...Professor/Instructor: Type of the Report: ? Individual,...
...1 Diagram of the equipment present in...
...2 Diagram of the system with additional...
...Time in (s) for Half Open Water...
...to Time (s) for Fully Open Water...
...with Ti=50s-1 and the Proportional Integral Controller...
...with Ti=50s-1 and the Proportional Integral Controller...
...Table 2: Calculation for manual control at...
...Table 3: Calculation for manual control at...
...is one of the widely used in...
...between each other. The first objective in...
...was to analyze the co-current behavior of...
...done by changing the response of the...
...the response of the system regarding a...
...step change in the steam percentage from...
...65% to 100%. The second objective was...
...was to investigate the performance of different...
...response were compared. The results of the...
...The results of the comparison between the...
...the comparison between the different types and...
...controller proved that the PID controllers are...
...PID controllers are the best types of...
...controllers to predict the behavior of a...
...and stable response for approaching the desired...
...response for approaching the desired set point....
...exchangers are cheap for both maintenance and...
...space and aren’t the most efficient type...
...of heat exchangers. The name derive from...
...which refer to the fluid flow directions...
...was flowing on the shell side. Proportional,...
...process information and the desired set point...
...on these errors the controller actuates in...
...controller actuates in the process to make...
...process to make the controlled variable reach...
...controlled variable reach the set point (1)....
...(1). Figure 1shows the function of a...
...Figure 2 shows the transfer function of...
...in Laplace domain. The parameters of a...

...Professor/Instructor: Type of the Report: ? Individual,...
............................. 13 Introduction The main objectives of...
...were to study the performance of the...
...the performance of the proportional-integral (PI) and...
...controllers in controlling the 1 liquid level...
...a tank using the Cascade control system...
...LabView and investigate the properties of the...
...the properties of the open and closed...
...closed control loops. The selection of proper...
...was assisted through the use of LabView,...
...simulation package design for control system. The...
...for control system. The simulation package was...
...in cascade mode. The performance of the...
...The performance of the different type of...
...and PID was for a liquid level...
...examined by adjusting the tuning parameters Kc,...
...In this experiment, The Multi-Process Control Trainer...
...cascade control system. The simulation process involved...
...simulation process involved the tuning of the...
...the tuning of the PI and PID...
...controllers to control the liquid level of...
...liquid level of the lower and upper...
...a set point. The main objective of...
...objective of using the PI and PID...
...was to investigate the control response of...
...control response of the system and reduce...
...system and reduce the effect of various...
...disturbances such as the change of the...
...the change of the liquid level rate...
...level rate in the system. However, the...
...the system. However, the control process was...
...of values 3.0 for Kc in order...
...order to accelerate the response of the...
...the response of the control process, and...
...process, and 0.010 for the Ti in...
...and 0.010 for the Ti in order...
...might occur in the control system. The...
...the control system. The PID parameters were...
...system to obtain the liquid level set...
...point of 20% for the upper tank...
...of 20% for the upper tank and...
...tank and 10% for the lower tank....
...and 10% for the lower tank. The...
...the lower tank. The three control setting...
...parameters used throughout the experiment for PID...
...throughout the experiment for PID controller in...
...and Ti= 1.3. The experimental result was...
...Ti to illustrate the effect of the...
...the effect of the tuning parameters on...
...tuning parameters on the control system at...
...several controllers available for engineers to use...
...process by determining the action 2 needs...
...needs to control the process variable. To...
...In this experiment, the upper tank and...
...controller after allowing the system to reach...
...feedback controller sends the output information back...
...information back to the controller in order...
...set point. When the liquid level was...
...was higher than the set point, the...
...the set point, the valves were opened...
...opened to reduce the level by allowing...
...level by allowing the liquid to flow...
...flow out of the tank. Alternatively, when...
...tank. Alternatively, when the liquid level was...
...level was below the desired set point,...
...an order by the controller is sent...
...sent to close the valves and allow...
...valves and allow the liquid level to...
...this is called the reverse action controller....
...monitor and record the data for both...
...record the data for both tanks. The...
...for both tanks. The mechanism is continues...
...is continues until the system reaches stability...
...both tanks reaches the set points. This...
...done by calculating the error between the...
...the error between the controller variable value...
...variable value and the desired set point...
...be represented by the following equation: ...

...Professor/Instructor: Type of the Report: ? Individual,...
...Liquid Level Percent for P Controller with...
...Liquid Level Percent for PI Controller with...
...Liquid Level Percent for PID Controller with...
...Liquid Level Percent for PID Controller with...
...7: Vessel Pressure for P Controller with...
...8: Vapour Pressure for PI Controller with...
...9: Vapour Pressure for PID Controller with...
...10: Vapour Pressure for PID Controller with...
...Liquid Mass Flow for P Controller with...
...Liquid Mass Flow for PI Controller with...
...Liquid Mass Flow for PID Controller with...
...Liquid Mass Flow for PID Controller with...
...Liquid Level Percent for P Controller with...
...Liquid Level Percent for PI Controller with...
...Liquid Level Percent for PID Controller with...
...Liquid Level Percent for PID Controller with...
...19: Vessel Pressure for P Controller with...
...20: Vessel Pressure for PI Controller with...
...21: Vessel Pressure for PID Controller with...
...22: Vessel Pressure for PID Controller with...
...Liquid Mass Flow for P Controller with...
...Liquid Mass Flow for PI Controller with...
...Liquid Mass Flow for PID Controller with...
...Liquid Mass Flow for PID Controller with...
...Technology Inc., 2015). The Aspen HYSYS is...
...process chemical plants. The objective of this...
...design and determine the effect along with...
...effect along with the functionality between different...
...and controlled by the use of PID...
...separation unit using the ATV method (Dhib...
...(Dhib R, 2013). The PID controllers is...
...in most of the control system industry....
...control system industry. The controller attempts to...
...attempts to minimize the error that may...
...may occur in the process by adjusting...
...process by adjusting the process variable trying...
...to keep at the set point. However,...
...set point. However, the PID controller used...
...control and calculate the vessel pressure as...
...as well as the liquid level percentage....
...liquid level percentage. The process variable set...
...used to control the process are the...
...the process are the input values of...
...input values of the process. With the...
...the process. With the use of the...
...the use of the HYSYS dynamic simulation,...
...HYSYS dynamic simulation, the system will be...
...be identify as the controller will be...
...be operated using the tune mode as...
...as well as the script charts. The...
...the script charts. The result of the...
...The result of the experiment that the...
...the experiment that the PID controller is...
...PID controller is the most accurate and...
...chemical industry over the Proportional and Proportional...
...Controller due to the functionality of it...
...32 constant on the process in reaching...
...process in reaching the steady state. However,...
...steady state. However, the addition of energy...
...of energy to the control showed a...
...minimum effect on the controller process. Page...
...very essential aspect for designing safe process...
...in most of the chemical process industry...
...industry that involve the manufacturing of very...
...Since most of the chemical processes are...
...occur. A such, the chemical process are...
...dynamic in nature, the selecting for the...
...nature, the selecting for the type of...
...the selecting for the type of a...
...and efficient of the process. Therefore, feed-backward...
...value continuously as the differences between the...
...the differences between the desired set point...
...set point and the process variable by...
...by computing both the derivative and the...
...the derivative and the integral of the...
...the integral of the signaled error. A...
...controller (PI); on the other hand, is...
...another type of the PID controller in...
...controller in which the derivative factor of...
...derivative factor of the error is not...
...more accurately in the simulation dynamic mode...
...polynomial interpolation in the vicinity of the...
...the vicinity of the operating point. The...
...the operating point. The PID process variable...
...is defined once the PID controller placed...
...controller placed onto the PFD as shown...
...as shown in the equation below: ...

...2 Type of the Report: ? Report...
...1: Schematic of the Double Pipe Heat...
...vs. Time (sec) for the half-open water...
...Time (sec) for the half-open water valve.............................
...vs. Time (sec) for various flow rates...
...13 Figure 4: The Change in Temperature...
...15 Figure 5: The Change in Temperature...
...15 Figure 6: The Change in Temperature...
...Table 1: Data for manual run: 100%...
...Table 2: Data for manual run: 65%...
...Table 3: Data for manual run: variable...
...Table 4: Data for manual run: variable...
...Temperature with time for 0% to 100%...
...Temperature with time for 0% to 100%...
...0 to 40 for Kp=3, Ti=25, Td=0...
...0 to 40 for Kp=3, Ti=25, Td=25...
...0 to 40 for Kp=3, Ti=0, Td=0...
...on co-current operations for a double pipe...
...pipe heat exchanger. The heat exchanger consisted...
...two concentric tubes, the water flowed through...
...water flowed through the inner pipe and...
...steam flowed in the annular space between...
...annular space between the two tubes. The...
...the two tubes. The first objective was...
...was to analyze the behavior between open...
...closed loop control for co-current heat exchanger...
...heat exchanger operations. The second objective of...
...Td to evaluate the performance of P,...
...completed and analyzed. The first 6 cases...
...control operations while the remaining 8 cases...
...parameters to choose the most suitable feedback...
...was observed that the closed loop control...
...system errors with the use of a...
...in comparison to the open loop control...
...feedback action. From the results obtained, the...
...the results obtained, the PID controller was...
...selected to be the most appropriate type...
...in comparison to the other two controllers....
...other two controllers. The PID controller also...
...used in industry. The double pipe heat...
...2 exchanger and the shell and tube...
...heat exchanger are the most commonly used....
...In this experiment, the double pipe heat...
...used to study the different control performances....
...different control performances. The double pipe heat...
...concentric pipes with the cold effluent passing...
...effluent passing through the annulus 1 of...
