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Class Notes for High-Acuity Nursing, 7th Edition - Page 1 preview imageInstructor’s Resource ManualForHigh-Acuity Nursing7thEditionKathleen Dorman Wagner, EdD, MSN, RNFaculty Emerita, University of Kentucky College of NursingMelanie G. Hardin-Pierce, DNP, RN, APRN, ACNP-BCAssociate Professor ofNursing, University of Kentucky College of NursingDarlene Welsh, PhD, MSN, RNAssociate Professor of Nursing, University of Kentucky College of NursingPrepared byMaria Baptiste, MSN, CCRN-CMC, APRN-BC, NP-C
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Class Notes for High-Acuity Nursing, 7th Edition - Page 2 preview image
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Class Notes for High-Acuity Nursing, 7th Edition - Page 3 preview image.CHAPTER1High-Acuity NursingObjectives:1.Discuss the varioushealthcare environmentsin whichhigh-acuity patientsreceive 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 EnvironmentA.Historical perspective1.Intensive care units (ICUs) were developed in the1960s. Medical advancesresulted in the initiation of these units.a)The implementation of CPRb)Improved management ofpatients experiencing hypovolemia and shockc)The implementation of emergency medical servicesd)Technological advancesthat required close observation for effective usee)The advancement of renal transplant servicesf)The first ICUs were recovery roomscreated for those postoperativepatients who required extra equipment and prolonged observation.B.Determining the level of care needed1.Systematic triage approach for high-acuity patients aids in giving the mostefficient and cost-effective care.a)ICUb)Intermediatecare unit (IMC)or progressive care unit (PCU)(1)Developed to manage those patients whose acute illness requiresless monitoring equipment and staffing than is provided in an ICU(2)Ability to manage patients with moderate or potentially severephysiological instability butwhodo not require artificial lifesupportc)Medical–surgical acute care unit
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Class Notes for High-Acuity Nursing, 7th Edition - Page 4 preview image.2.Nurses should use a prioritization model to triage and determine the level ofcare needed by acutely ill patients. The model divides patient needs into fourcategories:a)Priority 1: The patient is acutely ill, requiring intensive treatments notavailable outside of the intensive care unit.b)Priority 2: The patient is seriously ill and has the potential to requireimmediate medical interventions to prevent complications.c)Priority 3: The patient is critically ill but has a limited chance forrecovery. There might be limits placed on the amount of life-savinginterventions that may be implemented.d)Priority 4: This is a large category of patients. Their inclusion into theICU will depend on an individualized decision based on the appropriateuse of resources and current patient status.C.Levels of intensive care units1.The American College of Critical Care Medicine has identified three levels ofICUs as determined by resources available to the hospital:a)Level I: Hospitals with ICUs that provide comprehensive care forpatients with a wide range of disorders. Sophisticated equipment,specialized nursesand healthcare providers,and comprehensive supportservices.b)LevelII: Hospitals with ICUs that provide comprehensive care to mostcritically ill patients.c)Level III: Hospitals with ICUs that provide initial stabilization ofcritically ill patientsbut are limited in their ability to providecomprehensive care for all patients.D.Profile of the high-acuity nurse1.Able to analyze clinical situations2.Makesdecisions based on analysis3.Rapidly intervenesto ensure optimal patient outcomes4.Competent in detecting early signs of an impending complication5.Role of the nurse in the management of the high-acuity environment:a)Constant surveillance and monitoring to identify possible impending andlife-threatening complications(1)Studies show that constant surveillance of patients by nursesreduces mortalityand complications.II.Resource AllocationA.Nurse staffing1.Nurse–patient ratios
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Class Notes for High-Acuity Nursing, 7th Edition - Page 5 preview image.a)Many interrelated factors have led to a shortage of nurses able andwilling to workwith acutely ill patients. Factors linked to the nursingshortage include:(1)Hospital restructuring of nursing personnelreduced jobsatisfaction,which resultedin 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 inpersons requiring acute care health services(5)Increase in access to health care as a result of the AffordableCare Act(6)Legislation to support registered nurse-to-patient ratios and othernurse–patient issues have been raised to the national level.b)The reduction in the number of professional nurses has resulted in anincrease in thenurse–patient ratio.c)The Academy of Medical Surgical Nurses (AMSN) does not support thedevelopment of exact patient–nurse ratios.d)The needs of thepatient and the skill mix of the nursing staff must beconsidered when making decisions about staffing patterns.e)The first principle of staffing is to provide safe and effective patient care.f)Unlicensed assistive personnel (UAP) can be used to provide direct careunder direct supervision of the professional nurse.g)The professional nurse uses leadership skills to safely and legallydelegate tasks to the UAP.2.Magnetstatus:recruiting andretainingnursesa)Magnet designation is a status awarded to hospitals that demonstratesuccessfulrecruitmentandretention ofprofessional nurses.b)Magnet hospitals promote environmentsmeant toattractandretainprofessional nurses.c)Nurses who work at Magnet hospitals are more involved in decisionmaking, report better relations with physicians, and have higher nurse-to-patient ratios.B.Decreasing resources, increasing care needs1.WhoBelongs in an ICU?a)Deciding factors for ICU carearemultifactorial and may include severityof injury, futility of treatment andinformed refusal, the need to providethe quality of the dying and death experience, and family involvement.b)The assignment of patients to units requires a close review of availableresources.
