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High-Acuity Nursing, 6th Edition
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Transcript
Holistic Care of the Patient and Family
Objectives:
1. Discuss the impact of illness on the high-acuity patient and family.
2. Identify way the nurse can help high-acuity patients cope with an illness and/or injury event.
3. Describe the principles of patient and family-centered care in the high-acuity environment as it
relates to educational needs of visitation and policies.
4. Discuss the importance of awareness of cultural diversity when caring for high-acuity patients.
5. Examine the role of palliative care in the high-acuity environment and discuss end-of-life issues to be considered in caring for high-acuity patients.
6. Identify environmental stressors, their impact on high-acuity patients and strategies to alleviate those stressors.
I. Impact of Acute Illness on Patient and Family
A. Suchman’s stages of illness
1. Illnesses can cause the patients to experience a chronic loss of health, loss of limb, disfigurement, or necessary change in lifestyle. Patients might respond to the losses by passing through a series of phases. These are known as Suchman’s stages of illness. These stages are:
a) Shock and disbelief: Diagnoses does not have an emotional meaning.
b) Denial: Patient rejects diagnosis.
c) Awareness: Attempts to regain control.
d) Restitution; Diagnosis is accepted.
e) Resolution: Patient’s identity is changed.
B. Nursing considerations
1. The family is an important part of the patient’s health outcome.
2. Patients must participate in the care and recovery of their loved one.
3. Patients need information, comfort, support, assurance, and accessibility.
4. Open communication must be maintained.
PowerPoint Slides
1. Suchman’s Stages of Illness
Shock and disbelief
Denial
Awareness
Restitution
Resolution
2a. Needs of the Family of the Patient with High-Acuity Illness
Information
Comfort
Support
Accessibility
Assurance
2b. Communication Requirements of the Family
Openness
Honesty
Direct
Frequent
Ongoing
II. Coping with Acute Illness
A. Complementary and alternative therapies
1. Numerous strategies are used to help patients cope with psychological and physical illness–related stressors. Complementary and alternative therapies can help reduce stress include:
a) Aromatherapy
(1) Use of oils to reduce stress and anxiety. Oils may be inhaled or used with massage.
Commonly used oils include lavender, and jasmine.
b) Therapeutic Humor
(1) Humor is used to relieve stress. Humor strengthens the bonds among the patient, family, and nurse. The use of humor is tricky during a serious illness.
c) Massage Therapy and Therapeutic Touch
(1) Massage can help promote relaxation, reduce anxiety, and facilitate sleep.
(2) The vascular, muscular, and nervous systems are positively affected by massage.
(3) Massage is an acceptable tool to manage pain. Conditions that do not indicate massage therapy include advanced osteoporosis, bone fractures, burns, deep vein thrombosis,
eczema, phlebitis, and skin infections.
d) Guided Imagery
(1) Guided imagery is a technique that encourages relaxation.
(2) The patient is asked to focus on positive thoughts and experiences.
PowerPoint Slides
1. Complementary and Alternative Therapies
Aid in stress reduction
May be used in place of or in addition to traditional therapies
Must be an informed decision
2. Aromatherapy
Use of oils to reduce stress and anxiety
May be inhaled or used with massage
Common oils
3. Humor
Relieves stress
Promotes positive communication
Requires skill to use successfully in high-acuity situations
4a. Massage Therapy
Manipulation of soft tissues of the body using the hands
Can reduce anxiety, promote sleep, and reduce pain
Has positive effect on muscular and nervous systems
4b. Massage Therapy and Pain Management
Used to treat all pain domains:
Physical
Spiritual
Emotional
4c. Contraindications to Massage Therapy
Advanced osteoporosis
Bone fractures
Burns
Deep vein thrombosis
Eczema
Phlebitis
Skin infections
5. Guided Imagery
Focuses thinking on positive thoughts and images
Can be used to distract the patient from painful events or treatments
III. Patient- and Family-Centered Care
A. Educational needs of patients and families
1. Health literacy
a) Patients and families require education with a goal to reduce stress and promote comfort.