...annulus 1 of the pipe, while the...
...the pipe, while the hot fluid passes...
...fluid passes over the inner pipe. The...
...the inner pipe. The double pipe heat...
...known to be the simplest in comparison...
...heat exchangers. In the heat exchanger two...
...and counter current. The mechanism of the...
...The mechanism of the co-current flow 1...
...is represented by the hot and cold...
...fluid flowing in the same direction. However,...
...direction. However, if the hot and cold...
...flow is in the opposite direction the...
...the opposite direction the mechanism of flow...
...order to control the temperature and pressure...
...temperature and pressure for the heat transfer...
...and pressure for the heat transfer operations,...
...are adjusted to the desired set points....
...closed loop controllers. The open loop controller...
...a feedback and the input is selected...
...selected based on the current state of...
...current state of the system. The closed...
...of the system. The closed loop controller...
...operates by identifying the difference between the...
...the difference between the output and reference...
...closed loop process, the error of the...
...the error of the output signal is...
...will not impact the output. There are...
...integral derivative controllers. The stability of the...
...The stability of the response from controllers...
...1 usually important for industrial applications. The...
...for industrial applications. The PID controller is...
...from tuning operations the controller parameters are...
...parameters are selected. The stability of response...
...such Ti and Td.The following equation can...
...to 4 represent the output of the...
...the output of the PID controller: 4...
...= derivative gain The integral and derivative...
...its relationship to the 4 proportional gain...
...proportional gain by the following equations: Ki...
...= derivative time The transfer function of...
...transfer function of the P, PI and...
...be expressed through the relation 4 of...
...relation 4 of the proportional response by...
...proportional response by the following equations: Kp...
...where: Kp is the controller gain ?D...
...gain ?D is the derivative time ?i...
...time ?i is the integral time ?...
...time ? is the time constant 5...
...1: Schematic of the Double Pipe Heat...
...order to begin the experiment, all inlet...
...avoid burns. 3. The vent valves were...
...be present. 4. The main steam valve...
...opened fully. 5. The control box (which...
...box (which housed the Fisher-Rosemount apparatus, steam...
...turned on and the thermocouple reading number...
...Manual Mode 6. The system was set...
...was set up for co-current in the...
...for co-current in the first trail. 7....
...first trail. 7. The water inlet valve...
...half way. 8. The steam inlet valve...
...was opened all the way. 9. The...
...the way. 9. The steam controller was...
...to 100% and the starting water flow...
...was recorded. 10. The steam was allowed...
...to run through the heat exchanger until...
...state. This allowed the steam to enter...
...to enter from the steam valve, flow...
...flow parallel in the shell portion of...
...shell portion of the cold water and...
...then finally enter the drainage valve. 7...
...valve. 7 11. The inlet water valve...
...rate. To determine the exact water flow...
...water flow rate, the odometer was used...
...pass through. 12. The inlet water valve...
...avoid cracking. 13. The steam valve was...
...then opened. 14. The initial water flow...
...rate was recorded. The temperature was recorded...
...were seen in the temperature. This showed...
...This showed that the system was at...
...at steady state. The final water volume...
...was recorded. 15. The steam controller was...
...at 65% and the initial water flow...
...was repeated. 17. The steam controller was...
...at 100% and the starting water volume...
...was repeated. 19. The water inlet valve...
...three quarter and the steam controller was...
...to 65% of the way. 20. Step...
...Automatic Mode 21. The steam controller was...
...automatic mode. 22. The Kp (Proportional gain)...
...at 3 and the Ti (Proportional integral...
...at 50 and the Td (Proportional derivative...
...set at 0. The set point was...
...at 40% and the starting water volume...
...recorded 8 23. The temperatures were recorded...
...temperature was reached. The final water volume...
...was recorded. 24. The set point was...
...60% and with the same Kp, Ti...
...and Td values the water flow rate...
...was repeated. 26. The set point was...
...and Td values. The starting water flow...
...was repeated. 28. The set point was...
...and Td values. The starting water flow...
...was repeated. 30. The Ti value was...
...at 25 and the Td value change...
...change to 25. The starting water flow...
...values were recorded, the steam valve was...
...as well s the main steam valve...
...left over and the cold water valves...
...Results and Discussion The first set of...
...was performed in the manual mode, where...
...manual mode, where the temperature set point...
...10 seconds. In the second run, the...
...the second run, the set point was...
...to 100%, and the temperature readings were...
...in 10-second increments. The first 2 two...
...both performed while the water valve was...
...valve was half-open. The data trends from...
...data trends from the first two runs...
...vs. Time (sec) for the half-open water...
...Time (sec) for the half-open water valve...
...half-open water valve For the run where...
...water valve For the run where the...
...the run where the set point was...
...100% to 65%, the water flow rate...
...be 0.1852 gal/s. The resulting values for...
...The resulting values for step change, change...
...temperature, 63.2% of the step change, temperature...
...at 63.2% of the step change, time...
...are summarized in the table below. A...
...is shown in the appendix section of...
...Table 1: Data for manual run: 100%...
...7.9 63.2% of the Temperature Change 4.9928...
...at 63.2% of the Change 35.8 Corresponding...
...- Kp 0.225714286 The general equation for...
...The general equation for the transfer function...
...general equation for the transfer function is...
...(??s)+1 By substituting the controller gain and...
...constant value calculated for run 1, the...
...for run 1, the transfer function for...
...the transfer function for this run now...
...= (8) (0.60?s)+1 For the run where...
...(8) (0.60?s)+1 For the run where the...
...the run where the set point was...
...65% to 100%, the water flow rate...
...be 0.92 gal/s. The resulting values for...
...The resulting values for step change, change...
...temperature, 63.2% of the step change, temperature...
...at 63.2% of the step change, time...
...are summarized in the table below. 11...
...Table 2: Data for manual run: 65%...
...9.6 63.2% of the Temperature Change 6.0672...
...at 63.2% of the Change 29.1 Corresponding...
...0.274285714 By substituting the controller gain and...
...constant value calculated for run 1, the...
...for run 1, the transfer function for...
...the transfer function for this run now...
...(0.55?s)+1 From analyzing the two trends in...
...that they are the complete opposite of...
...if reflected across the x-axis. For the...
...across the x-axis. For the trend where...
...the x-axis. For the trend where the...
...the trend where the set point goes...
...100% to 65%, the curve decreases from...
...value of 23°C. For the trend where...
...of 23°C. For the trend where the...
...the trend where the set point goes...
...65% to 100%, the curve increases from...
...value of 30°C. The values of controller...
...0.23 and 0.27 for runs 1 and...
...and 2, respectively. The values of time...
...0.60 and 0.55 for runs 1 and...
...in both runs, the amount of time...
...amount of time for a response to...
...65% was approximately the same amount of...
...of time required for a response to...
...points at approximately the same amount of...
...of time. 12 The next runs were...
...flow rates, and the change in set...
...100% to 65%. The trends for the...
...65%. The trends for the two flow...
...The trends for the two flow rates...
...vs. Time (sec) for various flow rates...
...various flow rates The raw data for...
...The raw data for the run using...
...raw data for the run using the...
...the run using the flow rate of...
...in Table 8. The resulting values for...
...The resulting values for step change, change...
...temperature, 63.2% of the step change, temperature...
...at 63.2% of the step change, time...
...and controller gain for each flow rates...
...are summarized in the tables below. Table...
...Table 3: Data for manual run: variable...
...9.6 63.2% of the Temperature Change 6.0672...
...at 63.2% of the Change 29.1 Corresponding...
...Table 4: Data for manual run: variable...
...8.8 63.2% of the Temperature Change 5.5616...
...at 63.2% of the Change 28.8 Corresponding...
...0.251428571 By substituting the controller gain and...
...constant value calculated for the flow rate...
...value calculated for the flow rate of...
...of 0.92 gal/s, the transfer function for...
...the transfer function for this run now...
...(0.55?s)+1 By substituting the controller gain and...
...constant value calculated for the flow rate...
...value calculated for the flow rate of...
...of 0.25 gal/s, the transfer function for...
...the transfer function for this run now...
...(0.48?s)+1 By comparing the two transfer functions...
...two transfer functions for the two different...
...transfer functions for the two different flow...
...evident that both the controller gain and...
...values are larger for the run at...
...are larger for the run at 0.92...
...at 0.92 gal/s. The controller gain and...
...0.27 and 0.55 for the run at...
...and 0.55 for the run at 0.92...
...0.25 and 0.48 for the run at...
...and 0.48 for the run at 0.25...
...gal/s. Due to the direct proportionality between...
...proportionality between increasing the water flow rate...
...our results of the higher flow rate...
...flow rate allowing the system to reach...
...system to reach the desired set-point faster...
...set-point faster than the system with a...
...flow rate. 14 The next set of...
...of data was for the automatic mode,...
...data was for the automatic mode, where...
...automatic mode, where the performance of various...
...4 below demonstrates the temperature change of...
...(sec) Figure 4: The Change in Temperature...
...5 below demonstrates the temperature change of...
...of 40%, where the Kp value is...
...(sec) Figure 5: The Change in Temperature...
...Td =0) 15 The behavior of a...
...(sec) Figure 6: The Change in Temperature...
...4 above represented the performance of a...
...SP of 40%. The curve shows typical...
...a P-controller as the response does not...
...over and under the desired set point,...
...instead only approaches the set point. Figure...
...Figure 5 shows the performance of a...
...As per theory, the system with a...
...we see that the response with Ti=25...
...was stabilized at the desired set point...
...point faster than the response of the...
...the response of the system where Ti=50....
...system where Ti=50. The PI controller is...
...is represented using the following equation when...
...a disturbance in the system. ...

