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Class Notes for High-Acuity Nursing, 7th Edition

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    Instructor’s Resource Manual For High - Acuity Nursing 7 th Edition Kathleen Dorman Wagner, EdD, MSN, RN Faculty Emerita, University of Kentucky College of Nursing Melanie G. Hardin - Pierce, DNP, RN, APRN, ACNP - BC Associate Professor of Nursing, University of Kentucky College of Nursing Darlene Welsh, PhD, MSN, RN Associate Professor of Nursing, University of Kentucky College of Nursing Prepared by Maria Baptiste , MSN, CCRN - CMC, APRN - BC, NP - C

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    . CHAPTER 1 High - Acuity Nursing Objectives: 1. Discuss the various healthcare 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 that required close observation for effective use e) The advancement of renal transplant services f) The first ICUs were recovery rooms created for those postoperative patients who required extra equipment and prolonged observation . 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) or progressive care unit (PCU) (1) Developed to manage those patients who se acute illness requires less monitoring equipment and staffing than is provided in an ICU (2) Ability to manage patients with moderate or potentially severe physiological instability but who do not require artificial life support c) Medical – surgical acute care unit

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    . 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 healthcare providers , 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 but are limited in their ability to provide comprehensive care for all patients. D. Profile of the high - acuity nurse 1. Able to analyze clinical situations 2. Make s decisions based on analysis 3. Rapidly intervene s 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) Constant surveillance and monitoring to identify possible impending and life - threatening complications (1) Studies show that constant surveillance of patients by nurses reduces mortality and complications . II. Resource Allocation A. Nurse staffing 1. Nurse – patient ratios

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    . a) Many interrelated factors have led to a shortage of n urses able and willing to work with acutely ill patients. Factors linked to the nursing shortage include : (1) Hospital restructuring of nursing personnel reduced job satisfaction, which resulted 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 (5) Increase in access to health care as a result of the Affordable Care Act (6) Legislation to support registered nurse - to - patient ratios and other nurse – patient issues have been raised to the national level. 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 . d) The needs of the patient and the skill mix of the nursing staff must be considered 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 care under direct supervision of the professional nurse. g) The professional nurse uses leadership skills to safely and legally delegate tasks to the UAP. 2. Magnet s tatus: r ecruiting and r etaining n urses a) Magnet designation is a status awarded to hospitals that demonstrate success ful recruit ment and retention of professional nurses . b) Magnet hospitals promote environments meant to attract and ret ain professional nurses . c) Nurses who work at Magnet hospitals are more involved in decision making, report better relations with physicians, and have higher nurse - to - patient ratios. B. Decreasing resources, increasing care needs 1. Who Belongs in an ICU ? a) Deciding factors for ICU care are multifactorial and may include severity of injury, futility of treatment and informed refusal, the need to provide the quality of the dying and death experience, and family involvement. b) The assignment of patients to units requires a close review of available resources .

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    . c) 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 . d) Ethical, economic, and legal considerations must be addressed with regard 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, cost alone cannot be used to justify the use of healthcare resources. 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 unstable patient and can limit complications. 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 . 5. Nurses must be able to use technology but also recognize its limitations. B. Patient depersonalization 1. Difficulties arise when machines become the focus of care of the high - acuity patient . 2. Technology must be used to enhance care, not take the place of a nurse’s personal knowledge, observation skills, and senses. 3. 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. Alarm fatigue is one result of overload and overreliance on technology. 3. Support of patient well - being can be lost to the lure of technology. D. Finding a b alance 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 . 2. Appropriate training in the use of technology prevents technology from becoming the focus of care. 3. Nurses are at risk for becoming overly dependent on technology. IV. Healthy Work Environment

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    . 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 , burnout , and compassion fatigue 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 , managerial unresponsiveness, lack of team support b) Stress caused by exposure to patients experiencing pain and suffering c) Feelings of powerlessness d) Repeated exposure to pain and traumatic loss 3. Compassion fatigue describes the inability to reenergize because of the loss of compassion energy expended on others. a) Compassion fatigue results from stress nurses experience from daily relationships with patients and families. C. Coping with stress , burnout , and compassion fatigue 1. Factors that improve a nurse’s ability to cope with stress are a positive social climate, managerial support, and staff cohesiveness . 2. Critical incident stress d ebriefings (CISD) help to promote coping with special situations . 3. A sense of community allows the nurse the ability to share both stresses and joys . 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 . B. Patient safety