Establishing a relationship with the patient facilitates trust in the nurse and will promote
security and facilitate learning.
b) Some factors inhibit learning in the high-acuity patient. Obstacles to education can involve condition-related fatigue, blocks to communication and pain. The nurse must meet the
physiological needs of the patient before attempting to promote understanding.
c) Palazzo has established educational needs of patients and families. These Include:
(1) Information about progress
(2) Informed decision making
(3) Acknowledgement of the past
(4) Optimal learning environment
(5) Orientations to routines and care
(6) Motivation
2. Transfer anxiety
a) Transfer of the patient to a less-acute care unit could cause transfer anxiety in the patient or family.
b) The anxiety is the result of a change in environment.
c) A plan of care allowing the patient and family to ask questions will promote success of the transfer.
d) Moving the patient during daytime hours will help to lessen anxiety.
B. Visitation policies
1. Many intensive care units in the United States have restrictive visiting policies:
a) Studies indicate that patients prefer open visitation policies.
b) Patients demonstrate reduced risks of cardiovascular complications, decreased mortality, and anxiety levels when their visiting hours are unrestricted.
2. The visiting activities of children often are restricted in intensive care units:
a) The rationales for these limitations are concerns for the risk of infection and for the emotional well-being of the child.
b) In the event a family member is at risk for not recovering, exceptions should be made to allow for “goodbyes”
3. Traditionally, family members have been restricted from their loved ones during invasive procedures and cardiopulmonary resuscitation:
a) Studies reveal that many facilities do not have policies restricting family presence during CPR.
b) Twibell identified benefits of the presence of the family during CPR.
4. The care delivery model embraces the presence of the family members at the bedside:
a) Nursing staff should provide education to the family members regarding what to expect and actions that should be taken.
b) Hospital policies should carefully address the facility’s stance toward visitors exhibiting
negative behaviors.
PowerPoint Slides
1. Educating the High-Acuity Patient
Goals
Reduce stress
Promote comfort
Establish a relationship with the patient
2. Barriers to Learning for the High-Acuity Patient
Condition-related fatigue
Communication barriers
Endotracheal tubes
Hourly procedures
Diagnostic tests
Pain
Medications
3. Educational Needs of Patients and Families
Information about patient progress
Informed decision making
Acknowledgement of the past
Optimal learning environment
Orientation to routines and care
Motivation
4. Transfer Anxiety
Can result from movement to a less-acute care unit
Affects patient and family
Tips to reduce:
Provide information to patient and family
Encourage questions from patient and family
Transfer during daytime hours
5. Visitation Policies
Patients prefer open visitation policies
Benefits of flexible visitation policies:
Reduced incidence of cardiovascular complications
Decreased mortality
Reduced anxiety levels
6. Visitation of Children in Intensive Care Units
Limitations are based on:
Concerns for the risk of infection
Concerns for emotional well-being of the child
Should be allowed if death is imminent
7a. Visitation Limitations
During invasive procedures
During CPR
7b. Twibell’s Summary of Benefits of Family Presence during CPR
The ability of the family to grasp the seriousness of the patient’s illness.
Family members see firsthand that everything was done for the patient.
Families move more positively through the grieving process.
Removal of doubt by families about what is happening to the patient.
Families experience less anxiety and fear.
Provision of a sense of closure for families who lose a loved one.
Facilitation of the grieving process by families who lose a loved one.
IV. Cultural Diversity
A. Cultural competence
1. Cultural Assessment
a) Cultural competence is defined as an awareness of one’s own thoughts and feelings without letting them influence the care of patients with different backgrounds.
b) Nurses who have self-awareness have knowledge, understanding, respect, and acceptance for the patient’s culture.
c) Cultural competence includes sensitivity to the culture, race, gender, sexual orientation, social class, and economic status of the patients.
2. Other Sources of Diversity
a) Immigrants and refugees may have specific health beliefs and practices.
b) Racial and ethnic considerations must be taken into account.
c) Socioeconomic status.
d) Sexual orientation.
B. Developing cultural competence
1. In the quest for developing cultural competence, the nurse must give consideration to individual characteristics. This will prevent stereotyping. The nurse must assess and affirm differences. Educational materials provided must be in the language and at the level needed by the patient. Judgment cannot be made concerning the patient’s choices. The CRASH (culture, respect,
assess/affirm, sensitivity/self-awareness, and humility) model is often used:
a) Consider culture
b) Show respect
c) Assess and affirm differences
d) Show sensitivity and self-awareness
e) Provide care with humility
PowerPoint Slides
1a. Cultural Competence
Self-awareness of one’s own thoughts and feelings about others with different backgrounds
Self-awareness can improve:
Knowledge
Understanding
Respect
Acceptance
1b. Categories Included in Cultural Competence
Culture
Race
Gender
Sexual orientation
Social class
Economic status
2. The CRASH Model
Consider culture
Show respect
Assess and affirm differences
Show sensitivity and self-awareness
Provide care with humility
V. Palliative and End-of-Life Care
A. Palliative care
1. Why Palliative Care?
a) Palliative care is a multidisciplinary approach to relieving suffering and improving the quality of life.