...MAN-MADE PROCESSES : for given process conditions....
...Control. processes is the motivation for Process...
...is the motivation for Process The ability...
...motivation for Process The ability to predict...
...ability to predict the results and improve...
...are assessed on the basis of quanti?ed...
...Mathematical relationship(s) between the A property speci?ed...
...speci?ed or ?xed for the process De?nitions...
...or ?xed for the process De?nitions are...
...signify non-destruction of the entities: mass, rate...
...relations based on the constitution of a...
...represent its properties. the interrelations (model). The...
...the interrelations (model). The properties are interrelated...
...used to by the assumptions. mathematically solving...
...assumptions. mathematically solving the model. Results are...
...obtained (predicted) by The applicability of results...
...process) Simulation (simulate) the system properties the...
...the system properties the outcome of the...
...the outcome of the process how the...
...the process how the properties would change...
...a De?nitions is the solution of a...
...a model with the objectives to Steady...
...physically interpreted. ? The obtained (simulated) results...
...results and experimental The results are compared...
...compared with experimental The model is revised...
...goes on unless the discrepancies are De?nitions...
...discrepancies are De?nitions The revised model is...
...simulated again and the The revision involves...
...again and the The revision involves reduction...
...involves reduction in the number where ...
... Conservation of the Property,  Thermodynamics...
...of energy is the Laws of Conservation...
...Conservation Conservation of the Property,  is...
...balances. time yields the change in ...
...may be non-zero for the mass over...
...be non-zero for the mass over that...
...time. Integration of the last equation over...
...over a given The generation term is...
...term is zero for overall mass Laws...
...: To ?nd the % Alcohol recovered...
...? Mass balance for alcohol : W...
...D Mass balance for water : Mass...
...: Mass balance for benzene : Examples...
...: Liquid in the tank F )...

...cardiac cells and the relationship between membrane...
...levels. 2. Describe the cardiac conduction system,...
...cardiac conduction system, the normal electrocardiogram (ECG)...
...and nursing responsibilities for the patient who...
...nursing responsibilities for the patient who requires...
...person at risk for developing dysrhythmias. 5....
...dysrhythmias arising from the sinoatrial (SA) node...
...9. Distinguish among the four conduction abnormalities,...
...11. Identify indications for pacemaker and implantable...
...and nursing implications for the patient receiving...
...nursing implications for the patient receiving these...
...electrolytes. 2. During the resting state, the...
...the resting state, the inside of the...
...the inside of the cell is more...
...negative relative to the outside of the...
...the outside of the cell due to...
...cell due to the differences in ion...
...and repolarization a) The transmission of electrical...
...produces changes in the myocardial cell membrane’s...
...electrical charge, stimulating the cardiac cells extending...
...cells extending across the myocardial muscle to...
...relaxation. b) As the cardiac cell receives...
...and repolarization of the cardiac muscle. 2....
...a) Depolarization (Phase 0)—the cell is almost...
...b) Repolarization (Phases 1–3)—the process of repolarization...
...potential (Phase 4)—during the resting membrane potential...
...repolarization is completed, the original electrochemical gradient...
...in place, and the cell is ready...
...a) Absolute refractory period—the cell cannot respond...
...stimulus regardless of the strength of the...
...the strength of the stimulus. b) Relative...
...b) Relative refractory period—the cell is relatively...
...is greater inside the cell. Sodium concentration...
...is greater outside the cell. Calcium concentration...
...is greater outside the cell. Produces intracellular...
...Produces changes in the cell’s membrane electrical...
...Cardiac Conduction and the Electrocardiogram 1. The...
...the Electrocardiogram 1. The cardiac cycle is...
...electrical circuit in the myocardium, where specialized...
...myocardial cells influence the electrical conduction pathway....
...cycle is essential for electrocardiographic interpretation. A....
...Electrical conduction of the heart 1. The...
...the heart 1. The primary pacemaker of...
...primary pacemaker of the heart is the...
...the heart is the sinoatrial (SA) node,...
...node, which controls the heart rate normally...
...per minute (bpm). The impulse from the...
...The impulse from the SA node is...
...transmitted: a) From the atria b) To...
...atria b) To the ventricles c) Along...
...conduction pathway 2. The normal conduction pathway...
...conduction pathway a) The impulse from the...
...The impulse from the SA node is...
...transmitted: (1) From the atria (2) To...
...atria (2) To the ventricles (3) Along...
...b) Starting at the SA node, the...
...the SA node, the conduction pathways continues:...
...continues: (1) To the atrial-ventricular (AV) node...
...node (2) To the bundle of His...
...(3) Proceeding along the left and right...
...(4) Terminating at the Purkinje fibers (5)...
...muscle cells B. The electrocardiogram 1. The...
...The electrocardiogram 1. The Normal ECG Pattern....
...placement is essential for accurate cardiac monitoring,...
...is verified by the nurse at the...
...the nurse at the beginning of each...
...1. Always check for frayed wires or...
...Electrical Conduction of the Heart Intrinsic electrical...
...Conduction Pathway 4. The Electrocardiogram (ECG) Represents...
...Interpretation Guidelines 1. The ECG is printed...
...small block of the graph paper being...
...0.04 seconds on the horizontal axis. The...
...the horizontal axis. The horizontal axis also...
...also represents time. The vertical axis of...
...vertical axis of the graph paper represents...
...(0.1 mV) on the vertical axis. For...
...the vertical axis. For basic ECG interpretation,...
...interpretation, time is the most important factor...
...R–R interval, examine the P wave, measure...
...P wave, measure the PR interval, determine...
...examine and measure the QRS complex, examine...
...examine and measure the QT interval, and...
...interval, and diagnose/interpret the rhythm. A. ECG...
...paper B. Measure the heart rate C....
...rate C. Examine the R–R intervals D....
...intervals D. Examine the P waves E....
...waves E. Measure the PR interval F....
...Examine and measure the QRS complex H....
...complex H. Measure the QT interval I....
...interval I. Diagnose the rhythm J. Clinical...
...2. Eight steps for ECG Interpretation Measure...
...IV. Risk Factors for Development of Dysrhythmias...
...are Prone to the Development of Dysrhythmias....
...it originates in the SA node. It...
...medication that blocks the parasympathetic innervations to...
...parasympathetic innervations to the SA node. B....
...produce angina if the cardiac output decreases...
...output decreases to the point of reducing...
...coronary circulation. Treatment for sinus tachycardia is...
...aimed at relieving the cause of increased...
...ectopic impulses within the atria. They may...
...may develop when the SA node is...
...foci) develops in the atria. A. Premature...
...pacemakers located in the atria B. Supraventricular...
...150 and 250. The rhythm is regular;...
...is regular; however, the P waves are...
...are buried in the preceding T wave....
...complex indicates that the ectopic pacemaker is...
...is located above the ventricles. 2. Treatment...
...ventricles. 2. Treatment for SVT varies, from...
...Valsalva’s maneuver to the use of calcium...
...than 250 bpm. The ventricular rate depends...
...rate depends on the number of impulses...
...that pass through the AV node. D....
...condition in which the atria are contracting...
...waves Described by the number of atrial...
...dysrhythmias occur because the SA node fails...
...to fire, so the AV node initiates...
...AV node initiates the impulses. The junctional...
...initiates the impulses. The junctional area is...
...is located around the AV node. 2....
...Pacemaker cells around the AV node have...
...bpm. 3. Once the pacemaker cell discharges,...
...pacemaker cell discharges, the impulse spreads upward...
...upward to depolarize the atria and downward...
...downward to depolarize the ventricles. 4. The...
...the ventricles. 4. The QRS complex appears...
...complex appears normal, the atria are depolarized...
...abnormal manner; therefore, the P wave might...
...might be inverted. The timing of the...
...The timing of the P wave is...
...abnormal; it precedes the QRS complex, and...
...QRS complex, and the PR interval is...
...than 0.12 seconds. The P wave also...
...be buried in the QRS complex, and...
...or might follow the QRS complex. 5....
...100 bpm. If the rate is between...
...drug therapy and/or the insertion of a...
...that originate in the ventricle and can...
...from loss of the atrial kick from...
...that originate in the ventricle and discharge...
...and discharge before the next normal sinus...
...During ECG interpretation, the nurse assesses and...
...assesses and describes the patient’s underlying cardiac...
...cardiac rhythm and the type of PVCs...
...major responsibility of the nurse is to...
...is to assess the patient for factors...
...assess the patient for factors that contribute...
...that contribute to the development of PVCs...
...of PVCs and the presence of specific...
...fatal rhythm, is the most common cause...
...2. Defibrillation is the treatment of choice...
...or vasopressin. If the patient remains pulseless,...
...of electrical impulses. The patient is unconscious...
...is imperative that the nurse check that...
...nurse check that the rhythm is verified...
...5. Ventricular Fibrillation The most common cause...
...arrest. Defibrillation is the treatment of choice...
...inhibited anywhere along the conduction pathway. Factors...
...activity. 2. When the delay occurs at...
...delay occurs at the antrioventricular (AV) node...
...are based on the relationship of the...
...the relationship of the P wave to...
...P wave to the QRS complex. A....
...in conduction through the AV node; the...
...the AV node; the remainder of the...
...the remainder of the ECG is normal....
...asymptomatic; however, in the presence of acute...
...is present, but the PR interval is...
...constant before dropping the QRS complex. Nursing...
...management depends on the degree of block...
...are exhibited by the patient. c) Management...
...emergency treatment, because the atria and ventricles...
...inadequate filling of the ventricles. No impulses...
...are conducted through the AV node. The...
...the AV node. The atria and ventricles...
...regular, as is the R–R wave interval,...
...wave interval, but the PR intervals vary....
...no relationship between the P wave and...
