nursing 203 week 1 first 10 chapters of urden

Nursing 203 Cheri Rievley

Critical Care Nursing

Nursing 203 Syllabus Week 1.1


• Describe Critical Care Nursing RolesWhat is it that CCU RN’s do, can you define?Patient AdvocacyAdvanced AssessmentIntensive InterventionHigh Tech MonitoringSpecialized CareCommunication between all

disciplines

• Nursing is based on evidence. • It needs to be consistent• It needs to have research backing to show

the best possible results for the greatest number of patients.

Critical Care NursingNursing 203



• Show the importance of holistic care for the chronically ill patient and family

• Sheldon (2000) states:Patients need to feel that their circumstances and feelings are appreciated and understood by the health care team member without criticism or judgment. . . . If patients feel that the attention they receive is genuinely

caring and tailored to meet their needs, it is far more likely that they will develop trust and confidence in the organization.”

Shelton P.J.: Measuring and Improving Patient Satisfaction. New York: Aspen Publishers, 2000.

• Apply the six phases of the nursing process in critical care. (You will do this in clinical, be prepared)

– Assessment– Diagnosis– Outcome Identification– Planning– Implementation– Evaluation

Critical Care NursingNursing 203 Syllabus Week 1.3

• Compare and contrast interdisciplinary critical care management models and tools.– Case Management-overseeing care with MD

• Algorithm• Protocols• Practice Guidelines

– Outcome Management-manage outcomes with tools• Consistent standard of care• Patient functioning and well being (clinical outcomes)


Locate an example on the internet so you can be familiar with these be able to define them

• Explain ethical principles as they relate to critical care patients.


Mind

It is easy to focus on all the technology and physical aspects of patient care in the Critical Care Unit. Give some examples of how you would focus on mind or spirit:

Body Spirit

• Examine strategies to address moral distress in critical care nursing.– What is Moral Distress? (This can be very important

to your own sense of right and wrong)

– Moral distress occurs when:• 1.

• 2.

Critical Care NursingNursing 203 Syllabus

Week 1.6



• Identify and discuss specific legal isssues

in critical care nursing practice• Autonomy-• Beneficence-• Nonmalficence-• Veracity-• Fidelity-• Justice/allocation of resources

• Can you Define these before I do?

• Autonomy– Freedom of choice or self-determination– Basic human right– Nurses can get “caught in the middle” in

ethical situations• Assumes role of patient advocate

– Providing more information– Clarifying points – Reinforcing information– Providing support in decision-making process

Critical Care NursingNursing 203 Syllabus 1.7

Critical Care Nursing• Nursing 203

Syllabus Week 1. 8

Question

A terminally ill patient has a “do not resuscitate”(DNR) order per patient request. The patient’sfamily is opposed to the order. What is theresponsibility of the nurse?

A. Resuscitate the patient until the issue is resolvedB. Honor the patient’s requestC. Have the family contact a lawyerD. Ask the physician to talk with the family

Answer

B. Honor the patient’s request

First and foremost the nurse has a duty to honorthe patient’s request. The patient should not beresuscitated. The family can contact a lawyer ifthey wish but that is not the nurse’s responsibility.Asking the physician to talk with the family may ormay not help with the situation.

• Beneficence– Concept of doing good, preventing harm– Requires that one promote the well-being of patients– Weigh benefits, choosing best principles to follow

• Nonmaleficence– Dictates that one prevent harm and correct harmful

situations– Primary duty for the nurse

• What is the difference between these two?

Critcal Care NursingNursing 203 Syllabus 1.7

• Veracity– Truth-telling– Underlies the nurse-patient relationship

• Fidelity– Faithfulness and promise-keeping to patients– Forms bond between individuals– Extends to the families of patients

• Incorporates:– Confidentiality– Privacy

Critical Care NursingNursing 203Syllabus Week 1.7

• Justice– Allocation of resources– Equal access to health care

• Medical Futility– Defined as “any effort to achieve a result that is

possible but that reasoning or experience suggest is highly improbable and that cannot be systematically reproduced.”