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Class Notes for High-Acuity Nursing, 7th Edition - Page 6 preview image.c)Age and seriousness of illness can be controversial variables in theassignment of intensive care beds. Severity scales are models used todetermine which patients will benefit most from intensive care services.d)Ethical, economic, and legal considerations must be addressed withregard to ICU care.e)Patient death in a high-acuity area consumes significant resources.f)Each patient’s end-of-life care is subjective and different; therefore, costalone cannot be used to justify the use of healthcare resources.III.Use of Technology in High-Acuity EnvironmentsA.Benefits1.The use of technology in the intensive care unit allows for close monitoring oftheunstablepatientand can limit complications.2.The technology is a primary incentive for placement in the intensive care unit.3.The use of computers can provide aprogrammed approach to guide decisionmaking by providing decision-making trees.4.Programs are available to diagnose patient conditions. Handheld devices can beused to provide bedside reference guides.5.Nurses must be able to use technology but also recognize its limitations.B.Patient depersonalization1.Difficulties arise when machines become the focus of care of the high-acuitypatient.2.Technology must be used to enhance care, not take the place of a nurse’spersonal knowledge, observation skills, and senses.3.Technology may evoke fear in patients and contribute to their anxiety abouttheir recovery process.C.Overload and overreliance issues1.The potential for increased stress on the nurse as a result of informationoverload.2.Alarm fatigue is one result of overload and overreliance on technology.3.Support of patient well-being can be lost to thelureof technology.D.Finding abalance1.The skilled nurse who practices in a high-acuity setting must be able to bridgethe gap between complex technology and the art of caring.2.Appropriate training in the use of technology prevents technology frombecoming the focus of care.3.Nurses are at risk for becoming overly dependent on technology.IV.Healthy Work Environment
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Class Notes for High-Acuity Nursing, 7th Edition - Page 7 preview image.A.Healthy work environment1.The American Association ofCritical-Care Nurses (AACN) has identified sixstandards needed to sustain a healthy work environment. These standards are:a)Skilled communicationb)True collaborationc)Effective decision makingd)Appropriate staffinge)Meaningful recognitionf)AuthenticleadershipB.Stress,burnout, and compassion fatigue1.Burnout is a term used to describe feelings of personal and professionalfrustration, dissatisfaction, job insecurities, and emotional and physicalexertion.2.Causes for burnout:a)Nursing shortages, long work hours, and a loss of concentration,managerial unresponsiveness, lack of team supportb)Stress caused by exposure to patients experiencing pain and sufferingc)Feelings of powerlessnessd)Repeated exposure to pain and traumatic loss3.Compassion fatiguedescribes the inability to reenergize because of the loss ofcompassion energy expended on others.a)Compassion fatigue results from stress nurses experience from dailyrelationships with patients and families.C.Coping with stress,burnout,and compassion fatigue1.Factors that improve a nurse’s ability to cope with stress are a positive socialclimate, managerial support, and staff cohesiveness.2.Critical incident stressdebriefings(CISD)help to promote coping with specialsituations.3.A sense ofcommunity allows the nurse the ability to share both stresses andjoys.V.Ensuring Patient Safety in High-Acuity EnvironmentsA.The culture1.Studies have linked a relationship among work conditions, teamwork, andpatient outcomes:a)High levels of teamwork have been associated with a decreased length ofstay and decreased mortality.B.Patient safety
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Class Notes for High-Acuity Nursing, 7th Edition - Page 8 preview image.1.The Joint Commission (TJC) is an accrediting organization that seeks toimprove patient safety through an accreditation process.a)TJC developed National PatientSafety Goals for acute care hospitals.b)To receive accreditation, the applying organization must develop andprovide evidence that it is meeting the outlined safety goals.C.Technology and patient safety1.Computerized systems are used to prevent errors.a)The computerized provider order entry (CPOE) systems(1)Used to block incorrect medication orders; warn of druginteractions, allergies, and overdoses; provide current druginformation; and alert one tosimilardrug namesb)The barcodemedicationadministration(BCMA)(1)Allows nurses to scan their badges and then the patientwristbands to access medicationsprofiled for that specific patientc)Smartphones allow for text messaging, email retrieval, and the use ofclinical appsD.Other factors contributing to patient safety1.Patient safety can be promoted with factors other than technology.2.A strong educational foundation and solid orientation will help the high-acuitynurse provide a safe environment.3.Performance standards, specialty certification, culture of respect andprofessionalism,and strong physician–nurse relationshipsare among thefactors that contributeto patientsafety.VI.Clinical Reasoning CheckpointCase 1:RM is a 64-year-old with stage 4 metastatic colon cancer. She presents to the emergencydepartment with shortness of breath. A chest x-ray reveals right lower lobe pneumonia. She isadmitted to the hospital. She has advance directives that include no intubation or CPR.1.Is RM a candidate for admission to the ICU? Why or why not?2.Using theSociety of Critical Care Medicine (SCCM)prioritization model, identify thepatient’s priority level for ICU placement.Case 2:A patient with a history of new-onset seizures is admitted to a level III ICU. A diagnosis ofbrain tumor is made,and surgery will be required. The healthcare provider (HCP) informs the patientthat he needs to be transferred to another hospital that has a level I ICU.3.After the HCP leaves the room, the patient says he doesn’t understand why he needs to betransferred. As his nurse, explain the reason for the need for transfer.Case 3:You would like to work in a high-acuity unit that has a healthy practice environment thatsupports quality patient care and high levels of nurse satisfaction. You are aware of the six standardsidentified by AACN that are critical to creating and sustaining a healthy work environment.
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Class Notes for High-Acuity Nursing, 7th Edition - Page 9 preview image.4.Provide at least one example of how you might see each of the six standards operationalizedin the high-acuity unit.VII.Post-Test / Chapter1ReviewChapter 1 Question:ch01_01Question: The ICU nurse receives a call from the medical–surgical unit requesting transfer of apatient to the ICU. The patient is in acute respiratory failure and requires mechanical ventilation. Hewill require vasoactive drugs to help manage his profound hypotension. Based on theSCCMprioritization model, what is this patient’s priority for ICU placement?Answer:1. Priority 1Rationale:1. This patient is unstable and requires treatment and monitoring that cannot be provided outside theICU (newmechanical ventilation and vasoactive infusions). This condition meets the criteria forPriority 1 admission.Chapter 1 Question:ch01_02Question: A nurse is interviewing for a position in a community hospital. Hospital brochuresdescribe a Level III ICU. Which statement describes the resources that the nurse would expect in thishospital?Answer:3. Staff in the unit can provide initial stabilization of patients for transfer to more advanced care.Rationale:3. A Level III ICU provides initial stabilization of patients.Chapter 1 Question:ch01_03Question: A hospital has been working to achieve Magnet status. Which statements by an ICU nursereflect the benefits of Magnet status? (Select all that apply.)Answer:1. “I feel more ownership in the decisions being made to run the unit.”4. “Taking care of one less patient each shift makes such a difference.”Rationale:1. Nurses who work in Magnet hospitals are more involved in decision making, which increases theirownership of the decisions.4. Improved nurse–patient ratios are a benefit of work toward Magnet status.Chapter 1 Question:ch01_04Question: In the middle of a shift a nurse comes to the manager to discuss the acuity level andnumber of patients he has been assigned. Whichstatement would the manager interpret as indicatingthe nurse needs further education about nurse–patient ratios?Answer:2. “Our professional organizations would not approve of exceeding their recommended ratios.”