...P wave and the QRS complex, because...
...QRS complex, because the atria and the...
...the atria and the ventricles are paced...
...a separate pacemaker. The QRS complex is...
...wide because of the ventricular origin of...
...ventricular origin of the stimulus. In rare...
...In rare cases, the ventricular rate is...
...ventricular fibrillation. Treatment for complete heart block...
...heart block is the same as for...
...the same as for type II second-degree...
...in conduction through the bundle of His...
...blocked. Occurs in the AV nodal area....
...not conducted through the AV node. Atria...
...No relationship between the P wave and...
...in conduction through the bundle of His...
...travels slowly through the blocked side. 12-lead...
...their effects during the slow and fast...
...are summarized in the box called “Related...
...impulse conduction through the atria, ventricles, and...
...atria, ventricles, and the bundle of His....
...automaticity and prolonging the refractory period of...
...refractory period of the heart. They are...
...are indicated in the treatment of supraventricular...
...used chiefly in the treatment of ventricular...
...a maintenance therapy for supraventricular dysrhythmias. 3....
...II agents block the effects of catecholamines...
...(1) Most of the class II agents...
...II drugs decrease the heart rate, the...
...the heart rate, the heart rate might...
...repolarization and prolonging the refractory period. They...
...period. They increase the fibrillation threshold (making...
...fibrillation threshold (making the cell more resistant)...
...are indicated in the treatment of atrial...
...These drugs block the entry of calcium...
...of calcium through the cell membranes, thereby...
...depolarization. Automaticity in the SA node is...
...blockers commonly used for treating supraventricular tachydysrhythmias....
...not fit within the four major classes....
...any antiarrhythmic agent, the nurse assesses the...
...the nurse assesses the following baseline data:...
...ECG interpretation using the seven-step process b)...
...Physical assessment of the cardiac, respiratory, and...
...is synchronized with the patient’s heart rhythm....
...considerations. In preparation for the procedure, the...
...In preparation for the procedure, the nurse...
...for the procedure, the nurse obtains informed...
...consent and educates the patient as to...
...patient as to the purpose of the...
...the purpose of the cardioversion and what...
...again depending on the type of defibrillator...
...II Agents Block the effects of catecholamines....
...myocardial contractility Treatment for SVTs Nursing assessment...
...electrical stimulus to the heart when the...
...the heart when the heart fails to...
...cardiac output. a) The pulse generator is...
...electrical stimulus to the heart when necessary....
...exists: failure of the conduction system, failure...
...electric impulses to the myocardium transthoracically through...
...and posteriorly on the chest. b) This...
...a painful experience for the patient, who...
...painful experience for the patient, who should...
...medicated accordingly. c) The presence of an...
...placed directly on the surface of the...
...the surface of the heart. b) Affixed...
...b) Affixed to the epicardium, the pacing...
...to the epicardium, the pacing wires are...
...are brought through the skin (below the...
...the skin (below the sternum) for access....
...(below the sternum) for access. 4. Transvenous...
...electrical stimulation of the right ventricular or...
...two approaches available for placing a pacing...
...direct insertion of the pacing wire or...
...port c) When the procedure is complete,...
...proper placement of the lead wire in...
...addition to assuring the patient did not...
...experience complications from the central line placement...
...pneumothorax). d) Caring for the transvenous pacing...
...d) Caring for the transvenous pacing wire...
...line poses risks for blood stream infection....
...tissue pocket (above the muscles and ribs,...
...and ribs, below the clavicle) in the...
...the clavicle) in the chest wall. b)...
...chest wall. b) The leads are passed...
...passed transvenously into the heart and rest...
...and rest on the endocardium. c) The...
...the endocardium. c) The generator is a...
...programmed according to the needs of the...
...the needs of the patient (Fig. 8-38)....
...Ventricle— Pacemakers have the ability to pace...
...ability to pace the atrium, the ventricle,...
...pace the atrium, the ventricle, or both...
...sequential”) chamber. 2. Atrium—The atria can also...
...be noted on the ECG rhythm strip...
...appears just before the wave. This method...
...of pacing, both the atria and the...
...the atria and the ventricles are paced...
...Spikes appear before the wave and the...
...the wave and the QRS complex on...
...QRS complex on the ECG. C. Pacemaker...
...1. Pacemakers have the capability of sensing...
...be set into the device. Pacemakers have...
...electrical events in the heart. There are...
...Pacing problems 1. The number of times...
...number of times the pacemaker fires is...
...is determined by the sensitivity setting of...
...sensitivity setting of the pacemaker. If the...
...the pacemaker. If the sensitivity is too...
...is too low, the pacemaker may not...
...may not sense the patient’s own cardiac...
...more frequently. If the sensitivity is too...
...is too high, the pacemaker is better...
...able to sense the patient’s own cardiac...
...to describe how the device functions according...
...according to where the pacing leads are...
...leads are and the mode of pacing....
...of cardiomyopathy. b) The device is a...
...Patients must understand the difference between heart...
...cardiac arrest. e) The ICD does not...
...Patient education a) The patient is taught...
...is taught that the ICD can “reorganize”...
...well as stimulate the heart. (Pacemaker action...
...Considerations 1. Caring for a patient with...
...care, including preparing the patient for insertion...
...preparing the patient for insertion of an...
...electrical stimulus to the heart Used when...
...electrical stimulus to the myocardial cells Used...
...different areas of the heart. Most common...
...cardioverter/defibrillator (ICD) Implanted for those who aborted...
...XV. References Suggestions for Classroom Activities Have...
...Classroom Activities Have the students practice identifying...
...ventricular contractions using the seven steps in...
...they have cared for, past or present,...
...were predisposing factors for the development of...
...predisposing factors for the development of premature...
...Discuss nursing diagnoses for patients experiencing cardiac...
...cardiac dysrhythmias. Suggestions for Clinical Activities Have...
...Clinical Activities Have the students obtain ECG...
...they have cared for, past or present,...
...if predisposing factors for the development of...
...predisposing factors for the development of ventricular...
...Instructor’s Resource Manual for High-Acuity Nursing, 6th...

...Acute Pain in the High-Acuity Patient Objectives:...
...Objectives: 1. Explain the multidimensional nature of...
...issues related to the under treatment of...
...acute pain in the high-acuity adult patient...
...management of pain for the high-acuity adult...
...of pain for the high-acuity adult patient....
...focused assessments of the patient receiving opioid...
...populations. 8. Discuss the nursing management of...
...sedation populations. I. The Multifaceted Nature of...
...acute pain 1. The International Association for...
...The International Association for the Study of...
...International Association for the Study of Pain...
...of pain 1. The multifaceted conceptualization of...
...is based on the theoretical model by...
...pain behaviors 2. The First Facet: Nociception—refers...
...Facet: Nociception—refers to the activation of special...
...activate nociceptors in the affected tissue. a)...
...(2) Begins in the peripheral nervous system...
...system and initiates the exchange of sodium...
...and potassium across the neuronal membranes, causing...
...to conduction of the pain impulse through...
...pain impulse through the nervous system once...
...impulses rapidly along the myelin sheath, causing...
...(2) Role of the central nervous system...
...(i) Can decrease the patient’s pain threshold,...
...and to prolong the duration of pain....
...sensitization (i) Is the increased excitability of...
...of neurons in the CNS and is...
...c) Modulation (1) The body’s attempt to...
...perception refers to the patient’s subjective experience...
...subjective experience surrounding the pain. 3. The...
...the pain. 3. The second facet: Pain...
...are transmitted to the brain along multiple...
...(3) Upon reaching the lamina marginalis in...
...lamina marginalis in the dorsal horn, the...
...the dorsal horn, the impulse excites second-order...
...immediately crosses to the opposite side of...
...opposite side of the spinal cord. (4)...
...broad area of the brainstem. c) Person...
...(1) Transmission of the noxious stimulus terminates...
...stimulus terminates within the brain. d) Unknown...
...d) Unknown whether the patient’s ability to...
...chemically altered. 4. The third facet: Suffering...
...nervous centers of the brain. b) Closely...
...Closely connected to the personal meaning of...
...personal meaning of the pain. c) Clinician’s...
...chronic pain. 5. The fourth facet: Pain...
...lessen or control the pain PowerPoint Slides...
...PowerPoint Slides 1. The International Association for...
...The International Association for the Study of...
...International Association for the Study of Pain...
...that patient. 3. The first facet: Nociception...
...Beta-endorphins Dynorphins 8. The Second Facet: Pain:...
...are transmitted to the brain along multiple...
...Paleospinothalamic tract 9. The Third Facet: Suffering...
...Closely connected to the personal meaning of...
...personal meaning of the pain Clinician’s assessment...
...Chronic pain 10. The Fourth Facet: Pain...
...Acute Pain in the High-Acuity Patient A....
...Acute pain of the initial insult. (1)...
...of receptors in the viscera 3. Neuropathic...
...signal processing in the nervous system C....
...nervous system C. The effects of stress...
...and pain on the body 1. Tissue...
...muscle spasm. 2. The stress response is...
...events that increase the body’s chances of...
...organ damage. When the sympathetic nervous system...
...Acute pain of the initial insult Invasive...
...chronic conditions 2. The three major types...
...Stress associated with the hospital environment 4....
...useful in evaluating the effectiveness of interventions,...
...(3) Patient self-reports the level of pain...
...10 cm). (4) The point is then...
...(1) Variation of the VAS. (2) Uses...
...numbers from which the patient chooses. (3)...
...proven NRS is the 0–10 scale. (4)...
...within any of the pain dimensions (2)...
...dimensions (2) Useful for older adults unable...
...Using a list, the patient chooses the...
...the patient chooses the adjective that best...