• Ethical foundation for Nursing Practice– Framework for the profession– Based on 3 elements:

• The professional code of ethics• The purpose of the profession• The standards of practice of the professional


• Code of Ethics– Developed by the profession

• Look up online

– Delineation of its values and relationships with and among members of the profession and society


Question

What purpose does the ANA Code of Ethics serve?

A. Provides a framework for addressing moral distressB. Provides a description of expected nursing roles and responsibilitiesC. Provides recommendations for managing care and treatments for specific diseasesD. Provides guidance for analyzing ethical issues for the nursing profession

AnswerD. Provides guidance for analyzing ethical issues for the nursing profession

The American Nurses Association (ANA) Code ofEthics for Nurses provides the major source of

ethical guidance for the nursing profession. TheCode of Ethics for Nurses serves as the basis fornurses in analyzing ethical issues and decision

making

• Code of Ethics for Nursing – Nursing is concerned with:

• Protection of patient health• Promotion of patient health• Restoration of patient health• Prevention of patient illness• Alleviation of patient suffering

• Can you identify one intervention from each for the CCU nurse?


• Steps in Ethical Decision Making1. Identify the health problem.2. Define the ethical issue.3. Gather additional information.4. Delineate the decision maker.5. Examine ethical and moral principles.6. Explore alternative options.7. Implement decisions.8. Evaluate and modify actions.




• Administrative Law and Licensing Statues• Health care agencies/boards• Governed by administrative law• These guys make the rules


Negligence and MalpracticeFour elements of negligence and malpractice:

1. Duty and standard of care2. Breach of duty3. Causation4. Injury or damages

NegligenceThe doing of something which a reasonably prudent person would not do, or the failure to do something which a reasonably prudent person would do, under circumstances similar to those shown by the evidence. It is the

failure to use ordinary or reasonable care.

“ordinary or reasonable” careThat care which a person of ordinary prudence would use in order to

avoid injury to themselves or others under circumstances similar to those shown by the evidence. You will note that the person whose conduct sets

the standard is not the extraordinarily cautious individual, nor the exceptionally skillful one, but a person of reasonable and ordinary

prudence.Black H. C. (1998). Black’s Law Dictionary. 9th ed. St. Paul, MN: West Publishing Company


Question

Which of the following situations is an exampleof malpractice?A. The patient gets out of bed against nursing advice and falls and breaks a hip.B. The nurse makes derogatory comments about the patient in the medical record.C. The nurse gives the wrong medication to a patient and the patient dies as a result.D. The nurse gives confidential information about the patient to the media

Answer

C. The nurse gives the wrong medication to a patient and the patient dies as a result. The nurse giving the wrong medication to a patient and the patient dying as a result is an example ofmalpractice. It meets the 4 required elements of malpractice.

• Legal Duties of Critical Care Nurses– Observe– Assess– Conduct ongoing observations and– assessments– Recognize significance of information– Report– Plan, implement, and evaluate care


• Legal Duties of Critical Care Nurses –cont-

– Respond to changes– Interpret and carry out orders– Take reasonable measures to ensure patient

safety– Exercise professional judgment– Properly perform procedures– Follow hospital policies and procedures– Record and document


What happens if you don’t do these? if

Six General Areas of Nursing Negligence• 1. Improper administration of treatments• 2. Improper administration of medications• 3. Inadequate or false written and verbal communication• 4. Insufficient supervision of patients• 5. Improper postoperative treatment and wound care• 6. Incorrect perioperative instrument or sponge count

Critical Care NursingNursing 203 Syllabus week 1.7

Nursing 203 Syllabus week 1.7


Nurse Practice Act

• Right to practice and right to employment• Monitor practice, implement standards of care• Enforce rules and regulations• Issue sanctions and license revocation• Disciplinary action for unauthorized practice, negligence or malpractice, incompetence, chemical or other impairment, criminal acts, or violations of specific nurse practice act provisions These are your

rights as an RN

Specific Patient Care Issues• Informed consent and authorization for treatment

• Valid consent– Consent must be informed and timely

• Diagnosis, condition, prognosis, material risks and benefits of treatment, explanation of procedure or treatment, providers of treatment, and probable outcome


