Adults II exam 1 review

HIGH-ACUITY DEFINITION  

◼      Complex patients with unpredictable outcomes

◼      Most commonly thought of as being in critical care or intensive care units

◼      Clients with acute condition or chronic condition(s)

◼      Now high-acuity care has spread to progressive or intermediate care units as well as some medical-surgical floors depending on the setting

FACTORS CONTRIBUTING TO HIGH-ACUITY ADMISSIONS

◼      Acute issues (trauma, stroke, aneurysm etc.)

◼      Age (young and old are at the highest risk d/t compensatory mechanisms)

◼      Exacerbation of chronic conditions (heart failure, kidney disease, diabetes, COPD)

◼       Lack of access to care

◼       Economic factors

◼       Noncompliance (can’t do what they need to do) 

NURSING CARE CONSIDERATIONS FOR THE HIGH-ACUITY CLIENT

◼      Clients will come from a variety of cultures and educational backgrounds. CAN’T BE A ONE SIZE FITS ALL 

◼      Because there is no one profile of a high-acuity client (disease-wise or culturally), individual and family response to the situation will vary widely

◼      Proper care depends on adequate physical assessment, psychosocial assessment and use of resources to help client and family meet their needs and achieve their goals

◼      Major areas to consider in caring for high-acuity clients:

◼       The high-acuity environment

◼       Pharmacological management and issues

◼       Nutritional support

◼       Older adult considerations

◼       Palliative and end of life care

 THE HIGH-ACUITY ENVIRONMENT

 HIGH ACUITY ENVIRONMENT-THE GOOD

◼      Rapid access to labs and diagnostics

◼      Specialists available to consult

◼      24-hour, specialized care for individuals who need monitoring

◼      Rapid access to needed or potentially needed medications

◼      Ability to escalate care rapidly if needed

THE HIGH-ACUITY ENVIRONMENT- NOT SO GOOD

◼      A lot of people

◼      A lot of equipment

◼      A lot of information

◼      A lot of activity

◼      A lot of stimulation

◼      Not a lot of communication

PHYSICAL STRESSORS IN THE HIGH-ACUITY ENVIRONMENT

◼       Lack of sleep

◼       Isolation

◼       Pain

◼       Immobility

◼       Overstimulation (light, sound)

◼       Pharmacological effects (sedatives, antipsychotics)

SOCIAL AND PSYCHOLOGICAL STRESSORS IN THE HIGH-ACUITY ENVIRONMENT

◼      Anxiety

◼       Client

◼       Family

◼      Grief

◼      Family dynamics

◼      Stressors related to the event that brought the individual to the hospital

◼      Financial

◼      Post-stay concerns

COMMON COMPLICATIONS FROM STRESSORS

◼      Venous thromboembolism (VTE)

◼       Due to lack of mobility

◼       Common methods of prophylaxis: anticoagulant administration, compression stockings, sequential devices

◼      GI Bleed

◼       From stress causing GI bleed

◼       Common to give PPIs for stress prophylaxis

◼      Delirium

COMPLICATIONS FROM STRESSORS-DELIRIUM

◼      Acute disorder characterized by confusion, attention deficits, fluctuating mental status, altered level of consciousness, and possible disordered thinking

◼      Often involves a misinterpretation of stimuli

◼      Develops quickly as opposed to dementia which develops slowly

◼      Can be caused by infectious process, adverse drug reactions, or metabolic conditions, lack of sleep

◼      Most common cognitive disorder in the high-acuity setting

◼      Increase in delirium days increases risk for death—those with delirium have five times the risk for death than those who do not

DELIRIUM ASSESSMENT AND TREATMENT

◼      Several different assessment scales that are used (if it’s identified, always identify the underlying cause and treat it)

◼      Find the underlying cause and treat 

◼      Can use antipsychotics, but this should be a last choice for a client who is a danger to themselves or others (since they have side effects like Haldol, benzos, etc.)