...that best describes the pain: (a) E.g.,...
...choose words from the middle. d) Wong-Baker...
...Patient points to the face that represents...
...face that represents the current level of...
...pain 2. Adapting the Unidimensional Pain Assessment...
...Pain Assessment Tool for the Severely Ill...
...Assessment Tool for the Severely Ill Patient...
...VAS to indicate the “point.” b) Point...
...b) Point to the number on an...
...NRS or to the location on the...
...the location on the line of a...
...VAS. c) Raise the number of fingers...
...fingers that indicate the level of pain:...
...Pain Assessment provides the patient with a...
...means to expresses the affective and evaluative...
...evaluative aspects of the pain experience. a)...
...from which category the pain is originating...
...of pain in the adult with altered...
...pain assessment tools for those unable to...
...Patients rely on the nurse to advocate...
...advocate and intervene for them. c) Review...
...c) Review of the patient’s medical history...
...pain adapt to the stress response. (2)...
...frequently subjectively interpret the patient’s self-report of...
...attitudes frequently alter the assessment of pain....
...inappropriate use of the self-report tools. d)...
...self-report tools. d) The patient might be...
...coping skills. e) The patient’s use of...
...(cues) to indicate the presence of pain....
...with stimulation of the sympathetic nervous system...
...useful in evaluating the effectiveness of interventions...
...tools Patient expresses the affective and evaluative...
...evaluative aspects of the pain experience. Work...
...experience. Work best for patients with more...
...imaginable.” Patient self-reports the level of pain...
...along this line. The point is then...
...(NRS) Variation of the VAS. Uses a...
...numbers from which the patient chooses. Most...
...proven NRS is the 0–10 scale. 6....
...within any of the pain dimensions. Useful...
...pain dimensions. Useful for older adults unable...
...Using a list, the patient chooses the...
...the patient chooses the adjective that best...
...that best describes the pain. Potential disadvantages....
...Patient points to the face that represents...
...face that represents the current level of...
...pain 8. Adapt the scale for the...
...Adapt the scale for the severely ill...
...the scale for the severely ill patient....
...VAS to indicate the “point.” Point to...
...“point.” Point to the number on an...
...NRS or to the location on the...
...the location on the line of a...
...VAS. Raise up the number of fingers...
...fingers that indicates the level of pain....
...from which category the pain is originating....
...pain assessment tools for those unable to...
...Patients rely on the nurse to advocate...
...advocate and intervene for them. Review of...
...them. Review of the patient’s medical history...
...(cues) to indicate the presence of pain....
...with stimulation of the sympathetic nervous system...
...pain. Use of the sympathetic response criteria...
...pain management 1. The World Health Organization...
...choices based on the level of pain:...
...working peripherally at the site of injury....
...include: (a) Corticosteroids for cancer-related pain. (b)...
...Antidepressants or anticonvulsants for treatment of neuropathic...
...most commonly used for opioids (inexpensive, convenient)...
...in combination (6) The epidural route (a)...
...small catheter into the space located just...
...located just before the dura mater. (b)...
...combination. (d) Minimizes the potential for side...
...Minimizes the potential for side effects. d)...
...small catheter into the cerebrospinal fluid (CSF)...
...Opioid flows through the CSF and rapidly...
...nerve path transmitting the pain is located)...
...injected medial to the point of pain...
...(2) Duration of the analgesia depends on...
...analgesia depends on the half-life of the...
...the half-life of the local anesthetic. (3)...
...nerves medial to the insertion site of...
...is placed into the pleural space, and...
...to incorporate into the care plan. b)...
...Choices based on the level of pain...
...most commonly used for opioids. Might not...
...of analgesic. Minimizes the potential for side...
...Minimizes the potential for side effects. 12....
...Small catheter into the CSF space. Opioid...
...Opioid flows through the CSF, binds to...
...Duration depends on the half-life of the...
...the half-life of the local anesthetic. 14....
...of administration used for multiple rib fractures...
...catheter placed in the pleural space. Local...
...(3) Increased risk for chronic pain (4)...
...physical adaptation of the body to the...
...the body to the presence of opioids...
...(addiction): continued craving for an opioid d)...
...seeking. (a) Demands for different or more...
...relieved. C. Reasons for opioid undertreatment of...
...are less than the duration of action...
...Administering less than the physician orders (2)...
...Taking less than the amount prescribed (4)...
...Refusing to take the drug at all...
...dependence). a) Probably the major cause of...
...interval or increasing the dose. 5. Fear...
...depression. b) In the majority of hospitalized...
...close observation of the patient’s response. (1)...
...are administered before the patient complains of...
...of analgesic in the bloodstream. c) Diminishes...
...bloodstream. c) Diminishes the likelihood of undertreatment...
...based on effects the drug is having...
...than based on the milligrams being administered...
...b) Goal: Gain the desired level of...
...respiratory depression. In the majority, it is...
...based on effects the drug is having....
...drug. VI. Monitoring for Opioid-Induced Respiratory Depression...
...are unfamiliar with the patients’ needs. (2)...
...Sedation assessment a) The nurse’s recognition of...
...tone and depresses the response to hypoxia...
...(1) POSS and the RASS are valid...
...and reliable tools for monitoring sedation assessment....
...initiating opioid analgesia for patients at high...
...at high risk for opioid-induced respiratory depression...
...order to facilitate the identification of trends....
...changes in ventilation (the exchange of air...
...of air between the lungs and the...
...the lungs and the atmosphere) earlier than...
...which simply measures the oxygen saturation of...
...Nursing interventions 1. The plan of care...
...plan of care for patients at a...
...a higher risk for respiratory depression should...
...Working collaboratively with the prescribing health care...
...provider to consider the omission of, or...
...effective in reducing the risk of advancing...
...be required if the patient develops severe...
...respiratory depression. b) The half-life of naloxone...
...time during which the patient may be...
...extreme pain. c) The exact PCA opioid...
...be specified by the prescribing health care...
...frequently administered in the ICU and contribute...
...after discharge from the ICU. e) Decreasing...
...ICU. e) Decreasing the mean doses of...
...accomplished by individualizing the care of each...
...analgesia POSS and the RASS 3. Use...
...Working collaboratively with the prescribing health care...
...large doses Decreasing the mean doses of...
...at greater risk for drug toxicity than...
...has serious implications for analgesic therapy. a)...
...metabolized primarily in the liver. b) Kidneys...
...b) Kidneys have the major responsibility for...
...the major responsibility for opioid excretion. c)...
...be reduced and the patient monitored closely....
...C. Management of the tolerant patient with...
...1. Management of the tolerant patient with...
...Long-term opioid therapy for chronic pain can...
...titrated to manage the incidence of acute...
...acute pain. d) The continuous dose and...
...continuous dose and the incremental dose can...
...Hyperalgesia a) Both the use of high...
...prolonged time and the effects of chronic...
...chronic pain on the CNS can produce...
...opioids only makes the pain worse. d)...
...worse. d) Treatment for hyperalgesia requires careful...
...when appropriate. D. The known active or...
...(1) Experts in the fields of pain...
...substances abusers, have the right to pain...
...pain temporarily overrides the problem of addiction....
...exist to determine the level of monitoring...
...and Opioid Assessment for Patients with Pain...
...Set realistic goals for therapy c) Evaluate...
...symptoms e) Consider the impact of tolerance...
...Other clinical suggestions for treating an active/recovering...
...analgesics that have the same pharmacologic basis...
...pharmacologic basis as the abused drug. b)...
...Restrict short-acting opiates for breakthrough pain. d)...
...2. Pharmacology and the effect of aging...
...at greater risk for drug toxicity. Older...
...has serious implications for analgesic therapy. Analgesics...
...metabolized primarily in the liver. Kidneys have...
...liver. Kidneys have the major responsibility for...
...the major responsibility for opioid excretion. If...
...be reduced and the patient monitored closely....
...monitored closely. 6. The opioid-tolerant patient—management of...
...opioid-tolerant patient—management of the tolerant patient with...
...Long-term opioid therapy for chronic pain can...
...titrated to manage the incidence of acute...
...of acute pain. The continuous dose and...
...continuous dose and the incremental dose can...
...substances abusers, have the right to pain...
...pain temporarily overrides the problem of addiction....
...exist to determine the level of monitoring...
...and Opioid Assessment for Patients with Pain...
...Clinical management considerations for treating active/recovering substance...
...Set realistic goals for therapy Evaluate and...
...withdrawal symptoms Consider the impact of tolerance...
...Other clinical suggestions for treating an active/recovering...
...analgesics that have the same pharmacologic basis...
...pharmacologic basis as the abused drug. Choose...
...Restrict short-acting opiates for breakthrough pain. Avoid...
...cooperation is needed for a procedure. c)...
...clear understanding of the different stages of...
...assesses sedation in the intensive care unit....
...being performed outside the operating room. C....
...Nursing management of the patient undergoing moderate...
...requirements d) Process for validating competency e)...
...unstable) 2. Before the procedure a) Before...
...procedure a) Before the conscious sedation procedure:...
...b) Verify that the patient has given...
...c) Verify that the physician has explained...
...physician has explained the procedure to the...
...the procedure to the patient. (1) E.g.,...
...Do not leave the patient unattended or...
...Have knowledge of the legal liability of...
...sedation. f) Understand the principles of respiratory...
...available. 3. During the procedure. a) Continuously...
...a) Post-procedure (after the conscious sedation procedure):...
...procedure): b) Monitor the patient’s level of...
...If it’s necessary for the patient to...
...it’s necessary for the patient to go,...
...patient to go, the nurse must accompany....
...D. Drugs used for moderate sedation 1....
...drugs is available for use to attain...
...intravenous lines. c) The patient’s level of...
