nursing-care-process.pdf

NURSING CARE OF CLIENTS WITH LIFE-THREATENING CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION NCM 118 Care of Clients with Life-Threatening Conditions, Acutely Ill/Multi-Organ Problems, High Acuity and Emergency Situation LEC OUTLINE: Nursing C...

NURSING CARE OF CLIENTS WITH LIFE-THREATENING CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION NCM 118 Care of Clients with Life-Threatening Conditions, Acutely Ill/Multi-Organ Problems, High Acuity and Emergency Situation LEC OUTLINE: Nursing Care of Clients with Life- priorities and can be used as a generic template Threatening Conditions, Acutely Ill/Multi-Organ for assessing most critically ill patients and Problems, High Acuity and Emergency Situation families. A. Assessment 1. Subjective Data ® What is important is developing competence in History assessing critically ill patients and their 2. Objective Data families in a consistent and systematic Physical Assessment approach. This way, we do not miss out on Diagnostic Studies/ Procedures subtle signs or details that may point to an B. Analysis/ Nursing Diagnosis actual or potential problem or change in C. Planning patient status. 1. Planning for Health Promotion ® Take note, assessments focus first on the 2. Planning for Health Restoration and patient, then on the technology. Technology is Maintenance there to augment information obtained from D. Implementation of Care of Clients 1. Independent Nursing Care direct assessment of the patient. Physiologic Care ® Two standard approaches to assessing Psychosocial Care patients: the head-to-toe approach and the Spiritual Care body systems approach. Most critical care 2. Interdependent Care nurses use a combination of the two -- a Pharmacological Therapeutics systems approach applied in a “top-to-bottom” Complementary and Alternative manner. Therapies ® The assessment process can be viewed in four Nutritional and Diet Therapy distinct stages: Surgical Intervention Immunologic Therapy 1. Prearrival Assessment E. Client Education This stage begins the moment the F. Evaluation of the Outcome of Care nurse receives notification about the G. Reporting and Documentation of Care upcoming admission of the patient. This notification comes from the initial healthcare team contact. The contact The Nursing Process may be from: paramedics in the field reporting to the emergency The structure of CCN is a complex, challenging area of department (ED); a transfer from nursing practice. In keeping with the six core standards of another hospital; or a transfer from nursing practice described by the American Nurses other areas within the hospital, such as Association (ANA), CCN employs the nursing process, the ED, operating room (OR), a which, according to the ANA, is the “essential core of medical/surgical unit, etc. practice for the registered nurse” that involves the The prearrival assessment helps the following: critical care nurse to form an initial picture of the patient, thus allowing her to begin anticipating the patient’s A. Assessment (main focus of this discussion) needs. ® Collection of data, both subjective and objective 2. Admission Quick Check (“just the basics”) Immediately upon arrival of the ® Gathering of psychosocial, physical, spiritual, patient, an admission quick check economic, and lifestyle factors by: assessment is conducted and is based a. Interviewing the patient and/or family on the parameters presented by the members ABCDE acronym. (See Table A below): b. Reviewing past medical history and records TABLE A. ABCDE ACRONYM c. Completing a physical examination and reviewing current patient data Airway ® In the critical care setting, traditional methods Breathing of assessment which include a complete Circulation, Cerebral evaluation of the patient’s history and a perfusion, and Chief comprehensive physical examinations of all complaint body systems may not be possible since the Drugs and Diagnostic tests patient may be experiencing life-threatening Equipment problems during admission. ® Hereon, a specific assessment approach that This assessment is a quick overview of recognizes the complexities of the nature of the adequacy of ventilation and perfusion to ensure early intervention critical illness will be presented. This approach for any life-threatening situations. puts emphasis on the collection of assessment data in phases consistent with patient care  Focus is also on exploring the chief ü Abbreviated report on patient (age, gender, complaint and obtaining essential chief complaint, diagnosis, pertinent history, diagnostic tests to supplement and physiologic status. invasive devices, equipment support physical assessment findings. and status