◼      Prevention is the goal—avoid medications that are known to cause delirium (benzodiazepines) if possible and manage the environment to support good sleep hygiene

NURSE’S ROLE IN FACILITATING CARE IN THE HIGH-ACUITY ENVIRONMENT

◼      Acknowledge the stressors and involve the client and family in planning to reduce them

◼      You are the mouthpiece for the client/family

◼      Assess client and communicate changes quickly

◼      Assess and manage stressors

◼       Do not neglect the role of anxiety, pain, or lack of sleep

◼      Don’t jump straight to pharmacological interventions

◼      Connect to resources (Pastoral care, social work, client and family education, palliative care)

◼      Listen and understand the goals of the family/client

◼      Communicate needs to members of the team to orchestrate holistic care

PHARMACOLOGICAL MANAGEMENT AND ISSUES FOR THE HIGH-ACUITY CLIENT

MAJOR AREAS THAT REQUIRE PHARMACOLOGICAL MANAGEMENT

◼      Pain

◼      Sedation

◼      Chronic illness

◼       Could be unrelated or an exacerbation

◼       Will cover pharmacological management with each disease process in the course

◼      Acute illness

◼       Can be multiple issues at one time

◼       Will cover pharmacological management with each disease process in the course

PAIN IN THE HIGH-ACUITY CLIENT

◼      Can be acute (short-term) or chronic (long-term) pain

◼      Can be somatic, visceral, neuropathic or psychosomatic

◼      Pain perception varies widely because it includes psychosocial as well as physiological components

◼      Must have pain assessment as part of high-acuity nursing

◼      Pain can often cause anxiety and anxiety often makes pain worse (Oh et al., 2015)

COMMON PAIN ASSESSMENT TOOLS FOR THE HIGH-ACUITY CLIENT

Most reliable is the patient report

◼      Numeric pain scale

◼      FACES

◼      Behavioral Observation Scale

◼      Critical Care Pain Observation Tool

PAIN MANAGEMENT FOR THE HIGH-ACUITY CLIENT

◼      High-acuity clients typically have a higher level of pain based on the disease process

◼      Use opioids as well as non-opioids to manage pain

◼      Use non-opioids to augment the effects of opioids

◼      Can be delivered in multiple routes-for high-acuity clients intravenous administration as well as oral are the most common

◼      Managing anxiety can have a correlation with managing pain (Oh et al., 2015)

◼      Non-pharmacological methods are available as well-however may not be as effective due to the level of pain from the high-acuity issue

NURSE’S ROLE IN PAIN MANAGEMENT OF THE HIGH-ACUITY CLIENT

◼      Assess patient often

◼      Advocate for pain control

◼      Educate client and family

◼       Narcotic hesitancy

◼      Assess for potential side effects and complications

HIGH-ACUITY CLIENT PAIN MANAGEMENT EDUCATION

◼      Client and family should be educated on medications/techniques being used

◼      Let them know the schedule of medications

◼      Be realistic with expectations for pain control

HIGH-ACUITY CLIENT PAIN MANAGEMENT COMPLICATIONS

◼      Respiratory depression

◼      Altered level of consciousness

◼       Expected alteration vs problematic alteration

◼      Polypharmacy

SEDATION FOR THE HIGH-ACUITY CLIENT

◼      Sedation used most frequently in critical care areas

◼      Often associated with a client who is on the ventilator

◼      Can be used to help combat delirium

◼      Can also be used for procedures

COMMON SEDATION ASSESSMENT TOOLS FOR THE HIGH-ACUITY CLIENT (continuous) 

◼      Richmond Agitation and Sedation Scale (RASS)

◼      Pasero Opioid-Induced Sedation Scale (POSS)

SEDATION MANAGEMENT FOR THE HIGH-ACUITY CLIENT

◼      What drugs are used will be heavily dependent on the facility you work at

◼      Benzodiazepines used to be heavily used, however now some research is showing long-term consequences of their use for sedation

◼      Antipsychotics for delirium-Haldol common, however research is showing lack of efficacy in acute cases of delirium

◼      Newer approach to use as little as possible and only if completely necessary

NURSE’S ROLE IN SEDATION FOR HIGH-ACUITY CLIENT

◼      Administer the medications

◼      Watch for side-effects

◼      Monitor to make sure that client is not over-sedated

◼      Work with interdisciplinary team to find best plan of care for client

SEDATION EDUCATION FOR THE HIGH-ACUITY CLIENT

◼      What is being given

◼      Why it is being given

◼      What to look for for over-sedation

◼      Alternate ways to help calm client besides sedation

HIGH-ACUITY SEDATION COMPLICATIONS

◼      Long-term PTSD symptoms with benzodiazepines has been reported

◼      Can increase delirium

◼      Can lead to respiratory distress

◼      Interactions with other medications

NUTRITIONAL SUPPORT FOR THE HIGH-ACUITY CLIENT

IMPORTANCE OF NUTRITION FOR THE HIGH-ACUITY CLIENT

◼      Nutrition is key to proper recovery and healing

◼      Many high-acuity clients do not have the capability to take in nutrition on their own during their acute illness

◼      High-acuity clients often have very specific nutritional needs due to disease process

◼       Liver failure

◼       Renal failure

◼       Heart failure

ROUTES OF NUTRITION FOR THE HIGH-ACUITY CLIENT

◼      Oral

◼      Enteral

◼      Parenteral

ORAL NUTRITION FOR THE HIGH-ACUITY CLIENT

◼      Preferred method if available

◼      Helps the body to maintain its normal processes

◼      Client should be assessed for appropriateness of feeding by Speech Pathology with Nutrition consult

◼      May require supplementation due to lack of energy/appetite (calorie-dense diet like ensure, etc.)