...as indicated by the patient’s condition. E....
...conscious sedation. b) The nurse must be...
...a call to the Rapid Response Team...
...does not meet the standard. d) It...
...acceptable to continue the procedure if the...
...the procedure if the patient is oversedated....
...assesses sedation in the ICU. Sedation definitions....
...education requirements Process for validating competency Interface...
...training 5. Before the conscious sedation procedure:...
...sedation procedure: Verify the patient has given...
...informed consent. Verify the physician has explained...
...physician has explained the procedure. Do not...
...Do not leave the patient unattended. Have...
...Have knowledge of the legal liability. Understand...
...legal liability. Understand the principles of respiratory...
...available. 6. During the conscious sedation procedure:...
...7. Post-procedure (after the conscious sedation procedure):...
...sedation procedure): Monitor the patient’s LOC and...
...drugs are available for conscious sedation Etomidate...
...does not meet the standard. Do not...
...XII. References Suggestions for Classroom Activities Read...
...Classroom Activities Read the original AHCPR guideline...
...definition document. Discuss the AHCPR guideline definitions...
...definitions in detail for tolerance, physical dependence,...
...or thoughts on the undertreatment of pain,...
...have personally experienced the undertreatment of pain—and...
...pain management. Ask for student volunteers to...
...are found within the class? Suggestions for...
...the class? Suggestions for Clinical Activities Meet...
...pain. Ask about the four common misconceptions...
...play out in the actual clinical setting—how...
...avoided, etc. Obtain the pain management policies...
...pain management policies for the clinical facility....
...management policies for the clinical facility. Discuss...
...clinical facility. Discuss the policy with the...
...the policy with the clinical group. What...
...group. What are the specific nursing responsibilities?...
...nursing responsibilities? Do the students feel they...
...they are seeing the guidelines in the...
...the guidelines in the policy upheld on...
...regular basis on the clinical unit? Wagner...
...Instructor’s Resource Manual for High-Acuity Nursing, 6th...

...Acute Pain in the High-Acuity Patient Objectives:...
...Objectives: 1. Explain the multidimensional nature of...
...issues related to the under treatment of...
...acute pain in the high-acuity adult patient...
...management of pain for the high-acuity adult...
...of pain for the high-acuity adult patient....
...focused assessments of the patient receiving opioid...
...populations. 8. Discuss the nursing management of...
...sedation populations. I. The Multifaceted Nature of...
...acute pain 1. The International Association for...
...The International Association for the Study of...
...International Association for the Study of Pain...
...of pain 1. The multifaceted conceptualization of...
...is based on the theoretical model by...
...pain behaviors 2. The First Facet: Nociception—refers...
...Facet: Nociception—refers to the activation of special...
...activate nociceptors in the affected tissue. a)...
...(2) Begins in the peripheral nervous system...
...system and initiates the exchange of sodium...
...and potassium across the neuronal membranes, causing...
...to conduction of the pain impulse through...
...pain impulse through the nervous system once...
...impulses rapidly along the myelin sheath, causing...
...(2) Role of the central nervous system...
...(i) Can decrease the patient’s pain threshold,...
...and to prolong the duration of pain....
...sensitization (i) Is the increased excitability of...
...of neurons in the CNS and is...
...c) Modulation (1) The body’s attempt to...
...perception refers to the patient’s subjective experience...
...subjective experience surrounding the pain. 3. The...
...the pain. 3. The second facet: Pain...
...are transmitted to the brain along multiple...
...(3) Upon reaching the lamina marginalis in...
...lamina marginalis in the dorsal horn, the...
...the dorsal horn, the impulse excites second-order...
...immediately crosses to the opposite side of...
...opposite side of the spinal cord. (4)...
...broad area of the brainstem. c) Person...
...(1) Transmission of the noxious stimulus terminates...
...stimulus terminates within the brain. d) Unknown...
...d) Unknown whether the patient’s ability to...
...chemically altered. 4. The third facet: Suffering...
...nervous centers of the brain. b) Closely...
...Closely connected to the personal meaning of...
...personal meaning of the pain. c) Clinician’s...
...chronic pain. 5. The fourth facet: Pain...
...lessen or control the pain PowerPoint Slides...
...PowerPoint Slides 1. The International Association for...
...The International Association for the Study of...
...International Association for the Study of Pain...
...that patient. 3. The first facet: Nociception...
...Beta-endorphins Dynorphins 8. The Second Facet: Pain:...
...are transmitted to the brain along multiple...
...Paleospinothalamic tract 9. The Third Facet: Suffering...
...Closely connected to the personal meaning of...
...personal meaning of the pain Clinician’s assessment...
...Chronic pain 10. The Fourth Facet: Pain...
...Acute Pain in the High-Acuity Patient A....
...Acute pain of the initial insult. (1)...
...of receptors in the viscera 3. Neuropathic...
...signal processing in the nervous system C....
...nervous system C. The effects of stress...
...and pain on the body 1. Tissue...
...muscle spasm. 2. The stress response is...
...events that increase the body’s chances of...
...organ damage. When the sympathetic nervous system...
...Acute pain of the initial insult Invasive...
...chronic conditions 2. The three major types...
...Stress associated with the hospital environment 4....
...useful in evaluating the effectiveness of interventions,...
...(3) Patient self-reports the level of pain...
...10 cm). (4) The point is then...
...(1) Variation of the VAS. (2) Uses...
...numbers from which the patient chooses. (3)...
...proven NRS is the 0–10 scale. (4)...
...within any of the pain dimensions (2)...
...dimensions (2) Useful for older adults unable...
...Using a list, the patient chooses the...
...the patient chooses the adjective that best...
...that best describes the pain: (a) E.g.,...
...choose words from the middle. d) Wong-Baker...
...Patient points to the face that represents...
...face that represents the current level of...
...pain 2. Adapting the Unidimensional Pain Assessment...
...Pain Assessment Tool for the Severely Ill...
...Assessment Tool for the Severely Ill Patient...
...VAS to indicate the “point.” b) Point...
...b) Point to the number on an...
...NRS or to the location on the...
...the location on the line of a...
...VAS. c) Raise the number of fingers...
...fingers that indicate the level of pain:...
...Pain Assessment provides the patient with a...
...means to expresses the affective and evaluative...
...evaluative aspects of the pain experience. a)...
...from which category the pain is originating...
...of pain in the adult with altered...
...pain assessment tools for those unable to...
...Patients rely on the nurse to advocate...
...advocate and intervene for them. c) Review...
...c) Review of the patient’s medical history...
...pain adapt to the stress response. (2)...
...frequently subjectively interpret the patient’s self-report of...
...attitudes frequently alter the assessment of pain....
...inappropriate use of the self-report tools. d)...
...self-report tools. d) The patient might be...
...coping skills. e) The patient’s use of...
...(cues) to indicate the presence of pain....
...with stimulation of the sympathetic nervous system...
...useful in evaluating the effectiveness of interventions...
...tools Patient expresses the affective and evaluative...
...evaluative aspects of the pain experience. Work...
...experience. Work best for patients with more...
...imaginable.” Patient self-reports the level of pain...
...along this line. The point is then...
...(NRS) Variation of the VAS. Uses a...
...numbers from which the patient chooses. Most...
...proven NRS is the 0–10 scale. 6....
...within any of the pain dimensions. Useful...
...pain dimensions. Useful for older adults unable...
...Using a list, the patient chooses the...
...the patient chooses the adjective that best...
...that best describes the pain. Potential disadvantages....
...Patient points to the face that represents...
...face that represents the current level of...
...pain 8. Adapt the scale for the...
...Adapt the scale for the severely ill...
...the scale for the severely ill patient....
...VAS to indicate the “point.” Point to...
...“point.” Point to the number on an...
...NRS or to the location on the...
...the location on the line of a...
...VAS. Raise up the number of fingers...
...fingers that indicates the level of pain....
...from which category the pain is originating....
...pain assessment tools for those unable to...
...Patients rely on the nurse to advocate...
...advocate and intervene for them. Review of...
...them. Review of the patient’s medical history...
...(cues) to indicate the presence of pain....
...with stimulation of the sympathetic nervous system...
...pain. Use of the sympathetic response criteria...
...pain management 1. The World Health Organization...
...choices based on the level of pain:...
...working peripherally at the site of injury....
...include: (a) Corticosteroids for cancer-related pain. (b)...
...Antidepressants or anticonvulsants for treatment of neuropathic...
...most commonly used for opioids (inexpensive, convenient)...
...in combination (6) The epidural route (a)...
...small catheter into the space located just...
...located just before the dura mater. (b)...
...combination. (d) Minimizes the potential for side...
...Minimizes the potential for side effects. d)...
...small catheter into the cerebrospinal fluid (CSF)...
...Opioid flows through the CSF and rapidly...
...nerve path transmitting the pain is located)...
...injected medial to the point of pain...
...(2) Duration of the analgesia depends on...
...analgesia depends on the half-life of the...
...the half-life of the local anesthetic. (3)...
...nerves medial to the insertion site of...
...is placed into the pleural space, and...
...to incorporate into the care plan. b)...
...Choices based on the level of pain...
...most commonly used for opioids. Might not...
...of analgesic. Minimizes the potential for side...
...Minimizes the potential for side effects. 12....
...Small catheter into the CSF space. Opioid...
...Opioid flows through the CSF, binds to...
...Duration depends on the half-life of the...
...the half-life of the local anesthetic. 14....
...of administration used for multiple rib fractures...
...catheter placed in the pleural space. Local...
...(3) Increased risk for chronic pain (4)...
...physical adaptation of the body to the...
...the body to the presence of opioids...
...(addiction): continued craving for an opioid d)...