Specific Patient Care Issues (continued)• The right to accept or refuse medical treatment

and the law of advance directives• The right to informed consent• The right to refuse treatment• Withholding and withdrawing treatment• Ethical, legal, and practical problems• Specific guidelines to guide decision makers


Advanced Directives and the Patient Self-Determination Act (1990)

• All adults must be provided written information on an individual’s rights under state law to make medical decisions, including the right to refuse treatment and the right to formulate advance directives

• Living will• Durable power of attorney for health care• POLST Form


What is the difference between these?

• Assess informational needs of families of critically ill patients.– What do they need to know?– How do they get information?– If you don’t know answers, where do you find

them?


• Apply teaching learning theory to the critical care setting.– Be prepared to teach something in class

to show understanding of this concept.• When teaching an adult patient, tasks being taught

should focus on current problem. – True– False


• A. True• Adults bring a wealth of experience to the learning

environment that must be recognized and promoted in educational techniques. Because their orientation to learning is life centered, the tasks being taught should focus on current problem resolution.


Assessment Questions for the Critically Ill Patient and their Family

• What brings you to the hospital? Can you tell me more?• What have you been told so far about your your family member’s)

condition and plan of care?• What is the most important thing for you to know right now?• What would you like to know? What information can I give you right

now?• Who are your main support people?• Has anything like this ever happened to you (your family) before?• Have you (your family) ever been in an intensive care unit or hospital

before?• Do you have any special concerns that we need to address right now?




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Factors Affecting Patient Readiness to Learn• Physiological stressors• Psychological stressors• Sociocultural stressors• Financial stressors• Environmental stressors

Define a barrier in each of these areas.


Essential Critical Care Information for Patient/Family

• Orientation to the various care providers and the services they deliver• Orientation to the unit environment• Orientation to the unit routines and plan of care

• Visiting hours, frequency of monitoring and nurse assessments, venipunctures, daily weights, and special shift routines (extremely important)

(continued)


Essential Critical Care Information for Patient/Family• Explanations regarding reasons for equipment, monitors, and associated

alarms• Explanations of all procedures and expected sensations/discomforts

both in and off the unit• Medications given

• Drug name, reason for receiving, and side effects to report to nurse/others

• Immediate plan of care• Transition to next level of care

• Reason for transfer, environment, staffing, and availability of care providers

• Discharge plan• Medications, diet, activity, pathophysiology of disease, symptom management, special procedures and associated equipment, when to call health care provider, and available community resources.

Education Plan of Care– Expected outcomes– Objectives– Content to be taught– Interventions– Available education materials– Appropriate teaching strategies


Choose a critical disease process and practice, practice, practice, someone’s life may depend on you

• Prior to educating a patient what do you need to know? – Ready to learn?– Language– Comprehension level

• Remember age affects our ability to learn




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Question

Which of the following educational methodswould be best for teaching a patient how tocheck his or her blood sugar? Why?

A. LectureB. DiscussionC. Demonstration and practiceD. Closed-circuit television

Nursing 203 Syllabus week


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Answer

C. Demonstration and practice

Demonstration involves acting out a procedure whilegiving appropriate explanations to provide the learnerwith a clear idea of how to perform a task. Patientscan then practice the skill and can be given feedbackabout their performance. This method works bestwhen teaching patients how to check their bloodsugar.


Strategies to Enhance Education

Get the patient’s attentionInformation must be important to patient

Stick to the basicsUse simple everyday language

Make the most of your timeTeachable momentsReinforce learning


The Older Adult• Cognitive changes

Process information more slowly• Physical changes

Presbyopia, cataracts, glaucoma, and macular degeneration affect the vision, more susceptible to over sedation, doesn’t bounce back like a younger patient, more easily toxic with any medication.• Psychological changes

Depression

How will you assist these patients?


Question

Which of the following strategies should be used to facilitate learning the older adult?

A. Schedule sessions for later in the day.B. Keep sessions short.C. Withhold all pain medication 1 hour before

the session.D. Written instructions should be printed in

purple ink.