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Class Notes for High-Acuity Nursing, 7th Edition - Page 10 preview image.Rationale:2. AACN and AMSN do not set recommended ratios.Chapter 1 Question:ch01_05Question: New, fairly complex monitoring devices have been purchased to replace current monitorsin the ICU. How should the nurse manager plan to introduce this equipment to the unit?Answer:2. Require that all nurses caring for patients on this monitor have extensive training on its use.Rationale:2. All nurses who will use this equipment must be trained in its use before caring for a patient on themonitor.Chapter 1 Question:ch01_06Question: What is the best advice that an experienced ICU nurse can offer to new nurses on how toremain focused on the patient?Answer:3. “Try to arrange equipment so that you have ample opportunity to use the power of your touch withthe patient.”Rationale:3.Touch helps to personalize the patient for the nurse. Touch also helps to reduce anxiety in thepatient.Chapter 1 Question:ch01_07Question: A coworker has become increasingly withdrawn from social activities on the unit. She isoften late for work and is ambivalent about warnings from the nurse manager. She has become hostileand negative about proposed changes in the unit. The nurse should recognize that the coworker isexhibiting symptoms of which condition?Answer:1. BurnoutRationale:1. Ambivalence, withdrawal, hostility, and negativity are all symptoms of burnout.Chapter 1 Question:ch01_08Question: The nurse manager has made a commitment to improve the health of the ICU workenvironment. Which activities will help meet that goal? (Select all that apply.)Answer:1. Make every effort to assign patients so that their needs match the nurse’s strengths.3. Engage the hospital nurse executive in efforts to improve the health of the entire environment.5. Communicate in a clear and effective manner.Rationale:1. Matching patient need to nurse strength reflects appropriate staffing, which is one of the AACN
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Class Notes for High-Acuity Nursing, 7th Edition - Page 11 preview image.standards for a healthy work environment.3. The manager should demonstrate and encourage authentic leadership, embracing healthy living andenvironmental strategies.5. Skilled communication is one of the AACN standards for a healthy work environment.Chapter 1 Question:ch01_09Question: The hospital is planning to implement a CPOE system. One of the nurses says, “I don’t seehow that isgoing to help.” Which statement by another nurse is a good response to this concern?Answer:3. “Actually, hospitals that have used these systems generally see error reduction.”Rationale:3. CPOE systems have been found to reduce error.Chapter 1 Question:ch01_10Question: The high-acuity unit’s operations council is seeking suggestions concerning the use oftechnology to prevent errors on the unit. What statements by nurses are good responses to thisrequest? (Select all that apply.)Answer:1. “Barcode medication administration (BCMA) has been shown to reduce medication errors.”5. “If we had smartphones, we could look up so much information.”Rationale:1. BCMA systems do reduce medication errors.5. Smartphones do allow for quick and convenient access to data.VIII.ReferencesAcademy of Medical-Surgical Nurses (AMSN). (2011). Position statement: Staffing standards forpatient care. Retrieved August 20, 2015, from http://www.amsn.orgAiken, L. (2014). Baccalaureate nurses and hospital outcomes: More evidence.Medical Care,52(10),861–863. doi: 10.1097/MLR.0000000000000222American Association of Critical-Care Nurses (AACN). (2005). AACN standards for establishing andsustaining healthy work environments: A journey to excellence.American Journal of Critical Care,14, 187–197.American College of Critical Care Medicine (ACCM). (1993). Guidelines for the transfer of criticallyill patients.Critical Care Medicine,21, 931–937.American College of Critical Care Medicine (ACCM). (1998). Guidelines on admission anddischarge for adult intermediate care units.Critical Care Medicine,26(3), 608.American College of Critical Care Medicine (ACCM). (1999). Guidelines for intensive care unitadmission, discharge, and triage.Critical Care Medicine,27(3), 633–638.
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Class Notes for High-Acuity Nursing, 7th Edition - Page 12 preview image.American Nurses Association (ANA). (2005). Delegation: Joint ANA and National Council of StateBoards of Nursing Position Statement. Retrieved August 20, 2015, from http://nursingworld.orgAuerbach, D., Buerhaus, P., & Staiger, D. (2014). Registered nurses are delaying retirement, a shiftthat has contributed to recent growth in the nurse workforce.Health Affairs,33(8), 1474–1480. doi:10.1377/hlthaff.2014.0128Baker, M., Luce, J., & Bosslet, G. (2015). Integration of palliative care services in the intensive careunit.Clinics in Chest Medicine,36(3), 441–448. doi: 10.1016/ j.ccm.2015.05.010Baldwin, M. R. (2015). Measuring and predicting long-term outcomes in older survivors of criticalillness.Minerva Anestesiologica,81(6), 650–661.Bonafide, C., Lin, R., Zander, M., Graham, C., Paine, C., Rock, W., ... Keren, R. (2015). Associationbetween exposure to nonactionable physiologic monitor alarms and response time in a children’shospital.Journal of Hospital Medicine,10(6), 345–351. doi: 10.1002/jhm.2331Boyle, D. (2015). Compassion fatigue: The cost of caring.Nursing,45(7), 48–51. doi: 10.1097/01.NURSE.000061857.48809.a1Centers for Disease Control and Prevention. (2012). 2011 Guidelines for Field Triage of InjuredPatients. Retrieved September 15, 2017, from https://stacks.cdc.gov/view/cdc/23038/ShareCharles, K., Cannon, M., Hall, R., & Coustasse, A.(2014, Fall). Can utilizing a computerizedprovider order entry (CPOE) system prevent hospital medical errors and adverse drug events?Perspectives in Health Information Management, 1–16.Dabney, B., & Kalisch, B. (2015). Nurse staffing levels and patient-reported missed nursing care.Journal of Nursing Care Quality,30(4), 306–312. doi: 10.1097/ NCQ.0000000000000123Droogh, J., Smit, M., Absalom, A., Ligtenberg, J., & Zijlstra, J. (2015). Transferring the critically illpatient: Are we there yet?Critical Care,19(62). doi: 10.1186/ s13054-015-0749-4Furness, N., Bradford, O., & Paterson, M. (2013). Tablets in trauma: Using mobile computingplatforms to improve patient understanding and experience.Orthopedics,36(3), 205–208. doi:10.3928/01477447-20130222-06Haupt, M. T., Bekes, C. E., Carl, L. C., Gray, A. W., Jastremski, M. S., Naylor, D. F., ... Society ofCritical Care Medicine. (2003). Guidelines on critical care services and personnel: Recommendationsbased on a system of categorization of three levels of care.Critical Care Medicine,31(11), 2677–2683.Healy, S., & Tyrrell, M. (2013). Importance of debriefing following critical incidents.EmergencyNurse,20(10), 32–37.
