CHAPTER
1
High-Acuity Nursing
Objectives: 1. Discuss the various health care environments in which high-acuity patients receive care. 2. Identify the need for resource allocation and staffing strategies for high-acuity patients. 3. Examine the use of technology in high-acuity environments. 4. Identify the components of a healthy work environment. 5. Discuss the importance of patient safety in the high-acuity environment.
I. High-Acuity Environment A. Historical perspective 1. Intensive care units (ICUs) were developed in the 1960s. Medical advances resulted in the initiation of these units. a) The implementation of CPR b) Improved management of patients experiencing hypovolemia and shock c) The implementation of emergency medical services d) Technological advances e) The advancement of renal transplant services B. Determining the level of care needed 1. Systematic triage approach for high-acuity patients aids in giving the most efficient and cost-effective care. a) ICU b) Intermediate-care unit (IMC) (1) Developed to manage those patients who did not require life-saving, critical-care functions (2) Ability to manage the potentially serious health care needs of the patient whose condition is too complex for the traditional medical-surgical floor c) Medical-surgical acute care unit. 2. Nurses should use a prioritization model to triage and determine the level of care needed by acutely ill patients. The model divides patient needs into four categories: a) Priority 1: The patient is acutely ill, requiring intensive treatments not available outside of the intensive care unit. b) Priority 2: The patient is seriously ill and has the potential to require immediate medical interventions to prevent complications.
c) Priority 3: The patient is critically ill but has a limited chance for recovery. There might be limits placed on the amount of life-saving interventions that may be implemented. d) Priority 4: This is a large category of patients. Their inclusion into the ICU will depend on an individualized decision based on the appropriate use of resources and current patient status. C. Levels of intensive care units 1. The American College of Critical Care Medicine has identified three levels of ICUs as determined by resources available to the hospital: a) Level I: Hospitals with ICUs that provide comprehensive care for patients with a wide range of disorders. Sophisticated equipment, specialized nurses and comprehensive support services. b) Level II: Hospitals with ICUs that provide comprehensive care to most critically ill patients. c) Level III: Hospitals with ICUs that provide initial stabilization of critically ill patients. D. Profile of the high-acuity nurse 1. Able to analyze clinical situations. 2. Make decisions based on analysis. 3. Rapidly intervene to ensure optimal patient outcomes. 4. Competent in detecting early signs of an impending complication. 5. Role of the nurse in the management of the high-acuity environment: a) Review the patient’s clinical condition and implement a plan of care. (1) Studies show that constant surveillance of patients by nurses reduces mortality and complications.
PowerPoint Slides 1. Intensive Care Units (ICU) • Developed in 1960 • Why initiated 2. Intermediate Medical Care (IMC) Units • Intended for patients needing close observation but not in need of life-saving, critical interventions • Able to manage those patients too complex for the traditional medical surgical unit 3. Triage Prioritization Model • Priority 1: acutely ill patients requiring life-saving, critical interventions • Priority 2: seriously ill patients possibly in need of immediate medical interventions • Priority 3: critically ill patients who will not likely recover from their disorders • Priority 4: patients who might be terminally ill 4.
The Registered Nurse in High-Acuity Settings • Continual assessment of the patient’s status • Implementation of the plan of care
• Studies link to reduced mortality and complications
II. Resource Allocation A. Nurse staffing 1. Nurse-patient ratios a) Many interrelated factors have led to a shortage of nurses able and willing to work with acutely ill patients. Factors linked to the nursing shortage include: (1) Reduced job satisfaction, resulting in nurses leaving the workforce (2) Aging of the registered nurse workforce (3) Limited number of young adults choosing nursing as a career (4) Increasing number of aging persons, resulting in an increase in persons requiring acute care health services b) The reduction in the number of professional nurses has resulted in an increase in the nurse– patient ratio. c) The Academy of Medical Surgical Nurses (AMSN) does not support the development of exact patient–nurse ratios. 2. Magnet Status: Recruiting and Retaining Nurses a) Magnet designation is a status awarded to hospitals that demonstrate success in recruiting and retaining professional nurses. b) Magnet hospitals promote environments that are attractive to the retention of professional nurses. 3. Unlicensed assistive personnel (UAP) can be used to provide direct care. a) The UAP provides care under the direction of the professional nurse. B. Decreasing resources, increasing care needs 1. Who Belongs in an ICU? a) The health care needs of the patient and the skill mix available must be the deciding factors. b) The assignment of patients to units requires a close review of available resources. c) A goal is to ensure that those patients requiring the greatest level of care will be cared for in the intensive care unit. d) Age and seriousness of illness can be controversial variables in the assignment of intensive care beds. Severity scales are models used to determine which patients will benefit most from intensive care services. e) Additional considerations must be given to ethical, economic, and legal concerns.
