Medical-Surgical Nursing II

Nurs 4117

Anita Langston MSN,ANP-BC,CCRN

Together,Stronger,

Bolder

Critical Care

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

Organizations

History of Critical Care

Past: In the beginning…

– Florence Nightingale

1900’s– Baltimore, Chicago

WWII– Shock wards

1950’s– Mechanical

ventilators

Contemporary: Specialty Units

– Medical– Surgical– Transplant– Burn– Trauma– Respiratory– Cardiac– Cardiovascular– Neurosurgical– Pediatric– Neonatal

Contemporary Critical Care

Specialized knowledge– Nursing, RT’s, 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 Medical-Surgical, Pediatric,

Gerontology, Psych

Operating room Neuroscience Rehabilitation Oncology

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

CNOR CNRN CRRN OCN

Professional Organizations

American Association of Critical-Care Nurses (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– International– 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.

“When nurse competencies stem from patient needs and the characteristics of the nurse and patient synergize, optimal patient outcomes can result.”

www.aacn.org

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 evaluate

Negligence

Assessment failures

Planning failures

Implementation failures

Evaluation failures

AACN Standards of Professional Performance for Critical Care Nursing

I: Quality of PracticeII: EducationIII: Professional Practice EvaluationIV: CollegialityV: CollaborationVI: EthicsVII: ResearchVIII: Resource UtilizationIX: Leadership Urden,

pg:29-30

Healthy Work Environments Skilled Communication: Nurses must be

as proficient in communication skills as they are in clinical skills

True collaboration: Nurses must be relentless in pursuing and fostering true collaboration.

Effective decision-making: Nurses must be valued and committed partners in making policy, directing and evaluating critical care, and leading organizational operations

Appropriate staffing: Staffing must ensure the effective match between patients’ needs and nurses’ competencies.

Meaningful recognition: Nurses must be recognized and must recognize others for the value each person brings to the work of the organization

Authentic leadership: Nurse leaders 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

Clinical Excellence

Authentic Leadership

Meaningful Recognition

Appropriate Staffing

Effective Decision Making

True Collaboration

Skilled Communication

Healthy Work Environment

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 careMeasurement of disease-specific clinical

outcomesPatient functioning and well-beingAssessment 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: – Step wise decision tree, more focused than

path– Guide clinician thru “if, then” situations– Allow for variances

Practice 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

General Adaptation Syndrome)

List of stressors in the ICU setting in Box 6-1, p. 76

Reaction to stress varies: with age, gender, social support, culture, MD diagnosis and prognosis, spiritual values

Patients reaction to stress also influenced by Self-Concept, Body image, Self-esteem, Role

performance, Personal identity

Stress and Coping in the ICU

Nursing interventions must address person as whole or they will be ineffective.

Review Nursing Diagnosis, Powerlessness, Hopelessness, and Ineffective Coping including defining characteristics and interventions.

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

Overt hostility Severe Regression Noncompliance Severe Anxiety Despondence or despair

Enhancing the Coping Process

Providing support– Patient– Family Members

Spiritual Care

Complementary Therapies

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.

May lead to physical, psychological exhaustion and delay recovery. (changes in mood, fatigue, increased irritability)

Sleep Stages

Awake REM sleep

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

NREM sleep– 70-75% of night– 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

(RASS)

Sedation Medications Benzodiazepines

– diazepam– midazolam– lorazepam

Anesthetic agents– propofol

Neuroleptic agents– haloperidol

Alpha-Adrenergic agonists– dexmedetomide

Sedation Complications

– Under-sedation– Over-sedation

Respiratory depressionhypotension

– PIS Short-term sedation Intermediate-term sedation Long-term sedation 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 attention span Anxiety Agitation Confusion Impaired 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 lightsAlarms from machinesConversations in the unit

– Sleep deprivationConstant evaluation

– PainNoxious stimuli and pain

– AnxietyThreat of loss/death

Nursing Management Plan– pg 1110-1113, Urden

Acute Confusion/Delirium: Management

Assessment:– Hyperactive– Hypoactive– Mixed, sundowner’s 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

ICU-CAMFeature 1

Acute onset of changes or fluctuations in the course of mental status

Feature 2Inattention

Feature 3Disorganized thinking

Delirium

Feature 4Altered level of consciousness

and

and either

or

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 practice guidelines

Involve families

ReferencesUrden, L., Stacy, K. & Lough, M. (2010). Critical care nursing:

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?opendocument

American College of Critical Care Medicine. (1999). Guidelines for intensive care unit admission, discharge, and triage. Critical Care Medicine, 27, 633-638.

American 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.

References

McCauley, K. & Irwin, R. (2006). Changing the work environment in intensive care units to achieve patient-focused 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.

Tracy, M. & Linquist, R. (2003). Nursing’s role in complementary and alternative use in critical care. Critical Care Clinics in North America, 15, 289-294.