NURSING CARE OF CLIENTS WITH LIFE-THREATENING CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION

The structure of CCN is a complex, challenging area of nursing practice. In keeping with the six core standards of nursing practice described by the American Nurses Association (ANA), CCN employs the nursing process, which, according to the ANA, is the "essential core of practice for the registered nurse"

The Nursing Process

• Collection of data, both subjective and objective

• Gathering of psychosocial, physical, spiritual, economic, and lifestyle factors by:

1. Interviewing the patient and/or family members

2. Reviewing past medical history and records

3. Completing a physical examination and reviewing current patient data.

Assessment

• In the critical care setting, traditional methods of assessment which include a complete evaluation of the patient's history and a comprehensive physical examinations of all body systems may not be possible since the patient may be experiencing life-threatening problems during admission.

• Hence, a specific assessment approach that recognizes the complexities of the nature of critical illness will be presented. This approach puts emphasis on the collection of assessment data in phases consistent with patient care priorities and can be used as a generic template for assessing most critically ill patients and families.

Assessment

• What is important is developing competence in assessing critically ill patients and their families in a consistent and systematic approach. This way, we do not miss out on subtle signs or details that may point to an actual or potential problem or change in patient status.

• Take note, assessments focus first on the patient, then on the technology.
  Technology is there to augment information obtained from direct assessment of the patient.

• Two standard approaches to assessing patients: the head-to-toe approach and the body systems approach. Most critical care nurses use a combination of the two - a systems approach applied in a "top-to-bottom" manner.

Assessment

• This assessment is a quick overview of the adequacy of ventilation and perfusion to ensure early intervention for any life-threatening situations

• Focus is also on exploring the chief complaint and obtaining essential diagnostic tests to supplement and support physical assessment findings.

Assessment

• This assessment is done as soon as possible, with the timing determined by the degree of physiologic stability and emergent treatment needs of the patient.

• If the patient is being admitted directly to the intensive care unit (ICU) from outside the hospital, the comprehensive assessment is an in- depth assessment of the past medical and social history and a complete physical examination of each body system,

• If the patient is being transferred to the ICU from within the hospital, the comprehensive assessment includes a review of the admission assessment data and comparison to the current state of the patient.

• This assessment is vital to successful outcomes for the patient as it provides valuable insight into proactive interventions that maybe needed.

Comprehensive Initial Assessment

• Ongoing assessments, which are an abbreviated version of the comprehensive initial assessment, are performed at varying intervals according to unit protocol and the individual needs of the patient

• a patient is unable to cooperate in terms of supplying information needed for assessment, other sources may be used instead.

• These include: family members or friends; electronic health records (EHRs) or electronic medical records (EMRs); past medical records; transport record; or information from the patient's belongings.

Ongoing Assessment

• It is also imperative, that upon admission, accurate patient identification must be obtained, including past medical history, especially any known allergies.

• Careful physical assessment on admission to the critical care unit is pivotal in the prevention and/or early treatment for complications associated with critical illness.

Assessment

• Abbreviated report on patient (age, gender, chief complaint, diagnosis, pertinent history, physiologic status. invasive devices, equipment and status of laboratory/diagnostic tests)

• Allergies

• Complete verification of setup, proper including equipment functioning

• Do Not Resuscitate (DNR) Status

• Isolation Status

Prearrival Assessment

• General appearance (consciousness)

• Airway

• Breathing

• Circulation and Cerebral Perfusion

• Chief Complaint

• Drugs and Diagnostic Tests

• Equipment

Admission Quick Check Assessment

• Offer realistic hope

• Give honest answers and information

• Give reassurance

Quick Assessment

• Use open-ended communication and assess their communication style

• Assess family members' level of anxiety

• Assess perceptions of the situation (knowledge, comprehension, expectations of staff, expected outcomes)

• Assess family roles and dynamics (cultural and religious practices, values, spokesperson)

• Assess coping mechanisms and resources (what do they use, social network and support)

Comprehensive Assessment

• Past Medical History

• Medical conditions, surgical procedures

• Psychiatric/emotional problems

• Hospitalizations

• Medications (prescription, over-the-counter, illicit drugs) and time of last medication dose Allergies