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    . 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) U sed to block incorrect medication orders; warn of drug interactions, allergies, and overdoses; provide current drug information; an d alert one to similar drug names b) The barcode medication administration (B CMA ) (1) A llows nurses to scan their badges and then the patient wristbands to access medications profiled for that specific patient c) Smartphones allow for text messaging, email retrieval, and the use of clinical apps 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. Performance standards, specialty certification, culture of respect and professionalism , and s trong physician – nurse relationships are among the factors that contribute to patient safety. VI. Clinical Reasoning Checkpoint Case 1: RM is a 64 - year - old with stage 4 metastatic colon cancer. She presents to the emergency department with shortness of breath. A chest x - ray reveals right lower lobe pneumonia. She is admitted 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 the Society of Critical Care Medicine ( SCCM ) prioritization model, identify the patient’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 of brain tumor is made , and surgery will be required. The healthcare provider (HCP) informs the patient that 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 be transferred. 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 that supports quality patient care and high levels of nurse satisfaction. You are aware of the six standards identified by AACN that are critical to creating and sustaining a healthy work environment.

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    . 4. Provide at least one example of how you might see each of the six standards operationalized in the high - acuity unit. VII. Post - Test / Chapter 1 Review Chapter 1 Question: ch01_01 Question : The ICU nurse receives a call from the medical – surgical unit requesting transfer of a patient to the ICU. The patient is in acute respiratory failure and requires mechanical ventilation. He will require vasoactive drugs to help manage his profound hypotension. Based on the S CCM prioritization model, what is this patient’s priority for ICU placement? Answer : 1. Priority 1 Rationale : 1. This patient is unstable and requires treatment and monitoring that cannot be provided outside the ICU (new mechanical ventilation and vasoactive infusions). This condition meets the criteria for Priority 1 admission. Chapter 1 Question: ch01_02 Question : A nurse is interviewing for a position in a community hospital. Hospital brochures describe a Level III ICU. Which statement describes the resources that the nurse would expect in this hospital? 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_03 Question : A hospital has been working to achieve Magnet status. Which statements by an ICU nurse reflect 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 their ownership of the decisions. 4. Improved nurse – patient ratios are a benefit of work toward Magnet status. Chapter 1 Question: ch01_04 Question : In the middle of a shift a nurse comes to the manager to discuss the acuity level and number of patients he has been assigned. Which statement would the manager interpret as indicating the 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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    . Rationale : 2. AACN and AMSN do not set recommended ratios. Chapter 1 Question: ch01_05 Question : New, fairly complex monitoring devices have been purchased to replace current monitors in 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 the monitor. Chapter 1 Question: ch01_06 Question : What is the best advice that an experienced ICU nurse can offer to new nurses on how to remain focused on the patient? Answer : 3. “Try to arrange equipment so that you have ample opportunity to use the power of your touch with the patient.” Rationale : 3. Touch helps to personalize the patient for the nurse. Touch also helps to reduce anxiety in the patient. Chapter 1 Question: ch01_07 Question : A coworker has become increasingly withdrawn from social activities on the unit. She is often late for work and is ambivalent about warnings from the nurse manager. She has become hostile and negative about proposed changes in the unit. The nurse should recognize that the coworker is exhibiting symptoms of which condition? Answer : 1. Burnout Rationale : 1. Ambivalence, withdrawal, hostility, and negativity are all symptoms of burnout. Chapter 1 Question: ch01_08 Question : The nurse manager has made a commitment to improve the health of the ICU work environment. 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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    . standards for a healthy work environment. 3. The manager should demonstrate and encourage authentic leadership, embracing healthy living and environmental strategies. 5. Skilled communication is one of the AACN standards for a healthy work environment. Chapter 1 Question: ch01_09 Question : The hospital is planning to implement a CPOE system. One of the nurses says, “I don’t see how that is going 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_10 Question : The high - acuity unit’s operations council is seeking suggestions concerning the use of technology to prevent errors on the unit. What statements by nurses are good responses to this request? (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. References Academy of Medical - Surgical Nurses (AMSN). (2011). Position statement: Staffing standards for patient care. Retrieved August 20, 2015, from http://www.amsn.org Aiken, L. (2014). Baccalaureate nurses and hospital outcomes: More evidence. Medical Care , 52 (10), 861 – 863. doi: 10.1097/MLR.0000000000000222 American Association of Critical - Care Nurses (AACN). (2005). AACN standards for establishing and sustaining 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 critically ill patients. Critical Care Medicine , 21 , 931 – 937. American College of Critical Care Medicine (ACCM). (1998). Guidelines on admission and discharge for adult intermediate care units. Critical Care Medicine , 26 (3), 608. American College of Critical Care Medicine (ACCM). (1999). Guidelines for intensive care unit admission, discharge, and triage. Critical Care Medicine , 27 (3), 633 – 638.

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    . American Nurses Association (ANA). (2005). Delegation: Joint ANA and National Council of State Boards of Nursing Position Statement. Retrieved August 20, 2015, from http://nursingworld.org Auerbach, D., Buerhaus, P., & Staiger, D. (2014). Registered nurses are delaying retirement, a shift that has contributed to recent growth in the nurse workforce. Health Affairs , 33 (8), 1474 – 1480. doi: 10.1377/hlthaff.2014.0128 Baker, M., Luce, J., & Bosslet, G. (2015). Integration of palliative care services in the intensive care unit. Clinics in Chest Medicine , 36 (3), 441 – 448. doi: 10.1016/ j.ccm.2015.05.010 Baldwin, M. R. (2015). Measuring and predicting long - term outcomes in older survivors of critical illness. Minerva Anestesiologica , 81 (6), 650 – 661. Bonafide, C., Lin, R., Zander, M., Graham, C., Paine, C., Rock, W., ... Keren, R. (2015). Association between exposure to nonactionable physiologic monitor alarms and response time in a children’s hospital. Journal of Hospital Medicine , 10 (6), 345 – 351. doi: 10.1002/jhm.2331 Boyle, D. (2015). Compassion fatigue: The cost of caring. Nursing , 45 (7), 48 – 51. doi: 10.1097/01. NURSE.000061857.48809.a1 Centers for Disease Control and Prevention. (2012). 2011 Guidelines for Field Triage of Injured Patients. Retrieved September 15, 2017, from https://stacks.cdc.gov/view/cdc/23038/Share Charles, K., Cannon, M., Hall, R., & Coustasse, A. (2014, Fall). Can utilizing a computerized provider 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.0000000000000123 Droogh, J., Smit, M., Absalom, A., Ligtenberg, J., & Zijlstra, J. (2015). Transferring the critically ill patient: Are we there yet? Critical Care , 19 (62). doi: 10.1186/ s13054 - 015 - 0749 - 4 Furness, N., Bradford, O., & Paterson, M. (2013). Tablets in trauma: Using mobile computing platforms to improve patient understanding and experience. Orthopedics , 36 (3), 205 – 208. doi: 10.3928/01477447 - 20130222 - 06 Haupt, M. T., Bekes, C. E., Carl, L. C., Gray, A. W., Jastremski, M. S., Naylor, D. F., ... Society of Critical Care Medicine. (2003). Guidelines on critical care services and personnel: Recommendations based 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. Emergency Nurse , 20 (10), 32 – 37.

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    . Henderson, J. (2015). The effect of hardiness education on hardiness and burnout on registered nurses. 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 in trauma nurses. Journal of Trauma Nursing , 21 (4), 160 – 169. doi: 10.1097/ JTN.0000000000000055 Institute of Medicine (IOM), Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Retrieved November 24, 2016, from https://www.nap. edu/read/10027/chapter/1 Kelly, L., Runge, J., & Spencer, C. (2015). Predictors of compassion fatigue and compassion satisfaction in acute care nurses. Journal of Nursing Scholarship , 47 (6), 522 – 528. doi: 10.1111/jnu.12162 Kostakou, E., Rovina, N., Kyriakopoulou, M., Koulouris, N. G., & Koutsoukou, A. (2014). Critically ill 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). The evolution and development of an instrument to measure essential professional nursing practices. Journal of Nursing Administration , 44 (11), 569 – 576. doi: 10.1097/ NNA.0000000000000128 Kramer, M., Schmalenberg, C., & Maguire, P. (2010). Nine structures and leadership practices essential 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 in patient and nurse outcomes associated with magnet hospital recognition. Medical Care , 53 (6), 550 – 557. doi: 10.1097/ MLR.0000000000000355 Maresca, R., Eggenberger, T., Moffa , C., & Newman, D. (2015). Lessons learned: Accessing the voice of nurses to improve a novice nurse program. Journal for Nurses in Professional Development , 31 (4), 218 – 224. doi: 10.1097/ NND.0000000000000169 McHugh, 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 - x Meyer, M. (2003). Avoid PCU bottlenecks with proper admission and discharge criteria. Critical Care Nurse , 23 (3), 59 – 63. Mick, D. J., & Ackerman, M. H. (2004). Critical care nursing for older adults: Pathophysiological and functional considerations. Nursing Clinics of North America , 39 (3), 473 – 493. Ñamendys - Silva, S., Plata - Menchaca, E., Rivero - Sigarroa, E., & Herrera - Gómez, A. (2015). Opening the doors of the intensive care unit to cancer patients: A current perspective. World Journal of

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    . Critical Care Medicine , 4 (3), 159 – 162. doi: 10.5492/wjccm.v4.i3.159 Oerlemans, A., Van Sluisveld, N., Van Leeuwen, E., Wollersheim H., Dekkers, W., & Zegers, M. (2015). Ethical problems in intensive care unit admission and discharge decisions: A qualitative study among physicians and nurses in the Netherlands. BMC Medical Ethics , 16 (9), 1 – 10. doi: 10.1186/s12910 - 015 - 0001 - 4 Pattison, J., & Kline, T. (2015). Facilitating a just and trusting culture. International Journal of Health Care Quality Assurance , 28 (1), 11 – 26. doi: 10.1108/ IJHCQA - 05 - 2013 - 0055 Peigne, 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 administrative database. Annals of Intensive Care , 6 (7), 1 – 8. doi: 10.1186/s13613 - 016 - 0107 - y Riemer, H., Mates, J., Ryan, L., & Schleder, B. (2015). Decreased stress levels in nurses: A benefit of quiet oi: 10.4037/ajcc2015706 Rubin R. (2015). Bill takes aim at nationwide shortage of nurses. Journal of the American Medical Association , 313 (18), 1787. doi:10.1001/jama.2015.3747 Rubin , R. (2015). Bill takes aim at nationwide shortage of nurses. Journal of the American Medical Association, 313 (18), 1787. doi:10.1001/jama.2015.3747 Sabzevari, S., Mirzaei, T., Bagherian, B., & Iranpour, M. (2015). Critical care nurses’ attitudes about influences of technology on nursing care. British Journal of Medicine & Medical Research , 9 (8), 1 – 10. doi: 10.9734/ BJMMR/2015/18400 Seibert, H., Maddox, R., Flynn, E., & Williams, C. (2014). Effect of barcode technology with electronic medication administration record on medication accuracy rates. American Journal of Health - System Pharmacy , 71 , 209 – 218. Sendelbach, S., Wahl, S., Anthony, A., & Shotts , P. (2015). Stop the noise: A quality improvement project to decrease electrocardiographic nuisance alarms. Critical Care Nurse , 35 (4), 15 – 23. doi: 10.4037/ccn2015858 Sim, Y., Jung, H., Shin, T., Kim, D., & Park, S. (2015). Mortality and outcomes in very elderly patients 90 years of age or older admitted to the ICU. Respiratory Care , 60 (3), 347 – 355. doi: 10.4187/respcare.03155 The Joint Commission. (2015). National Patient Safety Goals Effective January 1, 2015. Retrieved November 21, 2016, from http://www.jointcommission.org/ assets/1/6/2015_NPSG_HAP.pdf Ulrich, B., & Kear, T. (2014). Patient safety and patient safety culture: Foundations of excellent health 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 by year. Retrieved November 19, 2016, from http://www.hhs.gov/ healthcare/facts/timeline/timeline -

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    . text.html Van Sluisveld, N., Zegers, M., Westert, G., Van der Hoeven, J., & Wollersheim, H. (2013). A strategy to enhance the safety and efficiency of handovers of ICU patients: Study protocol of the pICUp study. Implementation Science 2013 , 8 (67). doi:10.1186/1748 - 5908 - 8 - 67 West, 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 of Nursing Studies , 51 , 781 – 794. doi: 10.1016/j.ijnurstu.2014.02.007 White, 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.12845 Whittingham, K., & Oldroyd, L. (2014). Using an SBAR — Keeping it real! Demonstrating how improving safe care delivery has been incorporated into a top - up degree programme. Nurse Education Today , 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 polytrauma injury variable predicts mortality better than the New Injury Severity Score and the Injury Severity Score: A retrospective cohort study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine , 24 (25), 1 – 11. doi: 10.1186/ s13049 - 016 - 0215 - 6 IX. Suggestions for Classroom Activities • Develop three to four patient scenarios. Lead a class discussion as to whether the patients being referenced are suitable for 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 . • Ask students to identify behaviors associated with professional burnout. Lead the discussion on recognizing burnout and coping with the high - acuity nursing environment. X. Suggestions for Clinical Activities • During the clinical postconference, 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 .

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    . CHAPTER 2 Holistic Care of the Patient and Family Objectives: 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 it relates 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 alleviate those stressors. I. Impact of Acute Illness on Patient and Family A. Kübler - Ross’s Stages of Grief 1. Illnesses can cause the patient and family to experience loss of health, loss of limb, disfigurement, or necessary change in lifestyle that may alter the patient’s self - image and self - esteem. Patients may respond to losses in certain predictable phases. According to Kübler - Ross and Kessler , these stages of grief are: 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 considerations 1. 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 nuclear family. 3. High - acuity units are now more inclusive family environments. 4. Patients need information, comfort, support, assurance, and accessibility.

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    . 5. Proactive communication in the form of family meetings beginning early in the patient’s ICU stay contributes to family - centered plan of care. II. Coping with Acute Illness A. Complementary and Alternative Therapies (CAT) 1. Numerous strategies are used to help patients cope with psychological and physical illness – related stressors. Complementary and alternative therapies that can help reduce stress include: a) Aromatherapy (1) Use of oils to reduce stress and anxiety. Oils may be inhaled and used to enhance 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. III. Patient - and Family - centered Care A. Educational needs of patients and families 1. Health literacy a) Health literacy is the degree to which patients and families have the ability to obtain, process, and understand basic health information to make informed decisions about their healthcare. b) Health literacy includes the ability to: (1) C ommunicate with members of the health team (2) C omplet e complex forms

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    . (3) U nderstand concepts related to risks . c) Some groups at risk for low levels of health literacy include: patients older than 65 years of age, members of minority groups, immigrants, those of a lower socioeconomic status, or those suffering from chronic illnesses. 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 and care (6) Motivation f) The nurse should use return demonstration and teach - back techniques to supplement patient and family education as appropriate . 2. Transfer anxiety a) Transfer anxiety is the mixed - emotional experience of the patient and family as the patient is transferred from a secure to an unfamiliar environment. b) A plan of care allowing the patient and family to ask questions will promote 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 transfer 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. Historically, family members have been restricted from their loved ones during invasive procedures and cardiopulmonary resuscitation:

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    . a) Studies reveal that many facilities do not have policies restricting family presence during CPR. b) Benefits of family presence during CPR include: (1) Increas ing family 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 of posttraumatic stress disorder . 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. IV. Cultural Diversity A. Cultural competence 1. Cultural Assessment a) Knowledge of a patient’s cultural background is required to provide excellent care. b) The nurse should observe or ask culture - specific questions in order to understand the patient’s culture. c) The nurse should be aware of possible hindrances to communication including interpretation and speech. (1) The nurse should use short units of speech. (2) Simple language (3) Observe for nonverbal cues 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

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    . 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 . V. Environmental Stressors A. Sensory – perceptual alterations (SPA) 1. Sensory overload and deprivation a) Sensory overload occurs when patient is exposed to noise for continuous periods. b) Excessive noise affects the patient’s as well as the nurse’s physical and physiological state , contributing to caregiver stress and delivery of quality patient care. c) The World Health Organization recommends that in a patient’s room noise level should not exceed 35 dBA. 2. Delirium a) Delirium involves an acute onset of fluctuating awareness, impaired ability 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 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. 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 alterations 1. Prevent sleep deprivation a) Two hours of uninterrupted sleep is necessary to promote rapid eye movement ( REM ) , which promote s protein anabolism, restores the immune system, and promote s healing. 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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    . (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 quiet time . 2. Facilitate communications a) Communication with mechanically ventilated patients is needed to prevent SPA. b) Nonverbal behaviors will vary and must be closely reviewed for messages. (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 provide a means of communication appropriate to the patient’s ability such as large markers or pens, an alpha board, or using a coded eye - blink system . VI. Clinical Reasoning Checkpoint This values clarification exercise is designed to help the learner explore personal values in relation to the profession of nursing and bioethical issues. By reflecting on personal values, we gain a better understanding of what factors may limit our ability to reason clearly and of when we may not be suitable for the role of patient advocate . Values Clarification Exercise Directions: 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 what has 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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    . _____ 9. Children should participate in human experimentation that is not harmful even if it is of no benefit 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 their families through court action. _____ 13. Research using fetuses should be pursued vigorously. _____ 14. Life - support systems should be discontinued after several days of flat electroencephalograms. _____ 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 a humane way. _____ 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 developed countries. _____ 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 of medical practice. _____ 29. The nurse’s primary role in decision making on ethical issues is to implement the selected alternative. _____ 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 modification therapy to make them conform to societal norms. _____ 33. Personal possessions of patients should be removed to guarantee safekeeping during hospitalization. _____ 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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    . _____ 39. As a nurse, I should value responsibility. _____ 40. Nurses have a right to withhold information to facilitate nursing research on human subjects. _____ 41. The patient who refuses treatment should be dropped from the health supervision of an agency or professional. _____ 42. Transplantations should be done whenever needed. Personal Application 1. Add the number of 1s, 2s, 3s, 4s, and 5s that you have. 2. How many statements do you have clear ideas (1s and 5s) 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 the statements 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 these statements that influenced your responses? 6. Analyze the following cluster of statements. Is there any consistency in the way you rated these statements? What variables influenced your decision? Cluster 5, 8, 14, 25, 30 : Relates to issues pertaining to death Cluster 3, 4, 16, 17, 22, 27, 28, 29, 38 : Relates to the profession of nursing Cluster 2, 6, 14, 36, 37, 42 : Relates to issues raised by advanced technology Cluster 1, 7, 9, 12, 20, 31 : Relates to children Cluster 9, 10, 13, 40 : Relates to human experimentation Cluster 3, 7, 8, 11, 12, 18, 19, 21, 24, 25, 33, 34, 35, 38, 41 : Relates to patients’ rights Cluster 9, 10, 24, 26, 32, 37 : Relates to society’s rights Cluster 15, 23, 36 : Relates to allocation of resources Cluster 3, 4, 17, 18, 19, 22, 27, 29, 39 : Relates to perceptions of obligations VII. Post - Test / Chapter 2 Review Chapter 2 Question: ch02_01 Question: 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 this situation as a sign that the client is in which stage of grief ? Answer: 3. Depression Answer: 3 Rationale: 3. In the depression phase , the client may be sad and have frequent crying episodes. Fears about the future are revealed.

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    . Chapter 2 Question: ch02_02 Question: A client was recently admitted to the ICU after a myocardial infarction. The family wants to meet with the nurse. The nurse prepares for this meeting with the knowledge that at this stage of illness the family most needs which things? Select all that apply. Answer: 1. Frequent updates on the client’s condition 2. Rationale for interventions being started Rationale: 1. The communication between those providing care and the family is of primary importance. The family 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. Many interventions are frightening, and rationales help the family to cope. Chapter 2 Question: ch02_03 Question: The nurse is considering use of a complementary and alternative therapy (CAT) to help a client cope with the pain associated with burn treatment. The nurse designs this plan with full consideration that which CAT is a risky strategy? Answer: 1. Humor Rationale: 1. Humor is a very individual perception and is not thought to be appropriate during critical illness by some clients or nurses. When it is thoughtfully used, it can be very helpful as distraction. Chapter 2 Question: ch02_04 Question: High - acuity clients have a right to know and understand what procedures are being done to and 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 stress 2. To promote the client ’s comfort Rationale: 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_05 Question: The nurse is conducting an admission assessment on a client who is an immigrant to the United 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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    . 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 presence by asking sensitive questions. 5. The nurse must be self - aware. Chapter 2 Question: ch02_06 Question: A client has been an active participant in all aspects of hospitalization. This morning the client seems confused and has difficulty completing a form documenting consent to a procedure to be done 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 frequent etiology for delirium. 4. Clients who are depressed may have a decline in health literacy and may show signs of delirium. Chapter 2 Question: ch02_07 Question: A 79 - year - old client had a colon resection with colostomy 2 days ago for adenocarcinoma. She has had a patient - controlled analgesia pump for pain management. Since yesterday she has become 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 exhibiting symptoms of which condition? Answer: 1. Delirium Rationale: 1. Delirium is a sensory – perceptual alteration that can occur in high - acuity clients. It is more likely in older clients and is often preceded by increasing anxiety and agitation. Chapter 2 Question: ch02_08 Question: The hospital supports open visitation throughout the facility. Family members visiting in the coronary care unit have been noisy and disruptive even after being asked to keep down the level of 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 others and do not modify behavior when asked, they should be asked to leave the unit. Chapter 2 Question: ch02_09 Question: A client in the ICU speaks only broken English. The nurse has been unsuccessful in understanding the client , and it is apparent the client does not understand the nurse. How should the nurse proceed?

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    . 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_10 Question: A client has developed confusion while in the ICU. Medical reasons for the confusion have been ruled out and a diagnosis of sensory – perceptual alterations made. What should the nurse tell 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. References Agency for Healthcare Research and Quality (AHRQ). (2013). Guide to patient and family engagement in hospital quality and safety. Retrieved October 7, 2015, from http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/index.html Allen, D. (2014). Laughter really can be the best medicine. Nursing Standard , 28 (32), 24 – 25. doi:10.7748/ns2014.04.28.32.24.s28 American Nurses Association (ANA). (2015). Code of ethics for nurses. Retrieved January 11, 2017, from http://www.nursingworld.org/codeofethics Andrews, L., Silva, S., Kaplan, S., & Zimbro, K. (2015). Delirium monitoring and patient outcomes in a general intensive care unit. American Journal of Critical Care , 24 (1), 48 – 56. doi:10.4037/ajcc2015740 Berglund, B., Lindvall, T., & Schwela, D. H. (1999). Guidelines for community noise. Retrieved January 11, 2017, from http://apps.who.int/iris/handle/10665/66217 Burhenn, 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 - 503 Chevillon, C., Hellyar, M., Madani, C., Kerr, K., & Kim, S. (2015). Preoperative education on postoperative delirium, anxiety, and knowledge in pulmonary thromboendarterectomy clients, American Journal of Critical Care , 24 (2), 164 – 171. doi:10.4037/ajcc2015658 Crider, J., & Pate, M. (2011). Helping children say goodbye to loved ones in adult and pediatric intensive care units: Certified child life specialist – critical care nurse partnership. AACN Advanced Critical Care, 22 (2), 109 – 112.

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    . 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. Dimensions of Critical Care Nursing , 32 (5), 244 – 261. doi:10.1097/DCC.0b013e3182a07646 Ernst, E., Pittler, M., & Wider, B. (Eds.). (2006). The desktop guide to complementary and alternative medicine: 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.0000000000000128 Gay, 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.0000434515.58265.7d Hart, P., & Mareno, M. (2013). Cultural challenges and barriers through the voices of nurses. Journal of Clinical Nursing , 23 , 2223 – 2233. doi:10.1111/jocn.12500 Ingram, R., & Kautz, D. (2012). When the patient and family just do not get it: Overcoming low health literacy in critical care. Dimensions of Critical Care Nursing , 3 (1), 25 – 30. doi:10.1097/DCC.0b013e31823a5471 Institute for Patient - and Family - Centered Care. (n.d.). Core concepts of patient - and family - centered care. Retrieved November 28, 2016, from http://www.ipfcc.org/pdf/CoreConcepts.pdf Karadag, E., Samancioglu, S., Ozden, D., & Bakir, E. (2015). Effects of aromatherapy on sleep quality and anxiety of clients. Nursing in Critical Care , 20 (5), 1 – 8. doi:10.1111/nicc.12198 Kodali, S., Stametz, R., Bengier, A., Clarke, D., Layon, A., & Darer, J. (2014). Family experience with 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.2014.03.012 Kramlich, D. (2014). Introduction to complementary, alternative and traditional therapies. Critical Care Nurse , 34 (6), 50 – 56. doi:10.4037/ccn2014807 Kübler - Ross, E. K., & Kessler, D. (2005). On grief and grieving: Finding the meaning of grief through the five stages of loss. New York, NY: Scribner. Lipson, J., Dibble, S., & Minarik, P. (Eds.). (2001). Culture & nursing care: A pocket guide. San Francisco, CA: UCSF Nursing Press.

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    . 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 - 5820.2014.07.01 Martorella, G., Boitor, M., Michaud, C., & Gélinas, C. (2014). Feasibility and acceptability of hand massage therapy for pain management of postoperative cardiac surgery clients in the intensive care unit. Heart & Lung , 43 (5), 437 – 444. doi:10.1016/j.hrtlng.2014.06.047 Mattox, E. (2010). Identifying vulnerable patients at heightened risk for medical error. Critical Care Nurse, 30 (2), 61 – 69. Nilsen, M., Happ, M., Donovan, H., Barnato, A., Hoffman, L., & Sereika, S. (2014). Adaptation of a communication interaction behavior instrument for use in mechanically ventilated, nonvocal older adults. Nursing Research , 63 (1), 3 – 13. doi:10.1097/NNR.0000000000000012 Palazzo, M. O. (2001). Teaching in crisis. Patient and family education in critical care. Critical Care Clinics of North America, 13, 83 – 92. Polster, D. (2015). Information: Tools for success. Nursing , 45 (5), 42 – 49. doi:10.1097/01.NURSE.0000463652.55908.75 Riemer, H., Mates, J., Ryan, L., & Schleder, B. (2015). Decreased stress levels in nurses: A benefit of quiet time. American Journal of Critical Care , 24 (5), 396 – 402. doi:10.4037/ajcc2015706 Ritmala - Castren, M., Virtanen, I., Leivo, S., Kaukonen, K., & Leino - Kilpi, H. (2015). Sleep and nursing care activities in an intensive care unit. Nursing and Health Sciences , 17 , 354 – 361. doi:10.1111/nhs.12195 Rust, 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.0b013e3182a903f9 Steele, S., & Harmon, V. (1983). Values clarification in nursing. Norwalk, CT: Appleton - Century Crofts. 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 Nursing Journal , 36 (4), 325 – 334. doi:10.1097/TME.0000000000000027 IX. Suggestions for Classroom Activities • Ask each student to develop two study questions based on Kü bler - Ross’s s tages of g rief . Use these questions as part of an in - class review . • Ask students to pair off and develop a form of nonverbal communication .

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    . • Having the correct learning environment for educating the acutely ill patient is crucial. Ask students 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 alternative therapies being used. How and where should these therapies be documented ? • During clinical, assign students to patients who are considered to be high acuity. During the clinical postconference, ask the students to determine which of Kübler - Ross’s s tages of g rief the patient they cared for demonstrated . • Invite a massage therapist to visit with the clinical group. Ask the massage therapist to discuss the use of massage for patients experiencing pain .

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    . CHAPTER 3 Palliative and End - of - life Care Objectives: 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 - acuity patients and their families cope with an illness and/or injury event . 3. Describe the assessment and management of pain and other symptoms typically experienced by high - acuity patients . 4. Discuss nursing competencies to provide high - acuity nursing care for patients at the end of life and their families, including bereavement services . 5. Identify professional stressors, their impact on high - acuity nurses, and strategies to alleviate those stressors . I. Palliative Care P alliative care should be offered to patients early in the occurrences of a serious or life - threatening illness 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 of illness. Palliative care should not be initiated because cure - oriented care is not considered appropriate but instead should be offered as a comfort care approach. The high - acuity nurse provides care that is comprehensive , includin g addressing the patient's physiological status, his comfort needs, and the comfort needs of the patient's family. A. Defining Palliative Care 1. Palliative care is an interdisciplinary approach to relieve suffering and improve quality of life . 2. It is important for the high - acuity nurse to explain to patients and to their families that palliative care may be provided at the same time as medical treatment is directed toward a cure . 3. The National Consensus Projects (NCP) Clinical Practice Guidelines for quality palliative care advocates standardizing care with the goal of improving palliative care. The NCP defines eight domains of palliative care : a) S tructure and processes of care b) Physical aspects of care c) P sychological and psychiatric aspects of care

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    . d) S ocial aspects of care e) S piritual, religious, and existential aspects of care f) C ultural aspects of care g) C are of the patient at the end of life h) E thical and legal aspects of care B. Palliative Care in High - Acuity Settings 1. High - Acuity Patients and Palliative Care a) Unmet needs of dying patients and concerns about the cost of high - acuity care and limited bed availability have fostered the growth of palliative care in the hospital setting. b) Palliative care is a systematic approach to patient care in the ICU that provides an extra layer of support to critically ill patients and their families. c) The goal of palliative care is to improve quality of life through numerous components provided by different services as well as the support of the organization. 2. Barriers to Providing Palliative Care a) Barriers to palliative care may stem from patients, families, and in some cases members of the healthcare team having inflated expectations of the outcomes of medical therapies. b) Barriers to the delivery of palliative care include misunderstandings, difficulties with initiating discussions regarding palliative care, and in some cases cultural issues. c) Excellent communication is necessary to provide patients with consistent and effective care including palliative care. d) Healthcare professionals must be educated and trained in all aspects of palliative care. e) Health professional education in palliative care should include limitations of critical care therapies, embracing treatment goals that are attainable, and the benefits of palliative interventions. II. Communication and Decision Making A. Establishing goals of care for the high - acuity patient receiving palliative care includes the input of other team members for a multidisciplinary approach to formulating a plan to meet the patient's psychological, social, cultural, and spiritual needs. 1. Use of the Quality and Safety Education for Nurses (QSEN) quality improvement care and communication bundle helps to standardize the time frame in which the multidisciplinary team communicates and administers particular services.

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