MedicalMedical-Surgical Nursing II

Nurs 4117

Together, Stronger, Bolder

Anita Langston MSN,ANP-BC,CCRN MSN,ANP-

Critical Care
of Intensive Care Units  Contemporary Critical Care  Critical Care: Multidisciplinary teams  Nursing roles in critical care  Critical Care Professional Organizations
 History

History of Critical Care

Past:


Contemporary:


In the beginning
Florence Nightingale

Specialty Units
Medical Surgical Transplant Burn Trauma Respiratory Cardiac Cardiovascular Neurosurgical Pediatric Neonatal

1900s
Baltimore, Chicago

WWII
Shock wards

1950s
Mechanical ventilators

Contemporary Critical Care



Specialized knowledge
Nursing, RTs, Physical therapy, Pharmacist

Synergy
The needs of the patient drive the requirements of the provider

Shorter LOS
Sicker patients cared for on the floor Patients that would not have survived in the past are now being kept alive

Multidisciplinary Care
 Pharmacists  Respiratory

therapy  Physical therapy  Chaplain  Physician  Nursing  Case Managers  Social workers

Nursing Roles in Critical Care

Patient advocate  Manager  Patient Care Coordinator  Advanced Practice Nurse


Clinical Nurse Specialist Acute Care Nurse Practitioner

 Nurse

Educator  Patient Educator

Specialty Certification
   

Critical Care Progressive Care Emergency Nursing MedicalMedical-Surgical, Pediatric, Gerontology, Psych Operating room Neuroscience Rehabilitation Oncology

CCRN  PCCN  CEN  RN-BC or RN(CMSRN, CPN)

    

   

CNOR CNRN CRRN OCN

Professional Organizations


American Association of Critical-Care Nurses Critical(AACN)

The largest of any one specialty Utilizes the Synergy model Supports the nurse through education, certification, and research CCRN certification www.aacn.org

The Society of Critical Care Medicine

(SCCM) Multidisciplinary, multi-specialty multiInternational www.sccm.org

Scope of Practice in ICU

 Delineated

by professional organization: AACN Purpose: To promote the health and welfare of those experiencing critical illness or injury by advancing the art and science of critical care nursing and promoting environments that facilitate comprehensive professional nursing practice. www.aacn.org

Scope of practice in ICU

 Based

on specialized body of knowledge, skill, and experiences to provide optimal care to the critically ill patients.  Knowledge is evidence based  Care is holistic, individualized, includes the family, and culturally competent.

Synergy Model of Care

 Needs

of the patient/family are the forces to drive nursing care. nurse competencies stem from patient needs and the characteristics of the nurse and patient synergize, optimal patient outcomes can result.
www.aacn.org

 When

Evidence Based Nursing Practice



Research to clinical practice gap Using scientific research to guide nursing practice
Staffing ratios Policies & Procedures Nursing care

Goal:
Better patient outcomes Patient safety Effective use of resources, patient/hospital costs

Methods:
Unit based Journal Clubs Easily accessed internet data bases

AACN Standards of Care



Standard of Care I: Assessment

Collection of all relevant health care data Problem identification Anticipating & preventing potential problems

Standard of Care II: Diagnosis

Analyzes the assessment data in determining the diagnosis Can be resolved/improved upon with nursing interventions NANDA

Standards of Care


Standard of Care III: Outcome Identification

Identifies individualized expected outcomes for the patient Measurable, attainable Date and time of anticipated attainment

Standard of Care IV: Planning

Develops a plan of care that uses interventions to attain the expected outcome

Standards of Care
Standard of Care V: Implementation
Carries out the interventions prescribed in the plan of care
 Standard

of Care VI: Evaluation

Evaluates the progress toward the expected outcomes Uses pre-set formal intervals to preevaluate

Negligence
 Assessment  Planning

failures

failures failures

 Implementation  Evaluation

failures

AACN Standards of Professional Performance for Critical Care Nursing I: II: III: IV: V: VI: VII: VIII: IX: Quality of Practice Education Professional Practice Evaluation Collegiality Collaboration Ethics Research Resource Utilization Urden, Leadership pg:29-30

Healthy Work Environments



Skilled Communication: Nurses must be Communication: as proficient in communication skills as they are in clinical skills True collaboration: Nurses must be collaboration: relentless in pursuing and fostering true collaboration. Effective decision-making: Nurses must decision-making: be valued and committed partners in making policy, directing and evaluating critical care, and leading organizational operations