Answer

B. Keep sessions short.

Learning can be facilitated by scheduling teachingsessions early in the day, keeping sessions short,and managing pain prior to learning. Colors in theblue end of the spectrum are difficult for the olderadult to distinguish, thus blues, greens, and purples should not be used for written instructions.

• Documentation– What was taught?– To whom?– Verbalized, return demo, how did they show

they understood?– Nurses teach every shift but if it is not

documented it is not done!– Give examples of simple teaching that might be forgotten



Illiterate Patients

• Use simple language• Provide frequent examples• Use teach-back or return demonstration• Pictures, diagrams, and audio/videotapes can

be helpful

• Interpreters and Interpreter Phones– Look at the patient not the interpreter– Speak to the patient, don’t use “tell him”– Know what you want to say in advance– Ask for a return demonstration so you know

learning has taken place.

Critical Care NursingNursing 203Syllabus Week 1.

• Preparation for Transfer– Fear of the unknown– Explanations to relieve anxiety

• Transfer destination• Reason for transfer• Nurse who will assume care of the patient• Expected changes in care• Expected self-care• Visiting hours and notification of family


• Psychosocial Alterations– Anxiety and Pain– Powerlessness– Hopelessness– Spiritual Distress


Understand how these apply to the patient in CCU define measures to alleviate

• Examine measures that are useful in reducing stress.– Coping mechanisms

• Suppression Use of Family Support• Denial Sharing Concerns• Trust• Hope• Spiritual beliefs and Practices


• Assess the impact of illness on the patient’s family and on family functioning.– How are they functioning

• Helpful• Hostile• Overly concerned

• Think of ways you would interact with each type of family


• Examine safety issues in the critical care environment.– Cords/Plugs emergency versus regular power

supply– Fall Risk– Restraints– Endotrachial Intubation


• Assess changes in sleep pattern resulting from sleep apnea and critical care environment and interventions.– Sleep stages

• NREM vs REM what’s the difference?• Url link to youtube for REM example

– http://www.youtube.com/watch?v=SRwmDSkwpxk

• Sleep cycles• Changes with aging


http://www.youtube.com/watch?v=SRwmDSkwpxk

http://www.youtube.com/watch?v=SRwmDSkwpxk

• Abnormal Sleep– Sleep Apnea Syndrome– Obstructive Sleep Apnea

• Medications and altered sleep (see chart in Urden pp40-41)

• Medical management-What?• Nursing management-What?


• Nutrition– Types of diets in the Critical Care Unit

• Cardiac– Low Na, Low fat

• Renal– Low protein

• Enteric feeding– NGT placement is checked by xray the first time then by air

insertion/aspiration

• TPN– High glucose, great medium for infection, isolated line– High glucose can cause increased CO2 levels on vent pt

Critical Care Nursing Nursing 203

• PAIN– Very subjective– Use a pain scale for better consistency between

nurses and patient– Remember geriatric patients are more sensitive

to pain medications – If giving ANY medication to pediatric patient

must check with a second nurse


• Sedation Medications– Short and Long acting– It is always preferable to use a sedation scale for

consistency in medication– Any patient on a continuous sedation drip

should be on a protocol and have a sedation vacation every 24 hours to allow them to wake up, and attempt to breath on their own

– Anytime a pt is on a neuromuscular blocking agent they MUST be on sedation as well.


Nursing 203 Syllabus week


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Define: Death with Dignity

Watch this presentation on death with dignity:http://www.youtube.com/watch?v=OU284t4axQ0

http://www.youtube.com/watch?v=OU284t4axQ0

http://www.youtube.com/watch?v=OU284t4axQ0

• Death with Dignity – Should allow the patient to be kept comfortable– Should be explained fully to the family, we still

care for the patient, turn, keep them comfortable, we just don’t intervene if their heart or breathing stop.

– Palliative Care Nurses are very important to help the family during a difficult time.


Week One is Done!See you next week.

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nursing 203 week 1 first 10 chapters of urden

Healthcare