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Class Notes for High-Acuity Nursing, 7th Edition - Page 13 preview image.Henderson, J. (2015). The effect of hardiness education on hardiness and burnout on registerednurses.Nursing Economics,33(4), 204–209.Hinderer, K., VonRueden, K., Friedmann, E., McQuillan, K., Gilmore, R., Kramer, B., & Murray, M.(2014). Burnout, compassion fatigue, compassion satisfaction, and secondary traumatic stress intrauma nurses.Journal of Trauma Nursing,21(4), 160–169. doi: 10.1097/ JTN.0000000000000055Institute of Medicine (IOM), Committee on Quality of Health Care in America. (2001). Crossing thequality chasm: A new health system for the 21st century. Retrieved November 24, 2016, fromhttps://www.nap. edu/read/10027/chapter/1Kelly, L., Runge, J., & Spencer, C. (2015). Predictors of compassion fatigue and compassionsatisfaction in acute care nurses.Journal of Nursing Scholarship,47(6), 522–528. doi:10.1111/jnu.12162Kostakou, E., Rovina, N., Kyriakopoulou, M., Koulouris, N. G., & Koutsoukou, A. (2014). Criticallyill cancer patient in intensive care unit: Issues that arise.Journal of Critical Care,29, 817–822.Kramer, M., Brewer, B., Halfer, D., Hnatiuk, C., MacPhee, M., & Schmalenberg, C. (2014). Theevolution and development of an instrument to measure essential professional nursing practices.Journal of Nursing Administration,44(11), 569–576. doi: 10.1097/ NNA.0000000000000128Kramer, M., Schmalenberg, C., & Maguire, P. (2010). Nine structures and leadership practicesessential for a magnetic (healthy) work environment.Nursing Administration Quarterly,34(1), 4–17.Kutney-Lee, A., Stimpfel, A., Sloane, D., Cimiotti J., Quinn, L., & Aiken, L. (2015). Changes inpatientand nurse outcomes associated with magnet hospital recognition.Medical Care,53(6), 550–557. doi: 10.1097/ MLR.0000000000000355Maresca, R., Eggenberger, T., Moffa, C., & Newman, D. (2015). Lessons learned: Accessing thevoice of nurses to improve a novice nurse program.Journal for Nurses in Professional Development,31(4), 218–224. doi: 10.1097/ NND.0000000000000169McHugh, N., Baker, R., Mason, H., Williamson, L., Van Exel, J., Deogaonkar, R., ... Donaldson, C.(2015). Extending life for people with a terminal illness: A moral right and an expensive death?Exploring societal perspectives.BMC Medical Ethics,16(14). doi: 10.1186/ s12910-015-0008-xMeyer, M. (2003). Avoid PCU bottlenecks with proper admission and discharge criteria.CriticalCare Nurse,23(3), 59–63.Mick, D. J., & Ackerman, M. H. (2004). Critical care nursing for older adults: Pathophysiological andfunctional considerations.Nursing Clinics of North America,39(3), 473–493.Ñamendys-Silva, S., Plata-Menchaca, E., Rivero-Sigarroa, E., & Herrera-Gómez, A. (2015). Openingthe doorsof the intensive care unit to cancer patients: A current perspective.World Journal of
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Class Notes for High-Acuity Nursing, 7th Edition - Page 14 preview image.Critical Care Medicine,4(3), 159–162. doi: 10.5492/wjccm.v4.i3.159Oerlemans, A., Van Sluisveld, N., Van Leeuwen, E., Wollersheim H., Dekkers, W., & Zegers, M.(2015). Ethical problems in intensive care unit admissionand discharge decisions: A qualitativestudy among physicians and nurses in the Netherlands.BMC Medical Ethics,16(9), 1–10. doi:10.1186/s12910-015-0001-4Pattison, J., & Kline, T. (2015). Facilitating a just and trusting culture.International Journal ofHealth Care Quality Assurance,28(1), 11–26. doi: 10.1108/ IJHCQA-05-2013-0055Peigne, V., Somme, D., Guerot, E., Lenain, E., Chatellier, G., Fagon, J.-Y., & Saint-Jean, O. (2016).Treatment intensity, age and outcome in medical ICU patients: Results of a French administrativedatabase.Annals of Intensive Care,6(7), 1–8. doi: 10.1186/s13613-016-0107-yRiemer, H., Mates, J., Ryan, L., & Schleder, B. (2015). Decreased stress levels in nurses: A benefit ofquiet oi: 10.4037/ajcc2015706Rubin R. (2015). Bill takes aim at nationwide shortage of nurses.Journal of the American Medical Association,313(18), 1787. doi:10.1001/jama.2015.3747Rubin,R. (2015). Bill takes aim at nationwide shortage of nurses.Journal of the American MedicalAssociation, 313(18), 1787. doi:10.1001/jama.2015.3747Sabzevari, S., Mirzaei, T., Bagherian, B., & Iranpour, M. (2015). Critical care nurses’ attitudes aboutinfluences of technology on nursing care.British Journal of Medicine & Medical Research,9(8), 1–10. doi: 10.9734/ BJMMR/2015/18400Seibert, H., Maddox, R., Flynn, E., & Williams, C. (2014). Effect of barcode technology withelectronic medication administration record on medication accuracy rates.American Journal ofHealth-System Pharmacy,71, 209–218.Sendelbach, S., Wahl, S., Anthony, A., & Shotts, P. (2015). Stop the noise: A quality improvementproject to decrease electrocardiographic nuisance alarms.Critical Care Nurse,35(4), 15–23. doi:10.4037/ccn2015858Sim, Y., Jung, H., Shin, T., Kim, D., & Park, S. (2015). Mortality and outcomes in very elderlypatients 90 years of age or older admitted to the ICU.Respiratory Care,60(3), 347–355. doi:10.4187/respcare.03155The Joint Commission. (2015). National Patient Safety Goals Effective January 1, 2015. RetrievedNovember 21, 2016, from http://www.jointcommission.org/ assets/1/6/2015_NPSG_HAP.pdfUlrich, B., & Kear, T. (2014). Patient safety and patient safety culture: Foundations of excellenthealth care delivery.Nephrology Nursing Journal,41(5), 447–456, 505.U.S. Department of Health & Human Services. (2014). Key features of the Affordable Care Act byyear. Retrieved November 19, 2016, from http://www.hhs.gov/ healthcare/facts/timeline/timeline-
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Class Notes for High-Acuity Nursing, 7th Edition - Page 15 preview image.text.htmlVan Sluisveld, N., Zegers, M., Westert, G., Van der Hoeven, J., & Wollersheim, H. (2013). Astrategy to enhance the safety and efficiency of handovers of ICU patients: Study protocol of thepICUp study.Implementation Science 2013,8(67). doi:10.1186/1748-5908-8-67West, E., Barron, D., Harrison, D., Rafferty, A., Rowan, K., & Sanderson, C. (2014). Nurse staffing,medical staffing and mortality in intensive care: An observational study.International Journal ofNursing Studies,51, 781–794. doi: 10.1016/j.ijnurstu.2014.02.007White, K., Scott, I. A., Vaux, A., & Sullivan, C. M. (2015). Rapid response teams in adult hospitals:Time for another look?Internal Medicine Journal. doi: 10.1111/imj.12845Whittingham, K., & Oldroyd, L. (2014). Using an SBAR—Keeping it real! Demonstrating howimproving safe care delivery has been incorporated into a top-up degree programme.Nurse EducationToday,34(6), e47–e52.Wong, T. H., Krishnaswamy, G., Nadkarni, N. V., Nguyen, H. V., Lim, G. H., Bautista, D. C. T., . . .Ong, M. E. H. (2016). Combining the New Injury Severity Score with an anatomical polytraumainjury variable predicts mortality better than the New Injury Severity Score and the Injury SeverityScore: A retrospective cohort study.Scandinavian Journal of Trauma, Resuscitation and EmergencyMedicine,24(25), 1–11. doi: 10.1186/ s13049-016-0215-6IX.Suggestions for Classroom Activities•Develop three to four patient scenarios. Lead a class discussion as to whether the patients beingreferenced are suitableforthe ICU, IMC, or general medical–surgical unit.•Determine the students’interest level. Ask the students if they are considering a nursing career inan ICU, an IMC, or a generalized medical–surgical care unit. What factors do the students cite asthe reasons behind their choices?•Contact a local clinical facility. Ask to have a copy of its policies concerning the steps takenwhen the intensive care units are filled to capacity.•Ask students to identify behaviors associated with professional burnout. Lead the discussion onrecognizing burnout and coping with thehigh-acuity nursing environment.X.Suggestions for Clinical Activities•During the clinical postconference, ask the students to evaluate whether their assigned patientswere 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 beingconsidered a Priority 4 patient.•Provide the clinical group rotation opportunities to the ICU and the IMC. Ask the students todevelop a listing of the noted differences between theunits.