ENTERAL/TUBE FEEDINGS FOR THE HIGH-ACUITY CLIENT

◼       Can be delivered via variety of feeding tubes

◼      Nasogastric tube (tube down the nare, esophagus, and stomach)

◼      Dobhoff tube (goes down the nare, esophagus, stomach, and intestine to lower the risk for aspiration)

◼      PEG tube (through the abdominal wall into the stomach)

◼       Will take the form of tube feeds

◼       Help to maintain GI function and reduce metabolic stress by continuing to use the GI system

◼       Better for healing for inflammatory bowel disorders

◼       Lower risk for infection than TPN

PARENTERAL FEEDINGS FOR THE HIGH-ACUITY CLIENT

◼      Indicated when oral or enteral feedings are not available or when there are absorption issues. Mainly seen in those with pancreatitis since they want to completely rest the GI system 

◼      Total Parenteral Nutrition (TPN) most common

◼       Delivered via central line or PICC line

◼      Constituted in pharmacy based on nutritional needs

◼      High risk for infection, so lines should be changed every 24-72 hours

◼      Must taper on and off to prevent hyper/hypoglycemia

◼      Will spend more time discussing in the GI section of the course 

LOCATIONS AND TYPES OF FEEDINGS

NURSE’S ROLE IN NUTRITIONAL DELIVERY

◼      Check orders to ensure proper nutrition is being delivered

◼      Maintain tube/line that nutrition is used to deliver nutrition

◼      Assess for signs/symptoms of intolerance

NUTRITIONAL COMPLICATIONS

◼      Hyperglycemia

◼      Hypoglycemia

◼      Aspiration

◼      Poor healing

OLDER ADULT HIGH-ACUITY CLIENT CONSIDERATIONS 

WHY ARE WE TALKING ABOUT OLDER ADULTS    

◼      While older adult clients aren’t the only clients in the high-acuity environment, they are a large percentage

◼      Certain characteristics of older adults can influence the clinical course of older adult clients

MAJOR CONSIDERATIONS FOR HIGH-ACUITY OLDER ADULT CLIENTS

◼      Physiological changes

◼      Atypical presentations

◼      Comorbidities

◼      Cognitive changes

◼      Pharmacological considerations

EXPECTED CHANGES IN PHYSIOLOGY FOR THE OLDER ADULT CLIENT

◼      Neurological system

◼       Decrease in neurotransmitter production

◼       More permeable blood-brain barrier

◼       Dilation of the ventricles

◼      Cardiovascular system

◼       Decreased elasticity and increased stiffness of arterial walls

◼       Loss of conductive tissue

◼       Calcification of valves

◼      Respiratory system

◼       Calcification of costal cartilage

◼       Decreased chest wall compliance

◼       Less oxygen carried by RBCs

◼       Loss of lung elasticity and recoil

EXPECTED CHANGES IN PHYSIOLOGY FOR THE OLDER ADULT CLIENT

◼      Gastrointestinal system

◼       Wearing of teeth

◼       Decreased saliva production

◼       Decreased thirst response

◼       Decreased LES function

◼       Decreased digestive function

◼       Decreased absorption in GI tract (so oral medication won’t be absobred as well)

◼       Reduction of blood flow to liver

◼      Genitourinary system

◼       Decreased GFR (so decreased excretion of fluids)

◼       Decreased creatinine clearance

◼       Higher risk for UTIs

◼       Incontinence

EXPECTED CHANGES IN PHYSIOLOGY FOR THE OLDER ADULT CLIENT

◼      Integumentary system

◼       Loss of elasticity of connective tissue

◼       Decreased subcutaneous tissue

◼       Thinning of dermal and subdermal layers

◼       Fragile blood vessels

◼       Reduction of lean body mass

◼      Musculoskeletal system

◼       Decreased muscle mass

◼       Joint stiffness

◼       Decreased mobility

◼       Loss of bone mass

EXPECTED CHANGES IN PHYSIOLOGY FOR THE OLDER ADULT CLIENT

ATYPICAL PRESENTATIONS IN OLDER ADULT HIGH-ACUITY CLIENTS

◼      Rapid onset of symptoms

◼      UTIs often present with extreme confusion 

◼      Quicker deterioration of condition

◼      Early warning signs can be masked by comorbidities or side-effects of medications