PowerPoint Slides 1. Nursing Shortage • The nursing shortage has resulted in a scarcity of nurses available to work with acutely ill patients. Factors linked to the nursing shortage include: • Reduced job satisfaction • Aging of the nursing workforce
• Limited numbers of young adults choosing nursing as a career • The increasing number of aging persons leading to an increase in persons requiring acute care health services 2. Nurse–Patient Ratios • Linked to a reduction of professional nurses • Academy of Medical Surgical Nurses does not support exact ratios 3. Magnet Status • Awarded to hospitals demonstrating success with recruitment and retention of professional nurses • Promotes environments favorable to professional nurses 4. Unlicensed Assistive Personnel • Used to provide direct care • Work under the direct supervision of the professional nurse 5. Allocation of Resources and Patient Bed Assignments • Goals involve ensuring the most favorable use of resources • Resource allocation must include ethical, economic, and legal concerns
III. Use of Technology in High-Acuity Environments A. Benefits 1. The use of technology in the intensive care unit allows for close monitoring of the patient. 2. The technology is a primary incentive for placement in the intensive care unit. 3. The use of computers can provide a programmed approach to guide decision making by providing decision-making trees. 4. Programs are available to diagnose patient conditions. Handheld devices can be used to provide bedside reference guides. B. Patient depersonalization 1. Difficulties arise when machines become the focus of care of the high-acuity patient. 2. Technical devices present mechanical impediments to touching the patient. 3. Little surface area may be available for physical contact, and this may lead to a feeling of depersonalization. 4. Technology may evoke fear in patients and contribute to their anxiety about their recovery process. C. Overload and overreliance issues 1. The potential for increased stress on the nurse as a result of information overload. 2. A potential overreliance on technology by the nurse. D. Finding a Balance 1. The skilled nurse who practices in a high-acuity setting must be able to bridge the gap between complex technology and the art of caring.
PowerPoint Slides 1. Advantages of Technology in the ICU • Allows for close monitoring of the patient • Provides a programmed approach to decision making • Provides programs to diagnose patient disorders • Source of readily available reference information 2. Disadvantages of Technology • Depersonalization of the patient • Overload • Over-reliance
IV. Healthy Work Environment A. Healthy work environment 1. The American Association of Critical Care Nurses (AACN) has identified six standards needed to sustain a healthy work environment. These standards are: a) Skilled communication b) True collaboration c) Effective decision making d) Appropriate staffing e) Meaningful recognition f) Authentic leadership B. Stress and burnout 1. Burnout is a term used to describe feelings of personal and professional frustration, dissatisfaction, job insecurities, and emotional and physical exertion. 2. Causes for burnout: a) Nursing shortages, long work hours, and a loss of concentration b) Stress caused by exposure to patients experiencing pain and suffering c) Feelings of powerlessness d) Repeated exposure to pain and traumatic loss C. Coping with stress and burnout 1. Factors that improve a nurse’s ability to cope with stress are a positive social climate, managerial support, and staff cohesiveness. 2. Debriefings help to promote coping with special situations. 3. A sense of community allows the nurse the ability to share both stresses and joys.
PowerPoint Slides 1. AACN Standards for Healthy Work Environments • Skilled communication
• True collaboration • Effective decision making • Appropriate staffing • Meaningful recognition • Authentic leadership 2. Burnout • Describes feelings of personal and professional frustration, dissatisfaction, job insecurities, and emotional and physical exertion 3. Causes of Nursing Burnout • Nursing shortages • Long work hours • Loss of concentration • Repeated exposure to patients during suffering • Feelings of powerlessness • Exposure to pain and traumatic loss 4. Work-related factors that improve the ability of the nurse to manage stress: • Positive social climate • Managerial support • Staff cohesiveness • Availability of debriefings
V. Ensuring Patient Safety in High-Acuity Environments A. The culture 1. Studies have linked a relationship among work conditions, teamwork, and patient outcomes: a) High levels of teamwork have been associated with a decreased length of stay and decreased mortality. 2. The current culture is supportive of reporting health care errors. B. Patient safety 1. The Joint Commission (TJC) is an accrediting organization that seeks to improve patient safety through an accreditation process. a) TJC developed National Patient Safety Goals for acute care hospitals. b) To receive accreditation, the applying organization must develop and provide evidence that it is meeting the outlined safety goals. C. Technology and patient safety 1. Computerized systems are used to prevent errors
a) The computerized provider order entry (CPOE) systems (1) Used to block incorrect medication orders; warn of drug interactions, allergies, and overdoses; provide current drug information; and alert one to similar drug names b) The barcode point-of-care (BPOC) (1) Allows nurses to scan their badges and then the patient wristbands to access medications c) Personal digital assistants (PDAs) provide helpful reference information D. Other factors contributing to patient safety 1. Patient safety can be promoted with factors other than technology. 2. A strong educational foundation and solid orientation will help the high-acuity nurse provide a safe environment. 3. Strong physician–nurse relationships and responsible management are key.
PowerPoint Slide 1. Error Reporting • Culture in health care is supportive of error reporting. • Error reporting has been accompanied by systems improvement. 2. The Joint Commission (TJC) • Accrediting organization seeking to improve patient safety. • Developed National Patient Safety Goals. • Acute care facilities seeking accreditation must provide evidence of meeting safety goals. 3. Computerized Systems Used to Prevent Errors • Computerized provider order entry (CPOE) systems • Barcode point-of-care (BPOC) • Personal digital assistants (PDAs) 4. Non-Technological Elements That Promote Patient Safety • Strong educational foundation • Solid orientation • Specialty certification • Strong physician–nurse relationships
VI. Chapter Summary VII. Clinical Reasoning Checkpoint VIII. Post-Test IX. References
Suggestions for Classroom Activities • Develop three to four patient scenarios. Lead a class discussion as to whether the patients being referenced are suitable to the ICU, IMC, or general medical–surgical unit. • Determine the students’ interest level. Ask the students if they are considering a nursing career in an ICU, an IMC, or a generalized medical–surgical care unit. What factors do the students cite as the reasons behind their choices? • Contact a local clinical facility. Ask to have a copy of its policies concerning the steps taken when the intensive care units are filled to capacity.
Suggestions for Clinical Activities • During the clinical post conference, ask the students to evaluate whether their assigned patients were appropriate for the ICU, IMC, or general medical–surgical care unit. • Lead a class discussion to determine potential factors that would lead to a patient’s being considered a Priority 4 patient. • Provide the clinical group rotation opportunities to the ICU and the IMC. Ask the students to develop a listing of the noted differences between the units.
CHAPTER
2
Holistic Care of the Patient and Family
Objectives: 1. Discuss the impact of illness on the high-acuity patient and family. 2. Identify way the nurse can help high-acuity patients cope with an illness and/or injury event. 3. Describe the principles of patient and family-centered care in the high-acuity environment as it relates to educational needs of visitation and policies. 4. Discuss the importance of awareness of cultural diversity when caring for high-acuity patients. 5. Examine the role of palliative care in the high-acuity environment and discuss end-of-life issues to be considered in caring for high-acuity patients. 6. Identify environmental stressors, their impact on high-acuity patients and strategies to alleviate those stressors.