of laboratory/diagnostic tests) ü Allergies 3. Comprehensive initial Assessment ü Complete room setup, including This assessment is done as soon as verification of proper equipment possible, with the timing determined functioning by the degree of physiologic stability ü Do Not Resuscitate (DNR) Status and emergent treatment needs of the ü Isolation Status patient. Admission Quick Check Assessment If the patient is being admitted directly to the intensive care unit (ICU) from ü General appearance (consciousness) outside the hospital, the ü Airway: comprehensive assessment is an in- ñ Patency depth assessment of the past medical ñ Position of artificial airway (If present) and social history and a complete ü Breathing: physical examination of each body ñ Quantity and quality of respirations system. (rate, depth, pattern, symmetry, effort, use of accessory muscles) If the patient is being transferred to ñ Breath sounds the ICU from within the hospital, the ñ Presence of spontaneous breathing comprehensive assessment includes a ü Circulation and Cerebral Perfusion: review of the admission assessment ñ Electrocardiogram (ECG) (rate, data and comparison to the current rhythm, and presence of ectopy) state of the patient. ñ Blood pressure This assessment is vital to successful ñ Peripheral pulses and capillary refill outcomes for the patient as it provides ñ Skin, color, temperature, moisture valuable insight into proactive ñ Presence of bleeding interventions that maybe needed. ñ Level of consciousness, responsiveness ü Chief Complaint: 4. Ongoing Assessment ñ Primary body system Ongoing assessments, which are an ñ Associated symptoms abbreviated version of the ü Drugs and Diagnostic Tests: ñ Drugs prior to admission (prescribed, comprehensive initial assessment, are over-the-counter, illicit) performed at varying intervals ñ Current medications according to unit protocol and the ñ Review diagnostic test results individual needs of the patient. ü Equipment: ® If a patient is unable to cooperate in ñ Patency of vascular and drainage systems terms of supplying information needed for assessment, other sources ñ Appropriate functioning and labeling of all equipment connected to patient may be used instead. These include: family members or friends; electronic health records (EHRs) or electronic TABLE C. COMMON DIAGNOSTIC TESTS medical records (EMRs); past OBTAINED DURING ADMISSION QUICK medical records; transport record; or CHECK ASSESSMENT information from the patient’s belongings. v Serum electrolytes ® It is also imperative, that upon v Glucose admission, accurate patient v Complete blood count with platelets identification must be obtained, v Coagulation studies v Arterial blood gases including past medical history, v Chest x-ray especially any known allergies. v ECG ® Careful physical assessment on admission to the critical care unit is pivotal in the prevention and/or early TABLE D. EVIDENCE-BASED PRACTICE: treatment for complications FAMILY NEEDS ASSESSMENT associated with critical illness. ® The following tables are handy guides Quick Assessment for the critical care nurse: ü Offer realistic hope ü Give honest answers and information TABLE B. SUMMARY OF PREARRIVAL AND ü Give reassurance ADMISSION QUICK CHECK ASSESSMENTS Comprehensive Assessment Prearrival Assessment ü Use open-ended communication and assess their communication style  ü Assess family members' level of anxiety ü Assess perceptions of the situation B. Analysis/Diagnosis (knowledge, comprehension, expectations of ® Analysis of the data garnered to determine the staff, expected outcomes) nursing diagnosis ü Assess family roles and dynamics (cultural ® Basis on which the nursing care plan is and religious practices, values, spokesperson) developed. The nursing diagnosis is the nurse’s ü Assess coping mechanisms and resources clinical judgment regarding the patient’s (what do they use, social network and support) response to actual or possible medical problems. It is based on the assessment. ® Examples of nursing diagnoses you may TABLE E. SUMMARY OF COMPREHENSIVE formulate when caring for some critically ill ADMISSION ASSESSMENT patients: REQUIREMENTS a. Ineffective airway clearance related to presence of artificial airway, problems with Past Medical History positioning, accumulation of secretions, and Medical conditions, surgical procedures immobility as evidenced by presence of Psychiatric/emotional problems abnormal breath sounds, absent cough, and Hospitalizations presence of thick or copious secretions Medications (prescription, over-the-counter, b. Decreased cardiac output related illicit drugs) and time of last medication dose to impeded venous return by positive pressure