o Intensivist led rounds To implement care that is evidence based o Daily goal settings To challenge practices that have “always been done” but are not supported by clinical evidence Highest – meta-analysis of many related research studies Communication Conducting morning briefings before interdisciplinary rounds / conference Effective communication is essential for o Suggested content of the morning delivering safe patient care. Many adverse briefings include answers to three events are directly attributable to faulty questions: communication ▪ (1) What happened during the night that the team needs to know (e.g., adverse events, admissions)? ▪ (2) Where should rounds begin (e.g., the sickest patient who needs the most attention)? And ▪ (3) What potential problems have been identified for the day (e.g., staffing, SBAR / ISBAR Approach procedures)? PATIENT AND FAMILY RESPONSE TO CRITICAL ILLNESS A. Critical Care Environment ▪ Take advantage of natural lights and use of soft lights The built environment, or physical layout, of a critical care unit has a subtle but profound Sensory deprivation effect on patients, families, and the critical care Associated with increase in perceptual disturbances team. such as hallucinations, especially in older adults Resultant high stress levels are compounded by Provide stimulation by: the often unrelenting sensory stimulation from o Interacting with and orienting the patient o light and noise o Encourage visitation of family and friends o loss of privacy o Post family photos within the patient’s sight o lack of nonclinical physical contact, and o Provide music or television that the patient o emotional and physical pain usually enjoys Noise and light are among the stimuli listed by patients, families, and nurses as stressors B. Critically Ill Patient Issues related to Environment: Stressors related to treatment and critical care environment can lead to anxiety, fear, insecurity, Sensory overload d/t Noise and light isolation, and loneliness Noise o WHO for hospital noise level: 30dB in daytime 40dB at night o Effects ▪ Patient: discomfort, sleep deprivation, sensory overload ▪ Nurses: stress, emotional exhaustion, burnout, fatigue, difficult communication which may lead to medical errors, loud conversation may compromise patient confidentiality Strategies to reduce noise 1. Reduce volume of technical equipment 2. Adjust alarm volume if possible Nursing Interventions 3. Organize workflow to promote efficiency rather than multiple interruptions 1. Ensure safety 4. Closing patient doors 2. Minimize noxious sensory overload 5. Placing patient in private rooms 3. Group together nursing activities and medical 6. Installing sound absorbing textiles procedures to maximize resting periods 7. Designate private place for communication with the 4. Even if patient is unconscious or sedated, family and close the door many patients can still hear, understand and 8. Avoid excessive or loud talking respond emotionally to what is being said 9. Answer phones quickly o Talk to patients 10. Readily assess alarms on medical devices o Reorient them every 2-4 hours 11. Sedative music o Address patient directly to minimize distraction Light How to reorient patient? o Inadequate lighting ▪ more difficult to read medical records and medication labels ▪ complicates accurate physical assessment of patients ▪ Constant artificial light affect sleep pattern of patients due to melatonin Place clock or calendar within patient’s visual field  Ask family members to bring personal and Critical Care Family Needs Inventory meaningful items from home 1. Receiving information Promote sleep and pattern –group activities; 2. Receiving assurance natural lights during the day and reduced light 3. Remaining near the patient levels during night 4. Being comfortable 5. Having support available Discharge from Critical Care units Wants confirmation that everything is done for the Relocation Stress patient o Sense of abandonment and fear of losing security of higher level of care done in ICU 1. Establish partnership with the family Post-intensive care Syndrome (PICS) 2. Encourage family members to assist in patient o Consist of disability and weakness, assessment (eg.Identify changes) and psychiatric pathologies, cognitive participate in selected aspects of patients care dysfunction (e.g., oral hygiene, ROM exercises, o Post discharge therapy repositioning the patient Discharge Planning Evidence Based recommendations o Patient teaching and family involvement beginning at admission and continuing 1. Decision Making throughout hospital stay a. Involve family and patient; make decision based on partnership with them b. Communicate patient status, prognosis, C. Family Members and treatment options c. Hold family meetings Paradigm shift towards patient and family centered care 2. Family coping Old –focus on role of physician, nurses, a. Provide information procedure on pt’s recovery o Families have been reported to experience Now –role of patient and family is recognized in panic when patient updates are not decision making provided in a timely fashion and they are scared to make caregiving decisions when Family Assessment they do not have current information (Riley, A. Calgary Family Assessment Model White, Graham, & Alexandrov, 2014) 1. Structural Assessment o Monitors vs Blunters Done on admission b. Train ICU staff in assessment of family Identifies immediate family, extended needs, stress, and anxiety levels family members, and decision makers c. Assign consistent nursing and physician Also include ethnicity, race, religion and staff to each patient if possible spirituality 3. Staff Stress 2. Developmental assessment a. Debriefing sessions for staff Family’s developmental stages and task b. Keep all healthcare members informed of 3. Functional assessment treatment goals to ensure consistency of Reveals how family members function and messages given to family behave in relation to one another 4. Family Environment of Care a. Single bed rooms –improve patient’s B. Cultural and Spiritual Assessment confidentiality, privacy, and social support 5. Family visitation 1. What are your specific religious and spiritual a. Open visitation considering the best interest practices of the patient b. PICU/NICU –24 hours open visitation 2. What are your beliefs about illness and death c. Do not restrict pets that are clean and 3. What is most important to you and your family at properly immunized this time. d. Develop guidelines for animal-assisted therapy Family Needs  powerless