I. Impact of Acute Illness on Patient and Family A. Suchman’s stages of illness 1. Illnesses can cause the patients to experience a chronic loss of health, loss of limb, disfigurement, or necessary change in lifestyle. Patients might respond to the losses by passing through a series of phases. These are known as Suchman’s stages of illness. These stages are: a) Shock and disbelief: Diagnoses does not have an emotional meaning. b) Denial: Patient rejects diagnosis. c) Awareness: Attempts to regain control. d) Restitution; Diagnosis is accepted. e) Resolution: Patient’s identity is changed. B. Nursing considerations 1. The family is an important part of the patient’s health outcome. 2. Patients must participate in the care and recovery of their loved one. 3. Patients need information, comfort, support, assurance, and accessibility. 4. Open communication must be maintained.
PowerPoint Slides 1. Suchman’s Stages of Illness • Shock and disbelief
• Denial • Awareness • Restitution • Resolution 2a. Needs of the Family of the Patient with High-Acuity Illness • Information • Comfort • Support • Accessibility • Assurance 2b. Communication Requirements of the Family • Openness • Honesty • Direct • Frequent • Ongoing
II. Coping with Acute Illness A. Complementary and alternative therapies 1. Numerous strategies are used to help patients cope with psychological and physical illness– related stressors. Complementary and alternative therapies can help reduce stress include: a) Aromatherapy (1) Use of oils to reduce stress and anxiety. Oils may be inhaled or used with massage. Commonly used oils include lavender, and jasmine. b) Therapeutic Humor (1) Humor is used to relieve stress. Humor strengthens the bonds among the patient, family, and nurse. The use of humor is tricky during a serious illness. c) Massage Therapy and Therapeutic Touch (1) Massage can help promote relaxation, reduce anxiety, and facilitate sleep. (2) The vascular, muscular, and nervous systems are positively affected by massage. (3) Massage is an acceptable tool to manage pain. Conditions that do not indicate massage therapy include advanced osteoporosis, bone fractures, burns, deep vein thrombosis, eczema, phlebitis, and skin infections. d) Guided Imagery (1) Guided imagery is a technique that encourages relaxation. (2) The patient is asked to focus on positive thoughts and experiences.
PowerPoint Slides 1. Complementary and Alternative Therapies • Aid in stress reduction • May be used in place of or in addition to traditional therapies • Must be an informed decision 2. Aromatherapy • Use of oils to reduce stress and anxiety • May be inhaled or used with massage • Common oils 3. Humor • Relieves stress • Promotes positive communication • Requires skill to use successfully in high-acuity situations 4a. Massage Therapy • Manipulation of soft tissues of the body using the hands • Can reduce anxiety, promote sleep, and reduce pain • Has positive effect on muscular and nervous systems 4b. Massage Therapy and Pain Management • Used to treat all pain domains: • Physical • Spiritual • Emotional 4c. Contraindications to Massage Therapy • Advanced osteoporosis • Bone fractures • Burns • Deep vein thrombosis • Eczema • Phlebitis • Skin infections 5. Guided Imagery • Focuses thinking on positive thoughts and images • Can be used to distract the patient from painful events or treatments
III. Patient- and Family-Centered Care A. Educational needs of patients and families 1. Health literacy a) Patients and families require education with a goal to reduce stress and promote comfort. Establishing a relationship with the patient facilitates trust in the nurse and will promote security and facilitate learning. b) Some factors inhibit learning in the high-acuity patient. Obstacles to education can involve condition-related fatigue, blocks to communication and pain. The nurse must meet the physiological needs of the patient before attempting to promote understanding. c) Palazzo has established educational needs of patients and families. These Include: (1) Information about progress (2) Informed decision making (3) Acknowledgement of the past (4) Optimal learning environment (5) Orientations to routines and care (6) Motivation 2. Transfer anxiety a) Transfer of the patient to a less-acute care unit could cause transfer anxiety in the patient or family. b) The anxiety is the result of a change in environment. c) A plan of care allowing the patient and family to ask questions will promote success of the transfer. d) Moving the patient during daytime hours will help to lessen anxiety. B. Visitation policies 1. Many intensive care units in the United States have restrictive visiting policies: a) Studies indicate that patients prefer open visitation policies. b) Patients demonstrate reduced risks of cardiovascular complications, decreased mortality, and anxiety levels when their visiting hours are unrestricted. 2. The visiting activities of children often are restricted in intensive care units: a) The rationales for these limitations are concerns for the risk of infection and for the emotional well-being of the child. b) In the event a family member is at risk for not recovering, exceptions should be made to allow for “goodbyes” 3. Traditionally, family members have been restricted from their loved ones during invasive procedures and cardiopulmonary resuscitation: a) Studies reveal that many facilities do not have policies restricting family presence during CPR. b) Twibell identified benefits of the presence of the family during CPR. 4. The care delivery model embraces the presence of the family members at the bedside:
a) Nursing staff should provide education to the family members regarding what to expect and actions that should be taken. b) Hospital policies should carefully address the facility’s stance toward visitors exhibiting negative behaviors.