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Class Notes for High-Acuity Nursing, 7th Edition - Page 16 preview image.CHAPTER2Holistic Care of the Patient andFamilyObjectives:1.Describe the impact of illness on the high-acuity patient and family.2.Identify ways 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 itrelates to educational needs of visitation and policies.4.Explain the importance of awareness of cultural diversity when caring for high-acuity patients.5.Identify environmental stressors, their impact on high-acuity patients, and strategies to alleviatethose stressors.I.Impact of Acute Illness on Patient and FamilyA.Kübler-Ross’s Stages of Grief1.Illnesses can cause the patient and family to experience loss of health, loss oflimb, disfigurement, or necessary change in lifestyle that may alter the patient’sself-image and self-esteem. Patients may respond to losses in certainpredictable phases. According to Kübler-Ross and Kessler,these stages of griefare:a)Denial: The diagnosis does not have an emotional meaning.b)Anger: The patient rejects diagnosis.c)Bargaining: The patient attempts to regain control.d)Depression: The patient accepts the diagnosis.e)Acceptance: The patient’s identity is changed.B.Nursing considerations1.The family is an important part of the patient’s health outcome.2.The family is defined by the patient and may not be the traditional nuclearfamily.3.High-acuity units are now more inclusive family environments.4.Patients needinformation, comfort, support, assurance, and accessibility.
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Class Notes for High-Acuity Nursing, 7th Edition - Page 17 preview image.5.Proactive communication in the form of family meetings beginning early in thepatient’s ICU stay contributes to family-centered plan of care.II.Coping with Acute IllnessA.Complementary and Alternative Therapies (CAT)1.Numerous strategies are used to help patients cope with psychological andphysical illness–related stressors. Complementary and alternative therapiesthatcan help reduce stress include:a)Aromatherapy(1)Use of oils to reduce stress and anxiety. Oils may be inhaled andused to enhance massage. Commonly used oils include lavenderand jasmine.b)Therapeutic Humor(1)Humor is used to relieve stress. Humor strengthens the bondsamong the patient, family, and nurse. The use of humor is trickyduring a serious illness.c)Massage Therapy and Therapeutic Touch(1)Massage can help promote relaxation, reduce anxiety, andfacilitate sleep.(2)The vascular, muscular, and nervous systems are positivelyaffected by massage.(3)Massage is an acceptable tool to manage pain. Conditions that donot 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 andexperiences.III.Patient-and Family-centered CareA.Educational needs of patients and families1.Health literacya)Health literacy is the degree to which patients and families have theability to obtain, process, and understand basic health information tomake informed decisions about their healthcare.b)Health literacy includes the ability to:(1)Communicate with members of the health team(2)Completecomplex forms
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Class Notes for High-Acuity Nursing, 7th Edition - Page 18 preview image.(3)Understandconcepts related to risks.c)Some groups at risk for low levels of health literacy include: patientsolder than 65 years of age, members of minority groups, immigrants,those of a lower socioeconomic status, or those suffering from chronicillnesses.d)Patients with low health literacy are at risk for negative outcomes.e)Educational needs of the patient and family include:(1)Information about progress(2)Informed decision making(3)Acknowledgment of the past(4)Optimal learning environment(5)Orientations to routines andcare(6)Motivationf)The nurse should use return demonstration and teach-back techniques tosupplement patient and family education as appropriate.2.Transfer anxietya)Transfer anxiety is the mixed-emotional experience of the patient andfamily as the patient is transferredfroma secure to an unfamiliarenvironment.b)A plan of care allowing the patient and family to ask questions willpromote success of the transfer.c)Activities that promote reducing transfer anxiety include:(1)Moving the patient during daytime hours(2)Receiving information about unit routines and new equipment(3)Introducing the receiving nurse before the transferB.Visitation policies1.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 areunrestricted.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 infectionand for the emotional well-being of the child.b)In the event a family member is at risk for not recovering, exceptionsshould be made to allow for “goodbyes.”3.Historically, family members have been restricted from their loved ones duringinvasive procedures and cardiopulmonary resuscitation:
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Class Notes for High-Acuity Nursing, 7th Edition - Page 19 preview image.a)Studies reveal that many facilities do not have policies restricting familypresence during CPR.b)Benefits of family presence during CPR include:(1)Increasingfamily awareness of resuscitation efforts(2)The family is able to say goodbye.(3)Gaining a sense of control(4)The ability to preserve the patient’s dignity(5)Gaining a sense of closure(6)Decreasing family members’ experience ofposttraumatic stressdisorder.4.The care delivery model embraces the presence of the family members at thebedside:a)Nursing staff should provide education to the family members regardingwhat to expect and actions that should be taken.b)Hospital policies should carefully address the facility’s stance towardvisitors exhibiting negative behaviors.IV.Cultural DiversityA.Cultural competence1.Cultural Assessmenta)Knowledge of a patient’s cultural background is required to provideexcellent care.b)The nurseshould observe or ask culture-specific questions in order tounderstand the patient’s culture.c)The nurse should be aware of possible hindrances to communicationincluding interpretation and speech.(1)The nurse should use short units of speech.(2)Simple language(3)Observe for nonverbal cues2.Other Sources of Diversitya)Immigrants and refugees may have specific health beliefs and practices.b)Racial and ethnic considerations must be taken into account.c)Socioeconomic statusd)Sexual orientationB.Developing CulturalCompetence1.In the quest for developing cultural competence, the nurse must giveconsideration to individual characteristics. This will prevent stereotyping. Thenurse must assess and affirm differences. Educational materials provided must
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Class Notes for High-Acuity Nursing, 7th Edition - Page 20 preview image.be in the language and at the level needed by the patient. Judgment cannot bemade 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.V.Environmental StressorsA.Sensory–perceptual alterations(SPA)1.Sensory overload and deprivationa)Sensory overload occurs when patient is exposed to noise for continuousperiods.b)Excessive noise affects the patient’s as well as the nurse’s physical andphysiological state,contributing to caregiver stress and delivery ofquality patient care.c)The World Health Organization recommends that in a patient’s roomnoise level should not exceed 35 dBA.2.Deliriuma)Delirium involves an acute onset of fluctuating awareness, impairedability to attend to environmental stimuli, and disorganized thinking.b)Delirium is preceded by anxiety and restlessness.c)The nurse must assess and identify the underlying cause of the delirium.3.Sleep deprivationa)Normal rest and sleep are compromised in the high-acuity unit.b)The changes in the light/dark cycle, pain, and environmental stimuli arerelated factors.c)Sedating hypnotics may be helpful but are associated with falls, delirium,and functional decline especially in elderly patients.B.Interventions to decrease sensory–perceptual alterations1.Prevent sleep deprivationa)Two hours of uninterrupted sleep is necessary to promoterapid eyemovement (REM), whichpromotesprotein anabolism,restorestheimmune system, and promoteshealing.b)Some interventions to prevent sleep deprivation include:(1)Pain control(2)Relaxing music or earplugs(3)Placing pagers on vibrate
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Class Notes for High-Acuity Nursing, 7th Edition - Page 21 preview image.(4)Turning down volume on overhead announcement systems(5)Decreasing alarm volumes with caution(6)Adjusting light levels(7)Encouraging other services to return after rest period(8)Limiting visitation during rest periods(9)Mental preparation for quiet time(10)Planning the patient’s daily schedule to include quiettime.2.Facilitate communicationsa)Communication with mechanically ventilated patients is needed toprevent SPA.b)Nonverbal behaviors will vary and must be closely reviewed formessages.(1)Nonverbal cues include elevated heart rate and blood pressure,facial expression, hand gestures, moving legs.c)When caring for the patient who cannot speak, the nurse should providea means of communication appropriate to the patient’s ability such aslarge markers or pens, an alpha board, orusinga coded eye-blink system.VI.Clinical Reasoning CheckpointThisvalues clarification exercise is designed to help the learner explore personal values in relation tothe profession of nursing and bioethical issues. By reflecting on personal values, we gain a betterunderstanding of what factors may limit our ability to reason clearly and of when we may not besuitable for the role of patient advocate.Values Clarification ExerciseDirections: To the left of each statement, place the number that best explains your position: 1 =mostly agree, 2 = somewhat agree, 3 = neutral, 4 = somewhat disagree, 5 = mostly disagree._____ 1. Infants with severe handicaps ought to be left to die._____ 2. Extraordinary medical treatment is always indicated._____ 3. My role as a nurse is to always resuscitate patients who could benefit from it, no matter whathas been decided previously._____ 4. I must follow physician’s orders._____ 5. Older patients should be allowed to die with dignity._____ 6. Medical technology has advanced the quality of life._____ 7. Children should not be involved in giving consent for treatments._____ 8. Families ought to make decisions about life or death situations without involving the patient.