and that they cannot find meaning in the patients’ or families’ suffering. Ask-Affirm-Assess-Act: The 4 A’s to Rise Above Moral Distress Ask: o The nurse asks, “Am I or are members of my team feeling symptoms or showing signs of suffering?” or “Have others noticed these symptoms and behaviors in me?” Affirm: o The nurse recognizes that moral 6. Cultural support of the family distress is present and makes a commitment to take care of herself, 7. Spiritual and Religious support validate her perceptions, and affirm her 8. Family presence during rounds professional responsibility to act. Assess: 9. Family presence during resuscitation o The nurse identifies the sources of her distress by clarifying the circumstances 10. Palliative Care under which the distress occurs. o Is it a particular patient care situation? Is it a unit policy or practice? Does it Visitation result from lack of collaboration? The Greatly improves patient and family satisfaction nurse next determines the severity of Many are still reluctant to change. Some reasons the distress, her readiness to act, and cited but are unfounded the risks and benefits of any action. o Increase physiological stress to the patient Act: o Interference with provision of care and o Before acting, the nurse needs to family members being intrusive develop an action plan including a self- care plan, a list of sources of support, Family Presence during Resuscitation and and possibilities for outside sources of Invasive Procedures guidance and assistance. o Finally, the nurse needs to take actions Many institutions have implemented policies to that will address the specific sources of allow families to be present during CPR and distress within her work environment invasive procedures using polite but assertive Factors cited for limiting family presence communication. o Violation of patient’s confidentiality o Not enough staff members to assist Conscientious Refusal family members o Increased stress on healthcare team Ask to be excused from participating in or ▪ Performance anxiety assisting with the action ▪ Risk for litigation Conscientious refusal is not an option a nurse should choose without very careful FACTORS AFFECTING THE WELL-BEING OF consideration NURSES o Patient may wish the nurse to remain with them Moral Distress o Disrupt nurse patient relationship “a nurse would know the right thing to do, yet o Amount of support from admin institutional constraints such as lack of o Repercussions resources or personal authority would prevent Compassion Fatigue her from doing it” (Jameton, 1984) Nurses consistently state that when they do not Compassion fatigue is a “state of tension and have a voice in the decision-making, they feel preoccupation with the suffering of those being  helped that is traumatizing for the helper.” when called on to deliver help and will respond (Figley, 2005) quickly and effectively Occurs in care providers who may be so selfless Knowing when and how to secure help both and compassionate that they fail to pay personally and professionally sufficient attention to their own needs. Being involved in addressing and preventing moral harm Symptoms of Compassion Fatigue Enhancing Professional well-being Intrusive thoughts or images of patients’ situations or traumas Balancing work and home responsibilities Difficulty separating work life from personal life Establishing boundaries and setting limits Lowered tolerance for frustration and/or concerning: outbursts of anger or rage o Overworking Dread of working with certain patients o Therapeutic/professional boundaries Depression o Personal boundaries Increase in ineffective and/or self-destructive o Realism when differentiating between self-soothing behaviors things that one can change and Decreased functioning in nonprofessional accepting things that one cannot situations change Loss of hope Obtaining support at work from peers, supervisors, and mentors Standards of Self-Care Generating work satisfaction by noticing and The Academy of Traumatology/Green Cross has remembering the joys and achievements of the proposed standards of self-care for caregivers work. Purpose Job Satisfaction o To ensure that practitioners do no harm to themselves when helping or There is evidence that nurses who work with treating others critically ill patients do so because they obtain o To encourage providers to attend to satisfaction from the type of care they provide their own physical, social, emotional, Le Blanc, de Jonge, de Rijk, and Schaufeli and spiritual needs as a way of (2001) noted that although ICU nurses ensuring high-quality services to those identified providing nursing and medical care as who look to them for support as a being very demanding, it also “drove their human being. satisfaction.” Make a commitment to self-care. In 2013, 87% of critical care nurses responding Develop strategies for letting go of work. to a survey agreed with the statement, “Overall, Develop strategies for acquiring adequate rest I am satisfied with my choice of nursing as a and relaxation. career” (AMN Healthcare, 2013). Plan strategies for practicing effective daily Ulrich, Woods, Hart, Lavandero, Leggert, and stress reduction. Taylor, 2007 (2007) concluded that nurses working in critical care units striving for Enhancing Physical Well-Being excellence reported healthier work Monitoring all parts of the body for tension and environments and higher job satisfaction. utilizing appropriate techniques to reduce Higher nursing job satisfaction have been tension associated with better patient outcomes. Utilizing healthy methods that induce sleep and Healthy Work Environment return to sleep Monitoring all food and drink intake with an Unhealthy work environments lead to medical awareness of their implication for health and errors, suboptimal safety monitoring, functioning ineffective communication among health care providers, and increased conflict and stress Enhancing Social well-being among care providers Identifying at least five people (a minimum of Implementing the HWE standards is a method two at work) who will be highly supportive for building respect and reducing incivility in the workplace.  Appropriate staffing and HWEs were associated with o Better patient outcomes ▪ (e.g., fewer falls, fewer complications, lower mortality, fewer surgical site infections, and fewer catheter associated urinary tract infections) o Better nurse outcomes ▪ (e.g., higher quality of care and safety ratings, less job dissatisfaction and burnout, decreased intention to leave their jobs)