PowerPoint Slides 1. Educating the High-Acuity Patient • Goals • Reduce stress • Promote comfort • Establish a relationship with the patient 2. Barriers to Learning for the High-Acuity Patient • Condition-related fatigue • Communication barriers • Endotracheal tubes • Hourly procedures • Diagnostic tests • Pain • Medications 3. Educational Needs of Patients and Families • Information about patient progress • Informed decision making • Acknowledgement of the past • Optimal learning environment • Orientation to routines and care • Motivation 4. Transfer Anxiety • Can result from movement to a less-acute care unit • Affects patient and family • Tips to reduce: • Provide information to patient and family • Encourage questions from patient and family • Transfer during daytime hours 5. Visitation Policies • Patients prefer open visitation policies
• Benefits of flexible visitation policies: • Reduced incidence of cardiovascular complications • Decreased mortality • Reduced anxiety levels 6. Visitation of Children in Intensive Care Units • Limitations are based on: • Concerns for the risk of infection • Concerns for emotional well-being of the child • Should be allowed if death is imminent 7a. Visitation Limitations • During invasive procedures • During CPR 7b. Twibell’s Summary of Benefits of Family Presence during CPR • The ability of the family to grasp the seriousness of the patient’s illness. • Family members see firsthand that everything was done for the patient. • Families move more positively through the grieving process. • Removal of doubt by families about what is happening to the patient. • Families experience less anxiety and fear. • Provision of a sense of closure for families who lose a loved one. • Facilitation of the grieving process by families who lose a loved one.
IV. Cultural Diversity A. Cultural competence 1. Cultural Assessment a) Cultural competence is defined as an awareness of one’s own thoughts and feelings without letting them influence the care of patients with different backgrounds. b) Nurses who have self-awareness have knowledge, understanding, respect, and acceptance for the patient’s culture. c) Cultural competence includes sensitivity to the culture, race, gender, sexual orientation, social class, and economic status of the patients. 2. Other Sources of Diversity a) Immigrants and refugees may have specific health beliefs and practices. b) Racial and ethnic considerations must be taken into account. c) Socioeconomic status. d) Sexual orientation. B. Developing cultural competence
1. In the quest for developing cultural competence, the nurse must give consideration to individual characteristics. This will prevent stereotyping. The nurse must assess and affirm differences. Educational materials provided must be in the language and at the level needed by the patient. Judgment cannot be made concerning the patient’s choices. The CRASH (culture, respect, assess/affirm, sensitivity/self-awareness, and humility) model is often used: a) Consider culture b) Show respect c) Assess and affirm differences d) Show sensitivity and self-awareness e) Provide care with humility
PowerPoint Slides 1a. Cultural Competence • Self-awareness of one’s own thoughts and feelings about others with different backgrounds • Self-awareness can improve: • Knowledge • Understanding • Respect • Acceptance 1b. Categories Included in Cultural Competence • Culture • Race • Gender • Sexual orientation • Social class • Economic status 2. The CRASH Model • Consider culture • Show respect • Assess and affirm differences • Show sensitivity and self-awareness • Provide care with humility
V. Palliative and End-of-Life Care A. Palliative care 1. Why Palliative Care? a) Palliative care is a multidisciplinary approach to relieving suffering and improving the quality of life.