HIGH-ACUITY OLDER ADULT COMORBIDITIES

◼      As a patient population, older adults are more likely to have comorbidities

◼      This complicates care as other diseases must be considered as well as their treatment regimen in the acute care environment

◼      Multiple specialists get involved in care (lack of transparency)

◼      Can be lack of communication with specialists which can lead to conflicting orders and general fragmentation of care

COGNITIVE CHANGES IN THE OLDER ADULT CLIENT

◼      Depression

◼       Risk factors of major life changes, chronic disease, isolation, being outside of home environment

◼      Dementia

◼       Cognitive IRREVERSIBLE change that is due to changes within the brain

◼      Delirium

◼       Acute onset of problems that is the result of an acute illness or environmental factors

◼      Pain

◼       Common in the acute care setting

◼       Can be acute or due to pre-existing condition

PHARMACOLOGICAL CONSIDERATIONS FOR THE OLDER ADULT CLIENT

◼      Physiologic changes

◼       Decreased absorption

◼       Altered liver and kidney function

◼      Polypharmacy

◼       If has multiple chronic illnesses may be on large amounts of meds

◼       Can have cross-reactions that can be augmented by the physiologic changes that occur in older adults

◼      Adverse reactions

◼       Certain drugs can increase the risk for delirium, hypotension, or can impair renal or hepatic function

PALLIATIVE AND END OF LIFE CARE

 PALLIATIVE CARE

◼      Palliative care definition

◼       Interdisciplinary approach to relieve suffering and improve quality of life

◼      Palliative care is not withdrawal of care. There’s no cure for the disease, but they’re going to try to manage it 

◼      Management of conditions that aren’t going away and acceptance of a “new normal”

◼       Cancer, heart failure, dementia etc.

◼      Can receive curative treatments if available for the disease process

◼      Must work with client and family to establish goals for what they want and help them move towards those goals

◼      Extends to the end-of-life period 

BARRIERS TO PALLIATIVE CARE

◼      Lack of understanding of what palliative care is

◼      Denial of the reality of the reality of the client’s status

◼      Care carried out in silos

HOSPICE CARE

◼      Used when there is a prognosis of six months or less to live

◼      A form of palliative care that is designed to support clients and caregivers during the terminal period of their disease process

◼      Can be immediately at the end of life phase, or before

◼      Can be either inpatient or home hospice

END OF LIFE CARE

◼      Final phase of patient’s illness when death is imminent

◼      Can receive both hospice and palliative care at this time

◼      Care shifts to physiological and emotional comfort and support

WITHDRAWAL OF CARE

        ◼      Withdrawal of life-supporting measures such as dialysis, ventilator support,   vasopressor support, etc. (traumatic injury or serious illness and they’re not going to recover)

◼      Normally accompanied with medications to sedate, relieve pain and dry secretions etc. to help ease symptoms associated with EOL

◼      Family and client must be prepared since withdrawal of care leads to death 

◼      Important to use hospital resource such as pastoral care

WHAT TO EXPECT AT THE END OF LIFE

◼      Physiological:

◼       Cardiovascular and VS changes (tachy, hypotension (hypo and brady combo)

◼       Decreased efficacy of drugs

◼       Incontinence

◼       Cool, clammy skin (can’t maintain perfusion)

◼       Altered mental status

◼       Table 9.2 for more

◼      Psychosocial:

◼       Anxiety

◼       Isolation

◼       Fear

◼       Restlessness

◼       Withdrawal

◼       Peace

◼       Vision-like experiences

◼       See table 9.3 for more

BEREAVEMENT AND GRIEF

◼      Every person will experience these differently

◼      Nurse’s role is to facilitate and normalize the process and the feelings of the family members

◼      In the high-acuity environment, give time and environment to express their emotions

◼      Use resources of Pastoral care and bereavement counselors to help family members process

END OF LIFE CONSIDERATIONS FOR THE HIGH-ACUITY ENVIRONMENT

◼      Organ and tissue donation

◼      Advanced directives

◼      Resuscitation

SELF CARE IN THE HIGH-ACUITY ENVIRONMENT

◼      High-acuity environment can be stressful to the caregivers as well

◼      Important to understand what works for you to help deal with these realities and make those things a priority

◼      It’s also okay and encouraged to seek help to process and deal with your feelings