Allergies ventilation (PPV) as evidenced by ↓ BP, ↓ SV Review of history by body system and pulmonary artery wedge pressure (PAWP), ↑ heart rate, decreased urine output, Social History presence of dysrhythmias, and mental ü Age, gender, and self-identified gender confusion ü Ethnic origin c. Risk for injury related to artificial airway, ü Height, weight possible ventilator malfunction, accidental ü Highest educational level completed disconnection/extubation, inability to breathe ü Preferred language unassisted, asynchrony with ventilator, and ü Occupation settings ineffective in maintaining adequate ü Marital status oxygenation ü Primary family members/significant d. Risk for disuse syndrome related others/decision makers to imposed movement restrictions as ü Religious affiliation evidenced by limited range of motion, ü Advance Directive, Durable Power of difficulty turning, and muscle weakness Attorney for Health Care, Medical Orders e. Anxiety related to pain, inability to verbally for Life-Sustaining Treatment (MOLST) communicate, fear of ü Substance use/abuse (alcohol, illicit or death/suffocation/choking, ICU prescription drugs, caffeine, tobacco) environment as evidenced by anxious ü Domestic abuse or vulnerable adult screen appearance, agitation, rigid body posture, and asynchronous breathing with ventilator Psychosocial Assessment ü General communication ü Coping styles C. Planning ü Anxiety and stress ® Development of a detailed plan of ü Expectations of critical care unit interventions focused on achieving expected ü Current stresses outcomes ü Family needs ® The nursing care plan details planning and Spirituality outcomes by: a. Assigning priorities, if the patient has ü Faith/spiritual preference multiple nursing diagnoses ü Healing practices b. Setting short- and long-term goals that Physical Assessment are patient oriented and measurable c. Including assessment and diagnosis ü Nervous system details ü Cardiovascular system d. Stating appropriate nursing ü Respiratory system interventions and corresponding ü Renal system medical orders ü Gastrointestinal system e. Utilizing a standardized or ü Endocrine, hematologic, and immune computerized care plan or clinical systems pathway as a guideline, if appropriate ü Integumentary system ® Increasingly, however, a multi-disciplinary approach to the patient’s plan of care is being used to replace individual, discipline-specific plans of care. Particularly for the critically ill patient, an interprofessional plan of care would be the most useful approach to ensure  coordination of the care of the patient and to improve achievement of targeted clinical D. Implementation of Care outcomes. Collaborating in this plan of care ® Performance of the interventions noted in the would be, for example, critical care nurses, plan of care doctors, nutritionists, respiratory therapists, ® The performance of nursing care according to psychiatrists, social workers. the care plan by: ® By definition, an interprofessional plan of care a. Properly documenting the care is “a set of expectations for the major provided to the patient components of care a patient receives during b. Performing treatment in a way that the hospitalization to manage a specific minimizes complications and life- medical or surgical problem.” (Burns & threatening issues Delgado, 2019). c. Involving patients, families, ® Included in the interprofessional plan of care caregivers, and other members of the would be the tests, medications, care, and healthcare team as their abilities and treatments needed to help the patient move on patient safety allow to the next level of care in a timely manner with ® Aside from interventions focused on improving all patient outcomes met. patient outcomes in specific conditions (these ® What are the benefits of these types of plans? will be discussed in future lessons), They are as follows: implementation of care is also focused on the ü Improved patient outcomes (e.g., prevention of the common complications survival rates) mentioned above. ü Increased quality and continuity of v Physiologic instability care ü Improved communication and Perform ongoing assessments and collaboration monitoring of critically ill patients to ü Identification of hospital system immediately identify physiologic problems changes and to ensure that the patient ü Coordination of necessary services is progressing toward identified and reduced duplication patient outcomes. ü Prioritization of activities v Venous thromboembolism (VTE) ® The following categories are typical features of Avoid placing intravenous access in the format of interprofessional plans of care: the groin site or lower limbs as this ü Discharge outcomes limits mobility and may impede blood ü Patient goals (e.g., pain control, flow and can therefore increase the risk activity level, absence of for VTE complications) ü Assessment and evaluation Ensure adequate hydration. ü Consultations Administer low-dose heparin as ü Diagnostic studies prescribed as a preventive measure. ü Medications v Hospital-acquired infections ü Nutrition In general, ICUs have the highest ü Activity incidence of hospital-acquired ü Education infections because of the multiple ü Discharge planning invasive devices and constant presence ® It is noteworthy to mention that when nurses of debilitating underlying diseases. develop an ongoing plan of care, safety Standard precautions, aka “universal initiatives must be incorporated, particularly since acutely ill patient conditions can change precautions” or “body substance abruptly, hence constant awareness and isolation” must be observed and vigilance is imperative even when the patient practiced. appears to be stable or improving. Maintaining blood sugar levels for ® A major concern when providing care to both diabetic and non-diabetic critically ill patients is the prevention of patients may reduce the risk of the complications associated with critical illness. patient developing an infection. Some of the most common complications Replace peripheral IV lines as include: recommended by the Centers of ü Physiologic instability Disease Control and Prevention ü Venous thromboembolism (VTE) (CDC). These lines should not remain ü Hospital-acquired infections in place for longer than 72 to 96 hours. ü Pressure injury Exception to this rule is the tubings for ü Sleep pattern disturbance blood, blood products, or lipid-based ü Psychosocial impact (delirium, products as these have their own anxiety, depression) criteria for when they are to be changed. All catheters inserted in an emergency situation are to be replaced as soon as possible or within 48 hours.  Dressings are to be kept dry and intact, ü Equipment alarms and should be changed at the first ü Frequent care interruptions signs of becoming damp, soiled, or ü Lighting loosened. ü Lack of usual bedtime routine Of course, one of the most important ü Room temperature ü Uncomfortable sleep surface defenses in preventing infection is hand hygiene. This involves hand washing that CDC defines as “vigorous Knowledge of how the above factors rubbing together of lathered hands affect the patient’s sleep will help the with soap and water for 15 seconds, nurse know what areas to address to followed by a thorough rinsing under a enhance or improve the critically ill stream of running water”. (Burns & patient’s sleep. Delgado, 2019). Instituting a nighttime sleep protocol v Pressure injury where patients are untouched but still A major risk in critically ill patients is closely monitored from 1 to 5 AM is pressure injury. This is due to one way to eliminate hourly immobility, poor nutrition, invasive disturbances to the patient. lines, surgical sites, poor circulation, Refer to the table below for basic edema, and incontinence issues. recommendations for sleep Pressure injuries may start developing assessment, protecting or shielding in as little as two hours. the patient from the environment, and Interventions include: reposition the modifying the internal and external patient at least every two hours; use environments of the patient as part of pressure-reduction mattresses; elevate your implementation of care: heels off the bed with pillows under the calves or use heel protectors; elbow TABLE G. EVIDENCE-BASED PRACTICE: pads may also be used; use a skin care SLEEP PROMOTION IN CRITICAL CARE protocol with ointment barriers, ü Assess patient's usual sleep patterns especially for patients who are ü Minimize effects of underlying disease incontinent. process as much as possible (e.g., reduce v Sleep pattern disturbance fever, eliminate pain, and minimize The lack of sleep is a patient’s major metabolic disturbances) stressor, along with the discomfort of ü Avoid medications that disturb sleep patterns unrelieved pain and all critically ill ü Consult with providers to continue patients experience altered sleep behavioral medications as appropriate patterns. ü Mimic patients' usual bedtime routine as Be sensitive to the factors that affect a much as possible patient’s sleep as presented in the table ü Minimize environmental impact on sleep as below: much as possible ü Utilize complementary therapies to TABLE F. FACTORS CONTRIBUTING TO promote sleep as appropriate SLEEP DISTURBANCES IN CRITICAL CARE Illness v Psychosocial impact (delirium, anxiety, ü Metabolic changes depression) ü Underlying diseases (e.g., cardiovascular A condition