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Class Notes for High-Acuity Nursing, 7th Edition - Page 22 preview image._____ 9. Children should participate in human experimentation that is not harmful even if it is of nobenefit to them._____ 10. Prisoners should participate in scientific experiments to repay society for their wrongdoing._____ 11. Women should seek medical care from female physicians to avoid potential discrimination._____ 12. Children whose parents refuse medical care for them should be removed from theirfamilies through court action._____ 13. Research using fetuses should be pursued vigorously._____ 14. Life-support systems should be discontinued after several days of flatelectroencephalograms._____ 15. Health professionals are a scarce resource in many parts of the country._____ 16. Nursing is a subservient profession, especially to the medical profession._____ 17. As a nurse, I must relinquish my personal philosophy to support the philosophies of others._____ 18. All patients, regardless of differences, should be treated in ahumaneway._____ 19. I should give mouth-to-mouth resuscitation to a derelict if he needs it._____ 20. A child who is disabled has value._____ 21. All forms of human life have value._____ 22. I should be involved in decision making regarding ethical issues in practice._____ 23. Committees should decide who receives scarce resources, such as kidneys._____ 24. Patients’ individual rights should be more important than the rights of society at large._____ 25. A person has the right to make a living will._____ 26. Underdeveloped countries should be given health and financial support by developedcountries._____ 27.I should support all the positions on ethical issues taken by my professional association._____ 28. The care component of nursing practice is not as important as the cure component ofmedical practice._____ 29. The nurse’s primary role in decision making on ethical issues is to implement the selectedalternative._____ 30. I feel afraid when caring for a patient who is dying._____ 31. Children who have disabilities should be institutionalized._____ 32. Patients in mental health institutions and prisons should be given behavior modificationtherapy to make them conform to societal norms._____ 33. Personal possessions of patients should be removed to guarantee safekeeping duringhospitalization._____ 34. Patients should have access to their own health information._____ 35. Withholding health information fosters the patient’s recovery._____ 36. A patient with kidney failure is always able to get kidney dialysis when needed._____ 37. Society should bear the cost of extraordinary medical interventions._____ 38. Confidentiality is an important part of the nurse’s role.
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Class Notes for High-Acuity Nursing, 7th Edition - Page 23 preview image._____ 39. As a nurse, I should value responsibility._____ 40. Nurses have a right to withhold information to facilitate nursing research on humansubjects._____ 41. The patient who refuses treatment should be dropped from the health supervision of anagency or professional._____ 42. Transplantations should be done whenever needed.Personal Application1.Add the number of 1s, 2s, 3s, 4s, and 5s that you have.2.How many statements do you have clear ideas (1s and5s) about?3.Do these outweigh the number of ambivalent (neutral) statements you listed?4.Look at the statements that you agree with (1s and 2s). Is there a relationship between thestatements that influenced your responses (e.g., age of patient, patient acuity)?5.Look at the statements that you disagree with (4s and 5s). Is there a relationship between thesestatements that influenced your responses?6.Analyze the following cluster of statements. Is there any consistency in the way you rated thesestatements? What variables influenced your decision?Cluster 5, 8, 14, 25, 30: Relates to issues pertaining to deathCluster 3, 4, 16, 17, 22, 27, 28, 29, 38: Relates to the profession of nursingCluster 2, 6, 14, 36, 37, 42: Relates to issues raised by advanced technologyCluster 1, 7, 9, 12, 20, 31: Relates to childrenCluster 9, 10, 13, 40: Relates to human experimentationCluster 3, 7, 8, 11, 12, 18, 19, 21, 24, 25, 33, 34, 35, 38, 41: Relates to patients’ rightsCluster9, 10, 24, 26, 32, 37: Relates to society’s rightsCluster 15, 23, 36: Relates to allocation of resourcesCluster 3, 4, 17, 18, 19, 22, 27, 29, 39: Relates to perceptions of obligationsVII.Post-Test / Chapter 2 ReviewChapter 2 Question:ch02_01Question:A client is crying about a below-knee amputation sustained as a pedestrian in a pedestrian–vehicle crash. She expresses fears about ambulating in physical therapy. The nurse interprets thissituation as a sign that the client is in which stage ofgrief?Answer:3.DepressionAnswer: 3Rationale:3. In thedepressionphase,the client may be sad and have frequent crying episodes. Fears about thefuture are revealed.
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Class Notes for High-Acuity Nursing, 7th Edition - Page 24 preview image.Chapter 2 Question:ch02_02Question:A client was recently admitted to the ICU after a myocardial infarction. The family wantsto meet with the nurse. The nurse prepares for this meeting with the knowledge that at this stage ofillness the family most needs which things? Select all that apply.Answer:1. Frequent updates on the client’s condition2. Rationale for interventions being startedRationale:1. The communication between those providing care and the family is of primary importance. Thefamily members need to know how their loved one is progressing and need frequent updates.2. The family members need to know the purpose of the activities surrounding their loved one. Manyinterventions are frightening, and rationales help the family to cope.Chapter 2 Question:ch02_03Question:The nurse is considering use of a complementary and alternative therapy (CAT) to help aclient cope with the pain associated with burn treatment. The nurse designs this plan with fullconsideration that which CAT is a risky strategy?Answer:1. HumorRationale:1. Humor is a very individual perception and is not thought to be appropriate during critical illness bysomeclients or nurses. When it is thoughtfully used, it can be very helpful as distraction.Chapter 2 Question:ch02_04Question:High-acuity clients have a right to know and understand what procedures are being done toand for them. The nurse sets which initial goals when teaching the client about these procedures?Select all that apply.Answer:1. To decrease the client’s stress2. To promotetheclient’scomfortRationale:1. Initially teaching is done to decrease stress levels in the client and family.2. Initially teaching is done to promote comfort.Chapter 2 Question:ch02_05Question:The nurse is conducting an admission assessment on a client who is an immigrant to theUnited States. How would the nurse demonstrate cultural competence when caring for this client?Answer:1. Consider that the client’s culture may differ significantly from that of the nurse.2. Be respectful of the client and the family when providing care.3. When cultural differences are assessed, confirm their presence with the client or family.5. Be aware of the impact of cultural differences on the nurse.