b) Interventions involve both nursing and medical treatment to manage pain and symptoms. c) The program includes members from other disciplines, including social workers and chaplains. d) Palliative care models allow the needs of patients and families to be met in a cost-effective manner. e) Needs for palliative care are growing. f) Benefits of palliative care include reduced cost, increased bed capacity, and improved quality of care. 2. High-Acuity Patients and Palliative Care: a) Cancer is the most common disorder requiring palliative care. b) Other disorders can include cardiac disease, chronic renal failure, and neurological diseases. 3. Barriers to Providing Palliative Care: a) Barriers to palliative care exist for the high-acuity-care patient. b) It is often difficult to make the transition from a cure perspective to that of a palliative nature. c) The limited collaboration and inconsistent communication between physicians and nurses also plays a role. d) These barriers can be managed with education. 4. A Multidisciplinary Approach a) A palliative care team is needed to facilitate the patient’s progression to a successful palliative care path. b) The team will consist of the high-acuity nurse and personnel from related discipline. 5. Assessment of Sources of Conflict B. End-of-life care 1. Barriers to End-of-Life Care in High-Acuity Settings: a) The Patient Self-Determination Act requires all patients be given information about their right to formulate advanced directives. b) The American Association of Critical-Care Nurses (AACN) recommends nurses base their practice on individual professional accountability; thorough knowledge; recognition and appreciation of a person’s wholeness, uniqueness, and significant social–environmental relationships; and appreciation of the collaborative role of all health team members. c) The Patient Self-Determination Act requires that all patients be provided information about their right to make advanced directives, living wills, and appointment directives: (1) Living wills (2) Power of Attorney for health care 2. Allow Natural Deaths a) Allow Natural Death (AND) (1) Using this term implies that the patient is dying and that everything possible is being done to keep the patient comfortable and allow the dying process to occur naturally. (2) The goal of AND is to prevent unnecessary suffering and allow nature to take its course. 3. Educational Focus
a) Educational programs must be developed and directed toward those individuals already in the workforce as well as those who are completing their basic education requirements.
PowerPoint Slides 1. Palliative Care • Multidisciplinary approach • Geared toward improving quality of life and relieving suffering • Includes all health disciplines 2. Benefits of Palliative Care • Reduced cost • Increased bed capacity • Improved quality of care 3. Disorders Requiring Palliative Care • Cancer (most common) • Cardiac disease • Chronic renal failure • Neurological conditions 4. Barriers to Palliative Care • Difficulty transitioning from a “cure perspective” • Limited collaboration between physicians and nurses • Inconsistent communication • Fragmented care 5. The Palliative Care Team • Goals to meet psychological, social, cultural, and spiritual needs • Includes the high-acuity nurse and other members • Conferences are instrumental • The care plan must be comprehensive 6. The Patient Self-Determination Act • Part of the Omnibus Budget Reconciliation Act • Mandates all patients be given information about the right to formulate advanced directives: • Treatment directives (living wills) • Appointment directives (power of attorney for health care) 7. Allow Natural Death (AND) • Synonymous with DNR • Term acceptable to families
• Goals: • Prevent unnecessary suffering • Allow for nature to take its course
VI. Environmental Stressors A. Sensory perceptual alterations 1. Sensory overload and deprivation a) Environmental characteristics of the high-acuity care unit have a significant impact on the patient. b) The patient is at risk for both sensory overload and deprivation. c) The individual’s normal stimuli are interrupted, and the senses simultaneously are being bombarded with continuous strange stimuli. d) Those who are very old, very young, postoperative, or unresponsive are at the greatest risk for this difficulty, known as sensory perceptual alterations (SPAs). e) The nurse must recognize the stressors presented by the environment and promote adequate sleep and rest periods as well as work to reduce unnecessary noises: (1) The Environmental Protection Agency recommends that hospitals contain noise levels. Daytime levels should not exceed 45 dBA. (2) Nighttime levels should not exceed 35 dBA. Normal conversation is approximately 60 dBA. 2. Delirium a) Delirium can result from sensory perceptual alterations in awareness, impaired ability to attend to environmental stimuli, and disorganized thinking. b) The nurse must assess and identify the cause of the delirium. c) Causes of delirium vary. Once determined, the underlying causes must be treated. 3. Sleep deprivation a) Normal rest and sleep are compromised in the high-acuity unit. b) The changes in the light/dark cycle, pain, and environmental stimuli are related factors. B. Interventions to decrease sensory perceptual alterations 1. Prevent sleep deprivation a) Patients need at least two hours of uninterrupted sleep to promote REM functioning. 2. Facilitate communications a) Communication with mechanically ventilated patients is needed to prevent SPA. b) Stressors are caused by the inability to speak. c) Nonverbal behaviors will vary and must be closely reviewed for messages. d) When caring for the patient who cannot speak, the nurse must act as a patient advocate. (1) The nurse will need to provide support for the decision of the patient or designated surrogate. (2) These choices could conflict with those of the health care provider and family.