called Post-Intensive Care disease, chronic obstructive pulmonary disease [COPD], dementia) Syndrome (PICS) may result in ü Pain survivors and their family members ü Anxiety, fear where signs of posttraumatic stress ü Delirium disorder (PTSD) may be exhibited. This results from the time spent by the Medications patient and family in the ICU. PICS can ü Analgesics have long-term physical, mental, and ü Antidepressants cognitive changes that may impact the ü Beta-blockers patient and their family for years after ü Bronchodilators the illness. ü Benzodiazepines Below are some basic interventions ü Corticosteroids that can be done to help maintain psychological integrity during and Environment after a critical illness: ü Noise a. Keep stressors to a minimum. ü Staff conversations b. Encourage family participation in ü Television/radio care. c. Promote a proper sleep-wake  cycle. and reassure with realistic information d. Encourage communication, to promote a more hopeful outcome. questions, and honest and o If you suspect the patient may be positive feedback. suicidal, do clarify with the patient. e. Empower the patient to Oftentimes, when the patient participate in decisions as appropriate. communicates he is feeling suicidal it f. Provide patient and family is a cover for wanting to discuss fear, education about unit expectations pain, or loneliness. and rules, procedures, o For further evaluation and medications, and the patient’s intervention, a psychiatric referral is in physical condition. order. g. Ensure pain relief and comfort Anxiety h. Provide continuity for care o Anxiety and panic-like symptoms can providers. result from medical disorders and can i. Make available the patient’s usual cause distress to the patient and sensory and physical aids, such as family, which may exacerbate the glasses, hearing aids, dentures, as medical condition. these may help prevent confusion. o Applying both pharmacologic and Delirium non-pharmacologic interventions may o This may be evidenced by alleviate the problem. disorientation, confusion, perceptual o The goals of pharmacologic therapy disturbances, restlessness, are to titrate the drug dose to distractibility, and sleep-wake cycle maintain the patient’s cognition and disturbances. ability to interact with the people o It is most commonly seen in around them, to complement pain postsurgical and elderly patients and is control, and to assist in promoting the most common cause of disruptive sleep. behavior in the critically ill. o Non-pharmacologic interventions to o Medications that may also predispose decrease or control anxiety include a patient to delirium include: breathing techniques, muscle 1. Prochlorperazine (a first- relaxation, imagery, preparatory generation antipsychotic drug used to information, distraction techniques, treat severe nausea and vomiting, as well as short-term management of and use of previous coping methods. psychotic disorders) 2. Diphenhydramine (an anti- histamine with anticholinergic E. Client Education [drying] and sedative side effects) 3. Famotidine (histamine H2 receptor ® Patient and family education in the critical care antagonist medication that decreases environment is not to be overlooked by the stomach acid production) nurse and other members of the healthcare 4. Benzodiazepines (psychoactive team. It is essential to provide information drugs used to treat conditions such as regarding diagnosis, prognosis, treatments, anxiety, insomnia, seizures) and procedures. This helps allay fears and 5. Opioids (substances that act on concerns, or at least, puts them into opioid receptors to produce perspective. Through client education, the morphine-like effects) patient and their family are better able to take 6. Antiarrhythmic medications a more proactive role in the plan of care. (group of pharmaceuticals that are ® Education in the critical care setting is typically used to suppress abnormal rhythms done informally, where the nurse takes the of the heart, such as atrial fibrillation, opportunity of teaching moments when the atrial flutter, ventricular tachycardia, learner is able to comprehend and synthesize and ventricular fibrillation) the information to be shared. This is also Depression referred to as learning readiness. o What may predispose the critically ill TABLE G. ASSESSMENT OF LEARNING patient to depression are: social READINESS isolation, recent loss, pessimism, financial pressures, history of mood disorder, General Principles alcohol or substance abuse/withdrawal, previous suicide attempts, and pain. ü Do the patient and the family have questions o It is important to educate the patient about the diagnosis, prognosis, treatments, or and family that