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Class Notes for High-Acuity Nursing, 7th Edition - Page 25 preview image.Rationale:1. The nurse should always consider culture.2. The nurse who is culturally competent shows respect for the client and family.3. The nurse should not just assume that cultural differences exist but should confirm their presenceby asking sensitive questions.5. The nurse must be self-aware.Chapter 2 Question:ch02_06Question:A client has been an active participant in all aspects of hospitalization. This morning theclient seems confused and has difficulty completing a form documenting consent to a procedure to bedone tomorrow. What nursing actions are indicated? (Select all that apply.)Answer:3. Review the client’s most recent laboratory results.4. Assess the client for other findings of depression.Rationale:3. Alterations in blood chemistry constitute a frequentetiology for delirium.4. Clients who are depressed may have a decline in health literacy and may show signs of delirium.Chapter 2 Question:ch02_07Question:A 79-year-old client had a colon resection with colostomy2days ago for adenocarcinoma.She has had a patient-controlled analgesia pump for pain management. Since yesterday she hasbecome increasingly anxious and agitated. Today she is suddenly yelling out for help, is combative,and has pulled out her nasogastric tube. The nurse should recognize that this client is exhibitingsymptoms of which condition?Answer:1. DeliriumRationale:1. Delirium is a sensory–perceptual alteration that can occur in high-acuity clients. It is more likely inolder clients and is often preceded by increasing anxiety and agitation.Chapter 2 Question:ch02_08Question:The hospital supports open visitation throughout the facility. Family members visiting inthe coronary care unit have been noisy and disruptive even after being asked to keep down the levelof their voices. What nursing action is indicated?Answer:1. Ask the visitors to leave the unit.Rationale:1. The nurse’s first responsibility is to the clients in the unit. If family members are disturbing othersand do not modify behavior when asked, they should be asked to leave the unit.Chapter 2Question:ch02_09Question:A client in the ICU speaks only broken English. The nurse has been unsuccessful inunderstandingtheclient, and it is apparent the client does not understand the nurse. How should thenurse proceed?
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Class Notes for High-Acuity Nursing, 7th Edition - Page 26 preview image.Answer:4. Call social services and request an interpreter.Rationale:4. Social services should have a list of interpreters who will provide this service.Chapter 2 Question:ch02_10Question:A client has developed confusion while in the ICU. Medical reasons for the confusionhave been ruled out and a diagnosis of sensory–perceptual alterations made. What should the nursetell visitors about this client?Answer:2. Talk about familiar and calming things while in the room.Rationale:2. Visitors can help to reorient the client by talking about familiar and calming things.VIII.ReferencesAgency for Healthcare Research and Quality (AHRQ). (2013).Guide to patient and familyengagement in hospital quality and safety.Retrieved October 7, 2015, fromhttp://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/index.htmlAllen, D. (2014). Laughter really can be the best medicine.Nursing Standard,28(32), 24–25.doi:10.7748/ns2014.04.28.32.24.s28American Nurses Association (ANA). (2015).Code of ethics for nurses.Retrieved January 11, 2017,from http://www.nursingworld.org/codeofethicsAndrews, L., Silva, S., Kaplan, S., & Zimbro, K. (2015). Delirium monitoring and patient outcomesin a general intensive care unit.American Journal of Critical Care,24(1), 48–56.doi:10.4037/ajcc2015740Berglund, B., Lindvall, T., & Schwela, D. H. (1999).Guidelines for community noise.RetrievedJanuary 11, 2017, from http://apps.who.int/iris/handle/10665/66217Burhenn, P., Olausson, J., Villegas, G., & Kravits, K. (2014). Guided imagery for pain control.Clinical Journal of Oncology Nursing,18(5), 501–503. doi:10.1188/14.CJON.501-503Chevillon, C., Hellyar, M., Madani, C., Kerr, K., & Kim, S. (2015). Preoperative education onpostoperative delirium, anxiety, and knowledge in pulmonary thromboendarterectomy clients,American Journal of Critical Care,24(2), 164–171. doi:10.4037/ajcc2015658Crider, J., & Pate, M. (2011). Helping children say goodbye to loved ones in adult and pediatricintensive care units: Certified child life specialist–critical care nurse partnership.AACN AdvancedCritical Care, 22(2), 109–112.
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Class Notes for High-Acuity Nursing, 7th Edition - Page 27 preview image.Culturally competent nursing care and promoting diversity in our nursing workforce. (2015).Michigan Nurse,88(3), 7–11.Cypress, B. (2013). Transfer out of intensive care: An evidence-based literature review.Dimensionsof Critical Care Nursing,32(5), 244–261. doi:10.1097/DCC.0b013e3182a07646Ernst, E., Pittler, M., & Wider, B. (Eds.). (2006).The desktop guide to complementary and alternativemedicine: An evidence-based approach(2nd ed.). St. Louis, MO: Mosby/Edinburgh, Scotland:Elsevier.Fink, R., Makic, M., Poteet, A. W., & Oman, K. (2015). The ventilated patient’s experience.Dimensions of Critical Care Nursing,34(5), 301–308. doi:10.1097/DCC.0000000000000128Gay, E., Pronovost, P., Bassett, R., & Nelson, J. (2009). The intensive care unit family meetings:Making it happen.Journal of Critical Care, 24(4), 629.e1–629.e12.Hart, A., Hardin, S., Townsend, A., Ramsey, S., & Mahrle-Henson, A. (2013). Critical care visitation:Nurse and family preference.Dimensions of Critical Care Nursing,32(6), 289–299. doi:10.1097/01.DCC.0000434515.58265.7dHart, P., & Mareno, M. (2013). Cultural challenges and barriers through the voices of nurses.Journalof Clinical Nursing,23, 2223–2233. doi:10.1111/jocn.12500Ingram, R., & Kautz, D. (2012). When the patient and family just do not get it: Overcoming lowhealth literacy in critical care.Dimensions of Critical Care Nursing,3(1), 25–30.doi:10.1097/DCC.0b013e31823a5471Institute for Patient-and Family-Centered Care. (n.d.).Core concepts of patient-and family-centeredcare.Retrieved November 28, 2016, from http://www.ipfcc.org/pdf/CoreConcepts.pdfKaradag, E., Samancioglu, S., Ozden, D., & Bakir, E. (2015). Effects of aromatherapy on sleepquality and anxiety of clients.Nursing inCritical Care,20(5), 1–8. doi:10.1111/nicc.12198Kodali, S., Stametz, R., Bengier, A., Clarke, D., Layon, A., & Darer, J. (2014). Family experiencewith intensive care unit care: Association of self-reported family conferences and family satisfaction.Journal of Critical Care,29(4), 641–644. doi:10.1016/j.jcrc.2014.03.012Kramlich, D. (2014). Introduction to complementary, alternative and traditional therapies.CriticalCare Nurse,34(6), 50–56. doi:10.4037/ccn2014807Kübler-Ross, E. K., & Kessler, D. (2005).On grief and grieving: Finding the meaning of griefthrough the five stages of loss.New York, NY: Scribner.Lipson, J., Dibble, S., & Minarik, P. (Eds.). (2001).Culture & nursing care: A pocket guide.SanFrancisco, CA: UCSF Nursing Press.