PowerPoint Slides 1a. Cause of Environmental Stressors in High-Acuity Care Units • Sensory overload • Sensory deprivation • Pain • Loss of sleep 1b. Patients Most Affected by Environmental Stressors • The aged population • Very young patients • Postoperative patients • Unconsciousness patients 2. Role of the Nurse Caring for the High-Acuity Patient • Assess the patient’s normal environmental stimuli • Provide normal stimuli, if possible • Promote adequate rest and sleep • Reduce unnecessary environmental noise 3. Environmental Protection Agency Recommendations • Daytime levels not to exceed 45 dBA • Nighttime levels not to exceed 35 dBA 4. Environmental Stimuli and the Unconscious Patient • An assessment of the normal stimuli for the unconscious patient must be completed. • The nurse might need to consult a friend or family member about normal stimuli for the patient. 5a. Delirium • Sensory perceptual alterations • Physical disruptions 5b. Manifestations of Delirium • Fluctuating awareness • Impaired ability to attend to environmental stimuli • Disorganized thinking 5c. Potential Causes of Delirium • Hypoxemia • Alcohol or barbiturate withdrawal • Hyponatremia • Drug reactions
• Infections • Liver dysfunction 5d. Role of the Nurse Caring for the Patient Experiencing Delirium • Assess and determine cause • Manage cause 6a. Alterations of the Rest and Sleep Cycles • Associated with changes in the light/dark cycle • Causes: • Pain • Environmental noise • Caregiver interruptions • Stress 6b. Alterations of the Rest and Sleep Cycles (continued) • Management: • Planned rest periods of at least two hours • Nonpharmacologic induction of sleep recommended • Closing doors • Posting signs 6c. Benefits of REM Sleep • Protein anabolism • Improved immune function • Improved healing 7. Communication with Mechanically Ventilated Patients • Necessary to prevent SPA. • The inability to verbally communicate is a stressor. • Assessment of nonverbal behaviors needed. 8. The Patient Who Cannot Speak • Nurses must be patient advocates. • Nurse must represent the patient or patient representative: • Choices may conflict with provider or family desires.
VII. Chapter Summary VIII. Clinical Reasoning Checkpoint IX. Post-Test X. References
Suggestions for Classroom Activities • Ask each student to develop two study questions based on Suchman’s stages. Use these questions as part of an in-class review. • Divide the class into small groups of two to four students. Instruct student groups to develop small care plans addressing the education needs of the acutely ill patient. Allow only a short time for the exercise. Once complete, ask the student groups to share their work with the entire class. • Having the correct learning environment for educating for the acutely ill patient is crucial. Ask students to list their concepts of the optimal learning environment.
Suggestions for Clinical Activities • Discuss the implications of ensuring that patients report all complementary and alternative therapies being used. How and where should they be documented? • During clinical, assign students to patients who are considered to be high acuity. During the clinical post conference, ask the students to determine which Suchman stage the patient they cared for was demonstrating. • Invite a massage therapist to visit with the clinical group. Ask the massage therapist to discuss the use of massage for patients experiencing pain.