b) Interventions involve both nursing and medical treatment to manage pain and symptoms.
c) The program includes members from other disciplines, including social workers and chaplains.
d) Palliative care models allow the needs of patients and families to be met in a cost-effective manner.
e) Needs for palliative care are growing.
f) Benefits of palliative care include reduced cost, increased bed capacity, and improved quality of care.
2. High-Acuity Patients and Palliative Care:
a) Cancer is the most common disorder requiring palliative care.
b) Other disorders can include cardiac disease, chronic renal failure, and neurological diseases.
3. Barriers to Providing Palliative Care:
a) Barriers to palliative care exist for the high-acuity-care patient.
b) It is often difficult to make the transition from a cure perspective to that of a palliative nature.
c) The limited collaboration and inconsistent communication between physicians and nurses also plays a role.
d) These barriers can be managed with education.
4. A Multidisciplinary Approach
a) A palliative care team is needed to facilitate the patient’s progression to a successful palliative care path.
b) The team will consist of the high-acuity nurse and personnel from related discipline.
5. Assessment of Sources of Conflict
B. End-of-life care
1. Barriers to End-of-Life Care in High-Acuity Settings:
a) The Patient Self-Determination Act requires all patients be given information about their right to formulate advanced directives.
b) The American Association of Critical-Care Nurses (AACN) recommends nurses base their practice on individual professional accountability; thorough knowledge; recognition and
appreciation of a person’s wholeness, uniqueness, and significant social–environmental
relationships; and appreciation of the collaborative role of all health team members.
c) The Patient Self-Determination Act requires that all patients be provided information about their right to make advanced directives, living wills, and appointment directives:
(1) Living wills
(2) Power of Attorney for health care
2. Allow Natural Deaths
a) Allow Natural Death (AND)
(1) Using this term implies that the patient is dying and that everything possible is being done to keep the patient comfortable and allow the dying process to occur naturally.
(2) The goal of AND is to prevent unnecessary suffering and allow nature to take its course.
3. Educational Focus
a) Educational programs must be developed and directed toward those individuals already in the workforce as well as those who are completing their basic education requirements.
PowerPoint Slides
1. Palliative Care
Multidisciplinary approach
Geared toward improving quality of life and relieving suffering
Includes all health disciplines
2. Benefits of Palliative Care
Reduced cost
Increased bed capacity
Improved quality of care
3. Disorders Requiring Palliative Care
Cancer (most common)
Cardiac disease
Chronic renal failure
Neurological conditions
4. Barriers to Palliative Care
Difficulty transitioning from a “cure perspective”
Limited collaboration between physicians and nurses
Inconsistent communication
Fragmented care
5. The Palliative Care Team
Goals to meet psychological, social, cultural, and spiritual needs
Includes the high-acuity nurse and other members
Conferences are instrumental
The care plan must be comprehensive
6. The Patient Self-Determination Act
Part of the Omnibus Budget Reconciliation Act
Mandates all patients be given information about the right to formulate advanced directives:
Treatment directives (living wills)
Appointment directives (power of attorney for health care)
7. Allow Natural Death (AND)
Synonymous with DNR
Term acceptable to families
Goals:
Prevent unnecessary suffering
Allow for nature to take its course
VI. Environmental Stressors
A. Sensory perceptual alterations
1. Sensory overload and deprivation
a) Environmental characteristics of the high-acuity care unit have a significant impact on the
patient.
b) The patient is at risk for both sensory overload and deprivation.
c) The individual’s normal stimuli are interrupted, and the senses simultaneously are being
bombarded with continuous strange stimuli.
d) Those who are very old, very young, postoperative, or unresponsive are at the greatest risk for this difficulty, known as sensory perceptual alterations (SPAs).
e) The nurse must recognize the stressors presented by the environment and promote adequate sleep and rest periods as well as work to reduce unnecessary noises:
(1) The Environmental Protection Agency recommends that hospitals contain noise levels. Daytime levels should not exceed 45 dBA.
(2) Nighttime levels should not exceed 35 dBA. Normal conversation is approximately
60 dBA.
2. Delirium
a) Delirium can result from sensory perceptual alterations in awareness, impaired ability to attend to environmental stimuli, and disorganized thinking.
b) The nurse must assess and identify the cause of the delirium.
c) Causes of delirium vary. Once determined, the underlying causes must be treated.
3. Sleep deprivation
a) Normal rest and sleep are compromised in the high-acuity unit.
b) The changes in the light/dark cycle, pain, and environmental stimuli are related factors.
B. Interventions to decrease sensory perceptual alterations
1. Prevent sleep deprivation
a) Patients need at least two hours of uninterrupted sleep to promote REM functioning.
2. Facilitate communications
a) Communication with mechanically ventilated patients is needed to prevent SPA.
b) Stressors are caused by the inability to speak.
c) Nonverbal behaviors will vary and must be closely reviewed for messages.
d) When caring for the patient who cannot speak, the nurse must act as a patient advocate.
(1) The nurse will need to provide support for the decision of the patient or designated
surrogate.
(2) These choices could conflict with those of the health care provider and family.
PowerPoint Slides
1a. Cause of Environmental Stressors in High-Acuity Care Units
Sensory overload
Sensory deprivation
Pain
Loss of sleep
1b. Patients Most Affected by Environmental Stressors
The aged population
Very young patients
Postoperative patients
Unconsciousness patients
2. Role of the Nurse Caring for the High-Acuity Patient
Assess the patient’s normal environmental stimuli
Provide normal stimuli, if possible
Promote adequate rest and sleep
Reduce unnecessary environmental noise
3. Environmental Protection Agency Recommendations
Daytime levels not to exceed 45 dBA
Nighttime levels not to exceed 35 dBA
4. Environmental Stimuli and the Unconscious Patient
An assessment of the normal stimuli for the unconscious patient must be completed.
The nurse might need to consult a friend or family member about normal stimuli for the patient.
5a. Delirium
Sensory perceptual alterations
Physical disruptions
5b. Manifestations of Delirium
Fluctuating awareness
Impaired ability to attend to environmental stimuli
Disorganized thinking
5c. Potential Causes of Delirium
Hypoxemia
Alcohol or barbiturate withdrawal
Hyponatremia
Drug reactions
Infections
Liver dysfunction
5d. Role of the Nurse Caring for the Patient Experiencing Delirium
Assess and determine cause
Manage cause
6a. Alterations of the Rest and Sleep Cycles
Associated with changes in the light/dark cycle
Causes:
Pain
Environmental noise
Caregiver interruptions
Stress
6b. Alterations of the Rest and Sleep Cycles (continued)
Management:
Planned rest periods of at least two hours
Nonpharmacologic induction of sleep recommended
Closing doors
Posting signs
6c. Benefits of REM Sleep
Protein anabolism
Improved immune function
Improved healing
7. Communication with Mechanically Ventilated Patients
Necessary to prevent SPA.
The inability to verbally communicate is a stressor.
Assessment of nonverbal behaviors needed.
8. The Patient Who Cannot Speak
Nurses must be patient advocates.
Nurse must represent the patient or patient representative:
Choices may conflict with provider or family desires.
VII. Chapter Summary
VIII. Clinical Reasoning Checkpoint
IX. Post-Test
X. References
Suggestions for Classroom Activities
Ask each student to develop two study questions based on Suchman’s stages. Use these questions as part of an in-class review.
Divide the class into small groups of two to four students. Instruct student groups to develop small care plans addressing the education needs of the acutely ill patient. Allow only a short time for the exercise. Once complete, ask the student groups to share their work with the entire class.
Having the correct learning environment for educating for the acutely ill patient is crucial. Ask
students to list their concepts of the optimal learning environment.
Suggestions for Clinical Activities
Discuss the implications of ensuring that patients report all complementary and alternative therapies being used. How and where should they be documented?
During clinical, assign students to patients who are considered to be high acuity. During the clinical post conference, ask the students to determine which Suchman stage the patient they cared for was demonstrating.
Invite a massage therapist to visit with the clinical group. Ask the massage therapist to discuss the use of massage for patients experiencing pain.
Wagner et al., Instructor’s Resource Manual for High-Acuity Nursing, 6th Edition
©2014 by Education, Inc.
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