...seeking. (a) Demands for different or more...
...relieved. C. Reasons for opioid undertreatment of...
...are less than the duration of action...
...Administering less than the physician orders (2)...
...Taking less than the amount prescribed (4)...
...Refusing to take the drug at all...
...dependence). a) Probably the major cause of...
...interval or increasing the dose. 5. Fear...
...depression. b) In the majority of hospitalized...
...close observation of the patient’s response. (1)...
...are administered before the patient complains of...
...of analgesic in the bloodstream. c) Diminishes...
...bloodstream. c) Diminishes the likelihood of undertreatment...
...based on effects the drug is having...
...than based on the milligrams being administered...
...b) Goal: Gain the desired level of...
...respiratory depression. In the majority, it is...
...based on effects the drug is having....
...drug. VI. Monitoring for Opioid-Induced Respiratory Depression...
...are unfamiliar with the patients’ needs. (2)...
...Sedation assessment a) The nurse’s recognition of...
...tone and depresses the response to hypoxia...
...(1) POSS and the RASS are valid...
...and reliable tools for monitoring sedation assessment....
...initiating opioid analgesia for patients at high...
...at high risk for opioid-induced respiratory depression...
...order to facilitate the identification of trends....
...changes in ventilation (the exchange of air...
...of air between the lungs and the...
...the lungs and the atmosphere) earlier than...
...which simply measures the oxygen saturation of...
...Nursing interventions 1. The plan of care...
...plan of care for patients at a...
...a higher risk for respiratory depression should...
...Working collaboratively with the prescribing health care...
...provider to consider the omission of, or...
...effective in reducing the risk of advancing...
...be required if the patient develops severe...
...respiratory depression. b) The half-life of naloxone...
...time during which the patient may be...
...extreme pain. c) The exact PCA opioid...
...be specified by the prescribing health care...
...frequently administered in the ICU and contribute...
...after discharge from the ICU. e) Decreasing...
...ICU. e) Decreasing the mean doses of...
...accomplished by individualizing the care of each...
...analgesia POSS and the RASS 3. Use...
...Working collaboratively with the prescribing health care...
...large doses Decreasing the mean doses of...
...at greater risk for drug toxicity than...
...has serious implications for analgesic therapy. a)...
...metabolized primarily in the liver. b) Kidneys...
...b) Kidneys have the major responsibility for...
...the major responsibility for opioid excretion. c)...
...be reduced and the patient monitored closely....
...C. Management of the tolerant patient with...
...1. Management of the tolerant patient with...
...Long-term opioid therapy for chronic pain can...
...titrated to manage the incidence of acute...
...acute pain. d) The continuous dose and...
...continuous dose and the incremental dose can...
...Hyperalgesia a) Both the use of high...
...prolonged time and the effects of chronic...
...chronic pain on the CNS can produce...
...opioids only makes the pain worse. d)...
...worse. d) Treatment for hyperalgesia requires careful...
...when appropriate. D. The known active or...
...(1) Experts in the fields of pain...
...substances abusers, have the right to pain...
...pain temporarily overrides the problem of addiction....
...exist to determine the level of monitoring...
...and Opioid Assessment for Patients with Pain...
...Set realistic goals for therapy c) Evaluate...
...symptoms e) Consider the impact of tolerance...
...Other clinical suggestions for treating an active/recovering...
...analgesics that have the same pharmacologic basis...
...pharmacologic basis as the abused drug. b)...
...Restrict short-acting opiates for breakthrough pain. d)...
...2. Pharmacology and the effect of aging...
...at greater risk for drug toxicity. Older...
...has serious implications for analgesic therapy. Analgesics...
...metabolized primarily in the liver. Kidneys have...
...liver. Kidneys have the major responsibility for...
...the major responsibility for opioid excretion. If...
...be reduced and the patient monitored closely....
...monitored closely. 6. The opioid-tolerant patient—management of...
...opioid-tolerant patient—management of the tolerant patient with...
...Long-term opioid therapy for chronic pain can...
...titrated to manage the incidence of acute...
...of acute pain. The continuous dose and...
...continuous dose and the incremental dose can...
...substances abusers, have the right to pain...
...pain temporarily overrides the problem of addiction....
...exist to determine the level of monitoring...
...and Opioid Assessment for Patients with Pain...
...Clinical management considerations for treating active/recovering substance...
...Set realistic goals for therapy Evaluate and...
...withdrawal symptoms Consider the impact of tolerance...
...Other clinical suggestions for treating an active/recovering...
...analgesics that have the same pharmacologic basis...
...pharmacologic basis as the abused drug. Choose...
...Restrict short-acting opiates for breakthrough pain. Avoid...
...cooperation is needed for a procedure. c)...
...clear understanding of the different stages of...
...assesses sedation in the intensive care unit....
...being performed outside the operating room. C....
...Nursing management of the patient undergoing moderate...
...requirements d) Process for validating competency e)...
...unstable) 2. Before the procedure a) Before...
...procedure a) Before the conscious sedation procedure:...
...b) Verify that the patient has given...
...c) Verify that the physician has explained...
...physician has explained the procedure to the...
...the procedure to the patient. (1) E.g.,...
...Do not leave the patient unattended or...
...Have knowledge of the legal liability of...
...sedation. f) Understand the principles of respiratory...
...available. 3. During the procedure. a) Continuously...
...a) Post-procedure (after the conscious sedation procedure):...
...procedure): b) Monitor the patient’s level of...
...If it’s necessary for the patient to...
...it’s necessary for the patient to go,...
...patient to go, the nurse must accompany....
...D. Drugs used for moderate sedation 1....
...drugs is available for use to attain...
...intravenous lines. c) The patient’s level of...
...as indicated by the patient’s condition. E....
...conscious sedation. b) The nurse must be...
...a call to the Rapid Response Team...
...does not meet the standard. d) It...
...acceptable to continue the procedure if the...
...the procedure if the patient is oversedated....
...assesses sedation in the ICU. Sedation definitions....
...education requirements Process for validating competency Interface...
...training 5. Before the conscious sedation procedure:...
...sedation procedure: Verify the patient has given...
...informed consent. Verify the physician has explained...
...physician has explained the procedure. Do not...
...Do not leave the patient unattended. Have...
...Have knowledge of the legal liability. Understand...
...legal liability. Understand the principles of respiratory...
...available. 6. During the conscious sedation procedure:...
...7. Post-procedure (after the conscious sedation procedure):...
...sedation procedure): Monitor the patient’s LOC and...
...drugs are available for conscious sedation Etomidate...
...does not meet the standard. Do not...
...XII. References Suggestions for Classroom Activities Read...
...Classroom Activities Read the original AHCPR guideline...
...definition document. Discuss the AHCPR guideline definitions...
...definitions in detail for tolerance, physical dependence,...
...or thoughts on the undertreatment of pain,...
...have personally experienced the undertreatment of pain—and...
...pain management. Ask for student volunteers to...
...are found within the class? Suggestions for...
...the class? Suggestions for Clinical Activities Meet...
...pain. Ask about the four common misconceptions...
...play out in the actual clinical setting—how...
...avoided, etc. Obtain the pain management policies...
...pain management policies for the clinical facility....
...management policies for the clinical facility. Discuss...
...clinical facility. Discuss the policy with the...
...the policy with the clinical group. What...
...group. What are the specific nursing responsibilities?...
...nursing responsibilities? Do the students feel they...
...they are seeing the guidelines in the...
...the guidelines in the policy upheld on...
...regular basis on the clinical unit? Wagner...
...Instructor’s Resource Manual for High-Acuity Nursing, 6th...

... The Older Adult High-Acuity...
...Objectives: 1. Describe the characteristics of the...
...the characteristics of the aging population. 2....
...Apply knowledge of the age-related changes in...
...Apply knowledge of the age-related changes in...
...Apply knowledge of the age-related changes in...
...Apply knowledge of the age-related changes in...
...impact hospitalization in the older patient. 9....
...patient. 9. Demonstrate the use of common...
...tools. 10. Demonstrate the nursing management of...
...special situations including the culture of caring...
...culture of caring for older adults and...
...end-of-life care. I. The Older Adult Patient...
...Adult Patient A. The older adult patient...
...areas should understand the age-related changes that...
...that might impact the outcome of their...
...at greater risk for disability and becoming...
...critically ill. 3. The application of early...
...complications, and provide for the best possible...
...and provide for the best possible outcomes...
...best possible outcomes for hospitalized elderly patients....
...B. Characteristics of the older adult population...
...Demographic characteristics in the U.S. (people are...
...people 85+. (5) The “age wave” will...
...care services by the older population (1)...
...(b) 55% in the intensive care unit...
...reactions. Greater risk for disability and becoming...
...Demographics Characteristics in the U.S. Population aged...
...care services by the older population: Older...
...Changes associated with the normal aging process...
...pathological process c) The application of early...
...complications. (4) Provides the best possible outcomes....
...Age-related alterations in the central nervous system...
...not synthesized at the same rate. (3)...
...nervous changes impact the neurologic exam: (1)...
...in all of the sensory receptors: (1)...
...common). c) Smell: The sensitivity to smells...
...Touch: Sensitivity in the fingertips, palms, and...
...to changes in the environment. (1) Decline...
...Changes associated with the normal aging process...
...pathological process 3. The application of early...
...Prevents complications. Provides the best possible outcomes....
...Age-related alterations in the central nervous system...
...not synthesized at the same rate. Declines...
...nervous changes impact the neurologic exam: Mental...
...in all of the sensory receptors. Decline...
...common). 9. Olfactory: The sensitivity to smells...
...Touch: Sensitivity in the fingertips, palms, and...
...to changes in the environment: Decline in...