• Review of history by body system

SUMMARY OF COMPREHENSIVE ADMISSION ASSESSMENT REQUIREMENTS

• Age, gender, and self-identified gender

• Ethnic origin

• Height, weight

• Highest educational level completed

• Preferred language

• Occupation

• Marital status

• Primary family members/significant others/decision makers

• Religious affiliation

• Advance Directive, Durable Power of Attorney for Health Care, Medical Orders for Life-Sustaining Treatment (MOIST) / Substance use/abuse (alcohol, illicit or prescription drugs, caffeine, tobacco

• Domestic abuse or vulnerable adult sereen

Social History

• General communication

• Coping styles

• Anxiety and stress

• Expectations of critical care unit

• Current stresses

• Family needs

Psychosocial Assessment

• Faith/spiritual preference

• Healing practices

Spirituality

• Nervous system

• Cardiovascular svstem

• Respiratory system

• Renal system

• Gastrointestinal system

• Endocrine, hematologic, and immune systems

• Integumentary system

Physical Assessment

• Analysis of the data garnered to determine the nursing diagnosis

• Basis on which the nursing care plan is developed. The nursing diagnosis is the nurse's clinical judgment regarding the patient's response to actual or possible medical problems. It is based on the assessment.

Analysis/Diagnosis

• Physiologic instability

• Venous thromboembolism (VTE)

• Hospital-acquired infections

• Pressure Injury

• Sleep pattern disturbance

• Psychosocial impact (delirium, anxiety, depression)

most common complications

• Perform ongoing assessments and monitoring of critically ill patients to immediately identify physiologic changes and to ensure that the patient is progressing toward identified patient outcomes.

Physiologic instability

• Avoid placing intravenous access in the groin site or lower limbs as this limits mobility and may impede blood flow and can therefore increase the risk for VTE

• Ensure adequate hydration.

• Administer low-dose heparin as prescribed as a preventive measure.

Venous thromboembolism (VTE)

• In general, ICUs have the highest incidence of hospital-acquired infections because of the multiple invasive devices and constant presence of debilitating underlying diseases.

• Standard precautions, aka universal precautions" or "body substance isolation" must be observed and practiced.

• Maintaining blood sugar levels for both diabetic and non-diabetic patients may reduce the risk of the patient developing an infection.

• Replace peripheral IVilines as recommended by the Centers of Disease Control and Prevention (CDC). These lines should not remain in place for longer than 72 to 96 hours.

• Exception to this rule is the tubings for blood, blood products, or lipid-based products as these have their own criteria for when they are to be changed.

Hospital-acquired infections

• A major risk in critically ill patients is pressure injury. This is due to immobility, poor nutrition, invasive lines, surgical sites, poor circulation, edema, and incontinence issues. Pressure injuries may start developing in as little as two hours.

• Interventions include: reposition the patient at least every two hours; use pressure-reduction mattresses; elevate heels off the bed with pillows under the calves or use heel protectors; elbow pads may also be used; use a skin care protocol with ointment barriers, especially for patients who are incontinent.

Pressure Injury

• The skin is intact but shows a localized, persistent red area that does not turn white when pressed.

• In darker skin tones, the discoloration may appear blue, purple, or different from the surrounding skin.

Stage 1: Non-blanchable erythema

The top layer of skin (epidermis) is damaged or broken, creating a shallow, open sore or a ruptured/intact blister. The wound bed is usually red or pink

Stage 2: Partial-thickness skin loss

• The ulcer extends through all skin layers into the fatty (subcutaneous) tissue.

• Fat is visible, but underlying muscle, tendon, or bone are not exposed

Stage 3: Full-thickness skin loss

• The deepest stage, exposing muscle, bone, ligaments, or tendons.

• Dead tissue (eschar or slough) and tunneling under the skin are common

Stage 4): Full-thickness tissue loss

The full extent of the tissue damage is obscured by dead tissue (yellow/stringy slough or brown/black eschar). The true stage cannot be determined until this dead tissue is removed.

Unstageable Pressure Ulcer

are categorized into six stages based on tissue damage. As defined by the National Pressure Injury Advisory Panel (NPIAP), the categories range from mild skin redness to deep tissue destruction.

Pressure ulcers (bedsores)

An area of intact or non-intact skin that appears purple, maroon, or a deep red, or presents as a blood-filled blister. This indicates severe damage to the soft tissue beneath the skin, which can rapidly progress into a Category 3 or 4 ulcer.