most depressions that procedures? result during critical illness is not ü What do the patient and the family desire to unusual and may be only temporary. learn about? o If the family or patient have negative ü What ls the knowledge level of the individuals distortions about the illness and being taught? What do they already know about treatment, it is wise to correct, clarify, the Issues that will be taught? ü What is their current situation (condition and  environment) and have they had any prior the required assessments, care plans, EMARs, experience in a similar situation? physician orders, and multiple other ü Do the patient or the family have any components can be a very challenging task. The communication barriers (e.g. language, illiteracy, nurse must always be conscious of the nursing culture, listening/comprehension deficits)? process, liability, safety, and patient care when ü What ls patient's or family members' preferred documenting. It is always necessary to “save,” or store, the information after inputting it method of learning? properly. Special Considerations in Critical Care ® Each hospital should have a tech team available 24-7 whose responsibility is to help ü Does the patient's condition allow you to assess the staff resolve documentation problems this information from them (e.g. involving EMRs and EMARs physiologic/psychological stability)? ® The critical care nurse must remember that ü Is the patient's support despite all the technology employed in the ICU, system/family/significant other available or the rule “If it was not documented, it was not ready to receive this information? done” still holds true. EMRs and EMARs are ü What environmental factors (including time) the center of communication among nursing present as barriers in the critical care unit? staff, medical staff, therapists, the lab, the ü Are there other members of the healthcare team pharmacy, and all other members of the who may possess vital assessment information? healthcare team. If something is not documented, it cannot be verified and evaluated properly. ® As the nurse shares information with the patient and their family, in whatever manner, it is important to listen carefully to the needs expressed by the learner. The nurse must respond in a clear and precise manner to these needs. ® A good method to find out if the learner comprehends the information is to ask the patient or family member to relay in their own words what they learned. This method is referred to as teach-back. Of course, the learners may end up not retaining all the information hence reinforcement is often necessary and important to anticipate. SOURCES: Books F. Evaluation of the Outcome of Care Burns, S. M., & Delgado, S. A. (2019). AACN essentials of ® Evaluation of the patient’s progress toward the critical care nursing (4th ed.). McGraw- Hill Education / achievement of expected outcomes (ANA, Medical. 2015) Dina Hewett, C. (2019). Fast facts for the critical care ® The process of evaluating the status of the nurse (2nd ed.). Springer Publishing Company. patient and the effectiveness of the treatment. The plan of care may be modified if necessary. Paguio, J. T., & Banayat, A. C. (2018). Commentary on ® As mentioned earlier, creating and challenges to critical care nursing practice in the implementing interprofessional plans of care Philippines. Connect: The World of Critical Care improves communication and collaboration in Nursing, 12(1), 8- 11. https://doi.org/10.1891/1748- 6254.12.1.8 achieving optimal patient outcomes. A discussion of more specific patient outcomes will be discussed in further lessons. Webpages CCNAPI Membership and Seminars. (2011, November 25). Nurse Updates. https://www.nurseupdates.com/ccnapi- G. Reporting and Documentation membership-seminars/ ® All staff members who utilize the plan of care Critical Care Nursing Guidelines, Standards and need to be trained as to how to document Competencies. (2014, July 1). Critical Care Nurses consistently. The team approach in using the interprofessional plan of care improves and Association of the optimizes communication, collaboration, Philippines. https://www.ccnapi.org/news-and- coordination, and commitment to achieve events/critical-care- nursing-guidelines-standards- patient outcomes. and-competencies/ ® Electronic medical records (EMRs) and Linda Bucher & Maureen A. Seckel, U. (2016, November electronic medication administration records 17). Nursing management: Critical care. Nurse (EMARs) are designed to facilitate Key. https://nursekey.com/nursing-management-critical- documentation, since they have programs and pages for numerous situations that happen in care/ critical care units. However, documenting all