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Class Notes for High-Acuity Nursing, 7th Edition - Page 28 preview image.Marchand, L. (2014). Integrative and complementary therapies for clients with advanced cancer.Annals of Palliative Medicine,3(3), 160–171. doi:10.3978/j.issn.2224-5820.2014.07.01Martorella, G., Boitor, M., Michaud, C., & Gélinas, C. (2014). Feasibility and acceptability of handmassage therapy for pain management of postoperative cardiac surgery clients in the intensive careunit.Heart & Lung,43(5), 437–444. doi:10.1016/j.hrtlng.2014.06.047Mattox, E. (2010). Identifying vulnerable patients at heightened risk for medical error.Critical CareNurse, 30(2), 61–69.Nilsen, M., Happ, M., Donovan, H., Barnato, A., Hoffman, L., & Sereika, S. (2014). Adaptation of acommunication interaction behavior instrument for use in mechanically ventilated, nonvocal olderadults.Nursing Research,63(1), 3–13. doi:10.1097/NNR.0000000000000012Palazzo, M. O. (2001). Teaching in crisis. Patient and family education in critical care.Critical CareClinics of North America, 13,83–92.Polster, D. (2015). Information: Tools for success.Nursing,45(5), 42–49.doi:10.1097/01.NURSE.0000463652.55908.75Riemer, H., Mates, J., Ryan, L., & Schleder, B. (2015). Decreased stress levels in nurses: A benefit ofquiet time.American Journal of Critical Care,24(5), 396–402. doi:10.4037/ajcc2015706Ritmala-Castren, M., Virtanen, I., Leivo, S., Kaukonen, K., & Leino-Kilpi, H. (2015). Sleep andnursing care activities in an intensive care unit.Nursing and Health Sciences,17, 354–361.doi:10.1111/nhs.12195Rust, G., Kondwani, K., Martinez, R., Dansie, R., Wong, W., Fry-Johnson, Y., . . . Strothers, H.(2006). A crash-course in cultural competence.Ethnicity and Disease, 16(2, suppl. 3), 29–36.Sendelbach, S., & Funk, M. (2013). Alarm fatigue, a patient safety concern.Advanced Critical Care,24(4), 378–386. doi:10.1097/NCI.0b013e3182a903f9Steele, S., & Harmon, V. (1983).Values clarification in nursing.Norwalk, CT: Appleton-CenturyCrofts.Zavotsky, K., McCoy, J., Bell, G., Haussman, K., Joiner, J., Marcoux, K., . . . & Tortajada, D. (2014).Resuscitation team perceptions of family presence during CPR.Advanced Emergency NursingJournal,36(4), 325–334. doi:10.1097/TME.0000000000000027IX.Suggestions for Classroom Activities•Ask each student to develop two study questions based on Kübler-Ross’sstagesofgrief. Usethese questions as part of an in-class review.•Ask students to pair offanddevelop a form of nonverbal communication.
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Class Notes for High-Acuity Nursing, 7th Edition - Page 29 preview image.•Having the correct learning environment for educating the acutely ill patient is crucial. Askstudents to list their concepts of the optimal learning environment.X.Suggestions for Clinical Activities•Discuss the implications of ensuring that patients report all complementary and alternativetherapies being used. How and where shouldthese therapies be documented?•During clinical, assign students to patients who are considered to be high acuity. During theclinical postconference, ask the students to determine which of Kübler-Ross’sstagesofgriefthepatient they cared for demonstrated.•Invite a massage therapist to visit with the clinical group. Ask the massage therapist to discuss theuse of massage for patients experiencing pain.
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Class Notes for High-Acuity Nursing, 7th Edition - Page 30 preview image.CHAPTER3Palliative and End-of-life CareObjectives:1.Examine the role of palliative care for the high-acuity patient and family.2.Identify ways the nurse can facilitate therapeutic communication for palliative care to help high-acuitypatients and their families cope with an illness and/or injury event.3.Describe the assessment and management of pain and other symptoms typically experienced byhigh-acuity patients.4.Discuss nursing competencies to provide high-acuity nursing care for patientsat the end of lifeandtheirfamilies, including bereavement services.5.Identify professional stressors, their impact on high-acuity nurses, and strategies to alleviatethose stressors.I.Palliative CarePalliative care should beoffered to patients early in the occurrences of a serious or life-threateningillness or injury or when emotional symptoms are interfering with treatment and/or quality of life.Unfortunately, palliative care is more likely to be suggested as patients move into the last stages ofillness. Palliative care should not be initiated because cure-oriented care is not considered appropriatebut instead should be offered as a comfort care approach. The high-acuity nurse provides care that iscomprehensive,including addressing the patient's physiological status, his comfort needs, and thecomfort needs of the patient's family.A.Defining Palliative Care1.Palliative care is an interdisciplinary approach to relieve suffering and improvequality of life.2.It isimportant for the high-acuitynurse to explain to patients and to theirfamilies that palliative care may be provided at the same time as medicaltreatment is directed toward a cure.3.TheNational Consensus Projects(NCP)Clinical Practice Guidelinesforquality palliative care advocatesstandardizingcare with the goal of improvingpalliative care. The NCP defines eight domains of palliative care:a)Structure and processes of careb)Physical aspects of carec)Psychological and psychiatric aspects of care
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Class Notes for High-Acuity Nursing, 7th Edition - Page 31 preview image.d)Social aspects of caree)Spiritual, religious, and existential aspects of caref)Cultural aspects of careg)Care of the patient at the end of lifeh)Ethical and legal aspects of careB.Palliative Care in High-Acuity Settings1.High-Acuity Patients and Palliative Carea)Unmet needs of dying patients and concerns about the cost of high-acuitycare and limited bed availability have fostered the growth of palliativecare in the hospital setting.b)Palliative care is a systematic approach to patient care in the ICUthatprovides an extra layer of support to critically ill patients and theirfamilies.c)The goal of palliative care is to improve quality of life through numerouscomponents provided by different services as well as the support of theorganization.2.Barriers to Providing Palliative Carea)Barriers to palliative care may stem from patients, families, and in somecases members of the healthcare teamhavinginflated expectations of theoutcomes of medical therapies.b)Barriers to the delivery of palliative care include misunderstandings,difficulties with initiating discussions regarding palliative care, and insome cases cultural issues.c)Excellent communication is necessary to provide patients with consistentand effective care including palliative care.d)Healthcare professionals must be educated and trained in all aspects ofpalliative care.e)Health professional education in palliative care should includelimitations of critical care therapies, embracing treatment goals that areattainable, and the benefits of palliative interventions.II.Communication and DecisionMakingA.Establishing goals of carefor the high-acuity patient receiving palliative care includes theinput of other team members for a multidisciplinary approach to formulating a plan tomeet the patient'spsychological, social, cultural, and spiritual needs.1.Use of the Quality and Safety Education for Nurses (QSEN) qualityimprovement care and communication bundle helps to standardize the timeframe in which the multidisciplinary teamcommunicates and administersparticular services.
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