Appropriate staffing: Staffing must staffing: ensure the effective match between patients needs and nurses competencies. Meaningful recognition: Nurses must recognition: be recognized and must recognize others for the value each person brings to the work of the organization Authentic leadership: Nurse leaders leadership: must fully embrace the imperative of a healthy work environment, authentically live it, and engage others in its achievement
AACN as cited in McCauley, K. & Irwin, R., (2006)

Patient Outcomes

Skilled Communication

Authentic Leadership

Healthy Work Environment

Clinical Excellence

True Collaboration

Meaningful Recognition

Appropriate Staffing

Effective Decision Making

Predictive Scoring Systems

System to adjust mortality risk based on the severity of the illness and the presences of comorbidites  APACHE Acute Physiology and Chronic Health Evaluation Models II thru IV  SAPS II Simplified Acute Physiology Score II  MPM II Mortality Prediction Model II

Interdisciplinary Planning for Care: Care Management Models

 Care

management

Integrated processes to enable, support, and coordinate patient care

 Case

management

Overseeing patient care and organizing services Collaboration

Interdisciplinary Planning for Care: Care Management Models (continued)

 Outcomes

management

Places emphasis on the following

 Standards

of care  Measurement of disease-specific clinical diseaseoutcomes  Patient functioning and well-being well Assessment of clinical and outcome data

Takes place in multiple settings

Care Management Tools

 Clinical

pathway:

Looks at entire multidisciplinary plan of care for routine day to day care Uses latest research & best practices for high volume diagnosis groups
 Algorithm: Algorithm:

Step wise decision tree, more focused than path Guide clinician thru if, then situations Allow for variances

 Practice

guidelines: guidelines:

Developed by professional organizations Used as resources to develop clinical pathways or algorithms

 Protocol

More directive and rigid Common tool in research studies Can be computerized
 Order

set

Preprinted provider orders Can represent algorithms in order format Expedites order process

Quality and Safety



The Institute of Medicine (IOM)

report on Quality

AACN Practice Alerts The Joint Commission (TJC)

National Patient Safety Goals Core Measures

Agency for Healthcare Research and Quality (AHRQ) Betsy Lehman Center for Patient Safety and Medical Error Reduction

Genetics in Critical Care

 Cardiovascular

Long QT Syndrome (LQTS)

 Pharmacogenetics

Cytochrome P450 (CYP450) Warfarin Malignant Hyperthermia

Stress in the Critical Care Setting

Stress and Coping in the ICU



Review physiological events of stress (Selye and (Selye General Adaptation Syndrome) List of stressors in the ICU setting in Box 6-1, p. 76 6Reaction to stress varies: with age, gender, social support, culture, MD diagnosis and prognosis, spiritual values Patients reaction to stress also influenced by SelfSelf-Concept, Body image, Self-esteem, Role Selfperformance, Personal identity

Stress and Coping in the ICU

 Nursing

interventions must address person as whole or they will be ineffective. Nursing Diagnosis, Powerlessness, Hopelessness, and Ineffective Coping including defining characteristics and interventions.

 Review

Coping Mechanisms in Stress

Regression  Suppression  Denial  Trust  Hope  Hardiness and Resilience  Spiritual Beliefs and practice  Use of family support  Sharing concerns


Ineffective Coping Mechanisms

hostility  Severe Regression  Noncompliance  Severe Anxiety  Despondence or despair
 Overt

Enhancing the Coping Process

 Providing

support

Patient Family Members

 Spiritual

Care Therapies

 Complementary

Sleep Alterations
 Frequent

assessments and interventions 24 hours, every 2 hours, every 5 minutes  Research shows that 50% of all ICU patients are sleep deprived within 48 hours of admission.  Insufficient duration: Not enough sleep

Sleep Alterations
 Disruption

stages of sleep: Altered REM/NREM sleep cycles, called circadian desynchronization. lead to physical, psychological exhaustion and delay recovery. (changes in mood, fatigue, increased irritability)

 May

Sleep Stages
 Awake  REM

sleep

20-25% of night 20 Dream stage Paradoxic sleep Sympathetic nervous system dominates Refuels creative brain stores

 NREM

sleep

70-75% of night 70 Deeper sleep Parasympathetic system dominates Restorative period