Deep Tissue Injury (DTI)

• Metabolic changes

• Underlying diseases (e.g., cardiovascular disease, chronic obstructive pulmonary disease [COPD], dementia)

• Pain

• Anxiety fear

• Delirium

Illness

• Analgesics

• Antidepressants

• Beta-blockers

• Bronchodilators

• Benzodiazepines

• Corticosteroids

Medications

• Noise

• Staff conversations

• Television/radio

• Equipment alarms

• Frequent care interruptions

• Lighting

• Lack of usual bedtime routine

• Room temperature

• Uncomfortable sleep surface

Environment

• Knowledge of how the above factors affect the patient's sleep will help nurse know what areas to address toenhance or improve the critically ill patient's sleep.

• Instituting a nighttime sleep protocol where patients are untouched but still closely monitored from 1 to 5 AM is one way to eliminate hourly disturbances to the patient.

Implementation of Care

• Assess patient's usual sleep patterns

• Minimize effects of underlying disease process as much as possible (e.g., reduce fever, eliminate pain, and minimize metabolic disturbances)

• Avoid disturb sleep patterns

• Consult with providers to continue behavioral medications as appropriate

• Mimic patients' usual bedtime routine as much as possible

• Minimize environmental impact on sleep as much as possible

• Utilize complementary therapies promote sleep as appropriate

EVIDENCE-BASED PRACTICE: SLEEP PROMOTION IN CRITICAL CARE

• A condition called Post-Intensive Care Syndrome (PICS) may result in survivors and their family members where signs of posttraumatic stress disorder (PTSD) may be exhibited. This results from the time spent by the patient and family in the ICU. PICS can have long-term physical, mental, and cognitive changes that may impact the patient and their family for years after the illness.

Psychosocial impact (delirium, anxiety, depression)

A. Keep stressors to a minimum.

B. Encourage family participation in care

C. Promote a proper sleep-wake cycle

D. Encourage communication, questions, and honest and positive feedback.

E. Empower the patient to participate in decisions as appropriate

F. Provide patient and family education about unit expectations and rules, procedures, medications, and the patient's physical condition

G.Ensure pain relief and comfort

H. Provide continuity for care providers.

I. Make available the patient's usual sensory and physical aids, such as glasses, hearing aids, dentures, as these may help prevent confusion.

How to maintain psychological integrity during and after a critical illness:

• This may be evidenced by disorientation, confusion, perceptual disturbances, restlessness, distractibility, and sleep-wake cycle

disturbances.

• It is most commonly seen in postsurgical and elderly patients and is the most common cause of disruptive behavior in the critically ill.

Delirium

(a first-generation antipsychotic drug used to treat severe nausea and vomiting, as well as short-term management of psychotic disorders)

Prochlorperazine

(an anti-histamine with anticholinergic [drying] and sedative side effects)

Diphenhydramine

(histamine H2 receptor antagonist medication that decreases stomach acid production)

Famotidine

(substances that act on opioid receptors to produce morphine-like effects)

Benzodiazepines

(substances that act on opioid receptors to produce morphine-like effects)

Opiods

(group of pharmaceuticals that are used to suppress abnormal rhythms of the heart, such as atrial fibrillation, atrial flutter, ventricular tachycardia, and ventricular fibrillation

Antiarrhythmic medications

is a fast, validated bedside tool used by nurses and doctors to screen adult patients in the ICU for delirium. It takes about 1 to 2 minutes and works even for patients who are non-verbal or on breathing machines.

The CAM-ICU (Confusion Assessment Method for the Intensive Care Unit)

• What may predispose the critically ill patient to depression are: social isolation, recent loss, pessimism, financial pressures, history of mood disorder, alcohol or substance abuse/withdrawal, previous suicide attempts, and pain.

• It is important to educate the patient and family that most depressions that result during critical illness is not unusual and may be only temporary.

• If the family or patient have negative distortions about the illness and treatment, it is wise to correct, clarify, and reassure with realistic information to promote a more hopeful outcome.

• If you suspect the patient may be suicidal, do clarify with the patient. Oftentimes, when the patient communicates he is feeling suicidal it is a cover for wanting to discuss fear, pain, or loneliness.

• For further evaluation and intervention, a psychiatric referral is in order.

Depression

• Anxiety and panic-like symptoms can result from medical disorders and can cause distress to the patient and family, which may exacerbate the medical condition.

• Applying both pharmacologic and non-pharmacologic interventions may alleviate the problem

• The goals of pharmacologic therapy are to titrate the drug dose to maintain the patient's cognition and ability to interact with the people around them, to complement pain control, and to assist in promoting sleep.