CHAPTER
3
The Older Adult High-Acuity Patient
Objectives: 1. Describe the characteristics of the aging population. 2. Apply knowledge of age-related changes in neurologic and neurosensory function. 3. Apply knowledge of the age-related changes in cardiovascular and pulmonary function. 4. Apply knowledge of the age-related changes in integumentary and musculoskeletal function. 5. Apply knowledge of the age-related changes in gastrointestinal and genitourinary function. 6. Apply knowledge of the age-related changes in endocrine and immune function. 7. Differentiate between dementia, delirium, and depression, and describe their impact on older high-acuity patients and their families. 8. Discuss falls, pain, and pharmacology as factors that impact hospitalization in the older patient. 9. Demonstrate the use of common geriatric assessment tools. 10. Demonstrate the nursing management of older patients with high-risk injuries and trauma. 11. Explain special situations including the culture of caring for older adults and end-of-life care.
I. The Older Adult Patient A. The older adult patient 1. Nurses working in high-acuity areas should understand the age-related changes that make older patients vulnerable to complications and that might impact the outcome of their hospitalization. 2. Older adults may present with common problems in uncommon ways: symptoms are less predictable; older patients may have multiple other comorbidities or chronic conditions, multiple medications, and adverse drug reactions; and they are at greater risk for disability and becoming permanently critically ill. 3. The application of early and appropriate interventions and protocols can improve care, promote optimal function, prevent complications, and provide for the best possible outcomes for hospitalized elderly patients. B. Characteristics of the older adult population 1. Demographics a) Demographic characteristics in the U.S. (people are living longer) (1) Population aged 65+ expected to double within next 20 years. (2) By 2030, ~1 in 5 (over 72 million) will be 65+.
(3) More than 70,000 centenarians exist. (4) Fastest-growing group is people 85+. (5) The “age wave” will peak in 2030, when most baby boomers are 65+. 2. General health a) High rates of chronic disease are related to high levels of disability. (1) 82% have at least one chronic condition (many have multiple). (2) Over half have some difficulty with daily activities or self-care. (3) Most common conditions: (a) Hypertension (b) Arthritis or joint problems (c) Heart disease (d) Cancer (e) Diabetes (f) Stroke (g) Asthma (h) Chronic bronchitis 3. Health care a) Increased use of health care services by the older population (1) Older adults will be a majority in general hospital setting. (a) 3 times more hospitalization rates (b) 55% in the intensive care unit 4. Ethnic diversity a) Increasing racial and ethnic diversity in aging population (1) Growing immigrant and minority populations. (2) Older adults; changing percentages. (a) 2008: 6.8% non-Hispanic whites (b) 2050: 20% non-Hispanic whites (3) Nurses will need to strive to provide culturally competent care.
PowerPoint Slides 1. Nurse has to assess each older adult individually. • Multiple medications. • Adverse drug reactions. • Greater risk for disability and becoming permanently critically ill. • Older patients may have multiple other comorbidities or chronic conditions. 2. Aging Demographics Characteristics in the U.S. • Population aged 65+ to double within next 20 years. • By 2030, ~1 in 5 will be 65+.
• More than 70,000 centenarians exist. • Fastest growing group is people 85+. • “Age wave” will peak in 2030. 3a. High rates of chronic disease —> high levels of disability: • 82% have at least one chronic condition. • Over half have difficulty with ADL. 3b. Most common chronic disease conditions: • Hypertension • Arthritis or joint problem • Heart disease • Cancer • Diabetes • Stroke • Asthma • Chronic bronchitis 4. Increased use of health care services by the older population: • Older adults will be a majority in general hospital setting. 5. Increasing racial and ethnic diversity in aging population: • Growing immigrant and minority populations. • Older adults; changing percentages. • Nurses will need to strive to provide culturally competent care.
II. Neurologic and Neurosensory Systems Changes A. Neurologic system 1. Nursing implications of central nervous system changes a) Aging affects many aspects of a person’s life experience: (1) Physical (2) Psychological (3) Social (4) Spiritual (5) Economic b) Aging process: gradual loss of function in all organ systems: (1) Changes associated with the normal aging process (2) Changes occurring due to a pathological process c) The application of early and appropriate interventions: (1) Improves care. (2) Promotes optimal function.