 Cycles

of sleep

 Sleep

changes in elderly

Sleep Alterations
Nursing Interventions: help resynchronization and orientation
 opening

blinds  using clocks and calendars  family pictures in room  pharmacotherapy

Sedation Management
 Assessment

Light Moderate Deep

 Sedation

Scales

Riker (SAS) Ramsey Scale Richmond Agitation-Sedation Scale Agitation(RASS)

Sedation Medications
 Benzodiazepines

diazepam midazolam lorazepam

 Anesthetic

agents agents agonists

propofol
 Neuroleptic

haloperidol
 Alpha-Adrenergic Alpha-

dexmedetomide

Sedation
 Complications

Under-sedation Under Over-sedation Over Respiratory  hypotension

depression

PIS  Short-term sedation Short Intermediate-term sedation Intermediate Long-term sedation Long Sedation vacations

Acute Confusion/Delirium
Delirium, ICU psychosis, postcardiotomy delirium  Global cognitive impairment  Loss of orientation to person, place, or time and the ability to reason, follow directions, process information, or maintain concentration.  Incidence of delirium ranges from 60% to 85% in mechanically ventilated patients


Acute Confusion/Delirium: Manifestations

 Decreased  Anxiety  Agitation  Confusion  Impaired

attention span

Cognition  Inappropriate gestures/words  Anger  Hallucinations

Acute Confusion/Delirium: Etiology



Organic sources:
Hypoxia Drugs: Narcotic, hypersensitivity
Delayed metabolism and excretion drugs, interaction with other drugs  Drug/alcohol withdrawal


Fluid and electrolyte imbalance Organ dysfunction



Inorganic sources:
Stress/Anxiety Sleep deprivation

Etiology, Organic

Etiology, Inorganic
 Acute

confusion r/t

Sensory overload
 Artificial

lights  Alarms from machines  Conversations in the unit

Sleep deprivation
 Constant

evaluation

Pain
 Noxious

stimuli and pain

Anxiety


of loss/death Nursing Management Plan

pg 1110-1113, Urden 1110-

 Threat

Acute Confusion/Delirium: Management



Assessment:
Hyperactive Hypoactive Mixed, sundowners syndrome

Assessment Tools
Confusion Assessment Method for the Intensive Care Unit Intensive Care Delirium Screening Checklist Used in conjunction with sedation assessment tools

Evaluate for the etiology

Drug side effects or interactions Chemical imbalance Past medical & social history

Correct the cause

Correct any organic cause Sedation, scheduled doses, for the hyperactive Control environmental stressors

ICUICU-CAM
Feature 1 Acute onset of changes or fluctuations in the course of mental status

and
Feature 2 Inattention

and either
Feature 3 Disorganized thinking Feature 4 Altered level of consciousness

or

Delirium
icudelirium.org

Nonpharmacologic Strategies for Prevention

 Similar

to those used as adjuncts to minimize pain

Massage Music therapy Noise reduction Decreasing lights to promote sleep Clustering nursing activities Speaking in calm, quiet, gentle voice

Collaborative Management
 Responsibility

shared by all members of health care team  Recognize problem  Follow effective standard of patient care in sedation/analgesia management  Utilize evidence-based collaborative evidencepractice guidelines  Involve families

References
Urden, Urden, L., Stacy, K. & Lough, M. (2010). Critical care nursing: Lough, Diagnosis and management (6th ed.). St. Louis: Mosby. American Association of Critical Care Nurses (2007). The synergy model. Retrieved January 8, 2007 from: http://www.certcorp.org/certcorp/certcorp.nsf/vwdoc/SynModel?o pendocument American College of Critical Care Medicine. (1999). Guidelines for intensive care unit admission, discharge, and triage. Critical Care Medicine, 27, 633-638. 633American College of Critical Care Medicine. (2003). Guidelines for critical care services and personnel: Recommendations based on a system of categorization of resources: three levels of care. Critical Care Medicine,31, 2677-2683. 2677-2683.

References
McCauley, K. & Irwin, R. (2006). Changing the work environment in intensive care units to achieve patientfocused care: the time has come. American Journal of Critical Care,15(6), 541-543. Monarch, K. (2002). The mark of excellence: The ANCC Magnet Nursing Services Recognition Program. Maryland Nurse, 4(1), 12-15. 4(1), 12Tracy, M. & Linquist, R. (2003). Nursings role in complementary and alternative use in critical care. Critical Care Clinics in North America, 15, 289-294. 15, 289-