• Non-pharmacologic interventions to decrease or control anxiety include breathing techniques, muscle relaxation, imagery, preparatory information, distraction techniques, and use of previous coping methods.

Anxiety

• Patient and family education in the critical care environment is not to be overlooked by the nurse and other members of the healthcare team. It is essential to provide information regarding diagnosis, prognosis, treatments, and procedures. This helps allay fears and concerns, or at least, puts them into perspective. Through client education, the patient and their family are better able to take a more proactive role in the plan of care.

• Education in the critical care setting is typically done informally, where the nurse takes the opportunity of teaching moments when the learner is able to comprehend and synthesize the information to be shared. This is also referred to as learning readiness.

Client Education

• Do the patient and the family have questions about the diagnosis, prognosis, treatments, or procedures?

• What do the patient and the family desire to learn about?

• What is the knowledge level of the individuals being taught? What do they already know about the Issues that will be taught?

• What is their current situation condition and environment) and have they had any prior experience in a similar situation?

• Do the patient or the family have any communication barriers (e.g. language, illiteracy, culture, listening/comprehension deficits)?

• What Is patient's or family members' preferred method of learning?

Assessment of Readiness of Learning

• Does the patient's condition allow you to assess this information from them (e.g. physiologic/psychological stability)?

• Is the patient's support system/family/significant other available or ready to receive this information?

• What environmental factors (including time) present as barriers in the critical care unit?

• Are there other members of the healthcare team who may possess vital assessment information?

Special Consideration in Critical Care

• As the nurse shares information with the patient and their family, in whatever manner, it is important to listen carefully to the needs expressed by the learner. The nurse must respond in a clear and precise manner to these needs.

• A good method to find out if the learner comprehends the information is to ask the patient or family member to relay in their own words what they learned. This method is referred to as teach-back. Of course, the learners may end up not retaining all the information hence reinforcement is often necessary and important to anticipate.

Special Considerations in Critical Care

• Evaluation of the patient's progress toward the achievement of expected outcomes (ANA, 2015)

• The process of evaluating the status of the patient and the effectiveness of the treatment. The plan of care may be modified if necessary.

• As mentioned earlier, creating and implementing interprofessional plans of care improves communication and collaboration in achieving optimal patient outcomes.

Evaluation of the outcome

• All staff members who utilize the plan of care need to be trained as to how to document consistently. The team approach in using the interprofessional plan of care improves and optimizes communication, collaboration, coordination, and commitment to achieve patient outcomes.

• Electronic medical records (EMRs) and electronic medication administration records (EMARs) are designed to facilitate documentation, since they have programs and pages for numerous situations that happen in critical care units. However, documenting all the required assessments, care plans, EMARs, physician orders, and multiple other components can be a very challenging task. The nurse must always be conscious of the nursing process, liability, safety, and patient care when documenting. It is always necessary to "save," or store, the information after inputting it properly.

Reporting and Documentation

• Each hospital should have a tech team available 24-7 whose responsibility is to help the staff resolve documentation problems involving EMRs and EMARs. The critical care nurse must remember that despite all the technology employed in the ICU, the rule "if it was not documented, it was not done" still holds true.

• EMRs and EMARs are the center of communication among nursing staff, medical staff, therapists, the lab, the pharmacy, and all other members of the healthcare team. If something is not documented, it cannot be verified and evaluated properly.

Reporting and Documentation

• It is noteworthy to mention that when nurses develop an ongoing plan of care, safety initiatives must be incorporated, particularly since acutely ill patient conditions can change abruptly, hence constant awareness and vigilance is imperative even when the patient appears to be stable or improving.

• A major concern when providing care to critically ill patients is the prevention of complications associated with critical illness.

Planning

• Discharge outcomes

• Patient goals (e.g., pain control, activity level, absence of complications)

• Assessment and evaluation

• Consultations

• Diagnostic studies

• Medications

• Nutrition

• Activity

• Education

• Discharge planning

typical features of the format of interprofessional plans of care:

Development of a detailed plan of interventions focused on achieving expected outcomes

Planning

A. Assigning priorities, if the patient has multiple nursing diagnoses

B. Setting short-and long-term goals that are patient oriented and measurable

C. Including assessment and diagnosis details

D. Stating appropriate nursing interventions and corresponding medical order

E. Utilizing a standardized or computerized care plan or clinical pathway as a guideline, if appropriate.

The nursing care plan details planning and outcomes by: