High-Acuity Nursing, 6th Edition

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.