...a) CHD is the leading cause of...
...Cardiovascular changes alter the function of myocardium...
...Increased stiffness of the arterial walls (3)...
...less reliable in the older patient. a)...
...might be in the normal range. 6....
...mucus, increasing risk for infections. b) Surface...
...Surface area of the lungs is decreased,...
...of care of the elderly patient on...
...statistics: CHD is the leading cause of...
...(CV) changes alter the function of myocardium...
...less reliable in the older patient: 50%...
...might be in the normal range. 6....
...Therapeutic interventions in the elderly: Therapeutic treatments...
...mucus (increases risk for infections) Surface area...
...Surface area of the lungs is decreased...
...through changes in the skin: a) Wrinkling...
...with aging, predisposing the patient to: a)...
...assessment to monitor for changes in skin...
...a contamination of the deep layer of...
...surfaces. (b) Reposition the patient frequently. (c)...
...temperature. (b) Keep the patient covered while...
...(a) Close monitoring for infiltrations. (b) Use...
...musculoskeletal issues in the older adult: a)...
...4. Osteoarthritis is the most common arthritic...
...directly related to the aging process. c)...
...5. Compression of the spinal column or...
...spinal column or the spinal nerves is...
...stenosis (narrowing of the spinal canal). b)...
...b) Thinning of the cartilage between the...
...the cartilage between the vertebrae. c) Development...
...bone spurs around the vertebrae. 6. Nursing...
...Nursing Assessment: Monitor for changes in skin...
...support surfaces. Reposition the patient frequently. Optimize...
...room temperature. Keep the patient covered while...
...includes: Close monitoring for infiltrations. Use of...
...musculoskeletal issues in the older adult: Decreased...
...11. Osteoarthritis is the most common arthritic...
...stenosis. Thinning of the cartilage between vertebrae....
...13. Important implications for patient care: Posture,...
...a) Changes affecting the teeth include: (1)...
...or atrophy of the jawbone 2. Esophageal...
...(1) Refer patient for further evaluation if:...
...pylori) (1) Increases the risk for growth...
...Increases the risk for growth of bacteria...
...of bacteria in the stomach (2) Increases...
...stomach (2) Increases the risk of aspiration...
...altered. b) Impacts the absorption of vitamins...
...Diminished compliance of the rectum. 6. Pancreas...
...Blood flow to the liver is reduced....
...that relate to the health of the...
...the health of the GI system: (1)...
...(1) Atrophy of the efferent and afferent...
...to reflux of the vesicoureteral junction b)...
...4. Problems in the urination process might...
...f) Sensation of the need to void....
...genitourinary function in the older adult: a)...
...6. Nursing implications for GU changes are...
...(UTIs) b) Responsible for most community-acquired bacteremia...
...c) Attributed to the presence of indwelling...
...indwelling catheters in the hospital d) Often...
...sediment i) Screening for bacteria 10. Nurses...
...changes Changes affecting the teeth include: Oral...
...or atrophy of the jawbone. 2. Esophageal...
...is altered. Impacts the absorption of vitamins...
...Diminished compliance of the rectum. 6. Pancreas...
...Blood flow to the liver is reduced....
...to reflux of the vesicoureteral junction. Leads...
...13. Problems in the urination process can...
...Obstruction. Sensation of the need to void....
...genitourinary function in the older adult: Increased...
...15. Nursing implications for GU changes are...
...infections (UTIs) Responsible for most community-acquired bacteremia...
...bacteremia Attributed to the presence of indwelling...
...urinary sediment. Screening for bacteriuria. 19. Nurses...
...d) Increase in the prevalence of diabetes...
...(1) ~25.8% of the population with diabetes...
...(3) Increased risk for hypothyroidism. (4) TSH...
...Immune system 1. The immune system of...
...influenza are among the top ten causes...
...causes of death for older adults. a)...
...pneumococcal vaccines decrease the risk for pneumonia....
...decrease the risk for pneumonia. (1) A...
...at high risk for infection and assess...
...develop sepsis in the U.S. are 65+...
...glucose. Increase in the prevalence of diabetes...
...3. Changes in the thyroid Aging body...
...atrophies. Increased risk for hypothyroidism. TSH values...
...Heart complications. 6. The immune system of...
...influenza are among the top ten causes...
...vaccines decrease risk for pneumonia. 9. Nurses...
...at high risk for infection. Consider preexisting...
...Impacting Hospitalization A. The “three Ds”-dementia, depression,...
...professionals 2. Mistaken for one another 3....
...one another 3. The normal older adult...
...Alzheimer’s disease (responsible for the largest percentage)...
...disease (responsible for the largest percentage) (2)...
...neurofibrillary tangles in the brain d) Course:...
...make decisions, care for self, and communicate...
...slow progression of the disease. C. Depression...
...institutional settings. c) The highest rate of...
...very treatable in the older adult. c)...
...(acute confusion) is the rapid onset of...
...an insult to the brain as a...
...status (can be the first sign of...
...older people in the hospital overall b)...
...missed and mistaken for one another 2....
...to decide, care for self, communicate 5....
...is treatable in the older adult. Newer...
...10. Delirium is the rapid onset of...
...an insult to the brain as a...
...older people in the hospital overall. Develops...
...d) Fall prevention for older adults in...
...patients up in the chair as able....
...adequate pain control for the older adult...
...pain control for the older adult in...
...older adult in the high-acuity setting can...
...Age-related changes impact the ability to perceive...
...age. c) Impacts the ability to accurately...
...environment to decrease the perception of pain....
...a challenge in the older patient. a)...
...Evaluating a patient for any untoward reactions...
...of medications to the older adult is...
...surface area of the small intestine (2)...
...present and active for longer period of...
...effects. c) Tolerance for medications might be...
...Prescription medications. (2) Over-the-counter medications. (3) Vitamins...
...a) Inappropriate medications for the elderly—problems, solutions,...
...Inappropriate medications for the elderly—problems, solutions, considerations....
...Identify medications increasing the risk for adverse...
...increasing the risk for adverse drug reactions....
...(1) Beers’ Criteria for Potentially Inappropriate Medication...
...Medication Use in the Elderly b) When...
...go slow.” c) The therapeutic window might...
...risk. Fall prevention for older adults in...
...stimuli declines. Impacts the ability to accurately...
...(neurotoxicity). Evaluate patient for any bad reactions....
...surface area of the small intestine Decreased...
...side effects. Tolerance for medications might be...
...Evaluate Prescription medications. Over-the-counter medications. Vitamins and...
...medications increasing risk for adverse reactions. When...
...and go slow.” The therapeutic window might...
...Geriatric Assessment Tools for the High-Acuity Nurse...
...Assessment Tools for the High-Acuity Nurse 1....
...used to screen for problems in older...
...methods determine if the person has normal...
...items (2) Draw the face of a...
...try to repeat the original three items...
...Screening instrument walks the nurse through the...
...the nurse through the patient assessment. b)...
...scale (GDS) screens for depressive symptoms: a)...
...about mood over the past two weeks....
...is based on the number of answers...
...Assessment of risk for skin breakdown begins...
...Example: Braden scale for predicting pressure sores:...
...a higher risk for pressure sore development....
...prevented by reducing the risk factors. C....
...patients at risk for falling. a) Use...
...(4) Heavy surveillance (for delirious patients). c)...
...status changes, need for a walking aid,...
...patient’s account of the pain. b) Assess...
...pain: impact on the older adult’s ability...
...to recover from the present health condition....
...pain assessment. e) The most important consideration...
...important consideration in the assessment of the...
...the assessment of the presence and severity...
...of pain is the patient’s account of...
...patient’s account of the pain. f) Nurses...
...to set goals for pain management. E....
...be aware of the age-related alterations in...
...used to screen for problems in older...
...depression scale (GDS)—Screens for depressive symptoms. Series...
...about mood over the past two weeks....
...or no. Score the number of depressed...
...Example: Braden scale for predicting pressure sores...
...Patient’s account of the pain. Nurses work...
...to set goals for pain management. 8....
...of death in the elderly. Contributing factors:...
...traumatic injuries a) Falls—the most common cause...
...vehicle crashes account for the most fatalities....
...crashes account for the most fatalities. c)...
...mortality rate in the elderly. 3. Nursing...
...aimed at stabilizing the injuries and preventing...
...More difficulty compensating for injury or trauma...
...(2) Greater risk for complications b) Priorities...
...complications b) Priorities for care in the...
...for care in the high-acuity area include:...
...be obscured, as the heart rate might...
...impaired. 4. Determining the cause a) Perform...
...an in-depth history for information. b) Assess...
...reserve: (1) Increase the risk of pulmonary...
...wall: (1) Increase the likelihood of abdominal...
...and osteoporosis increase the susceptibility of the...
...the susceptibility of the older adult to...
...healing (particularly in the presence of malnutrition)....
...include: Falls are the most common. MVC...
...common. MVC have the most fatalities. Burns...
...nursing care: Stabilize the injuries, prevent complications:...
...complications: Difficulty compensating for injury or trauma...
...trauma Greater risk for complications 4. Priorities...
...complications 4. Priorities for nursing care in...
...nursing care in the high-acuity area include:...
...impaired. 5. Determining the cause of injury:...
...be absent. Assess for subtle LOC changes...
...b) Greater risk for functional decline or...
...culture of caring for older adults 1....
...1. Hartford Institute for Geriatric Nursing (HIGN)...
...Nursing, funded by the John A. Hartford...
...b) Provides steps the nurse can follow...
...deliver better care for the older high-acuity...
...better care for the older high-acuity patient....
...care 1. End-of-life care—the problem a) In...
...acute care settings, the focus of patient...
...b) Needs of the elderly person at...
...elderly person at the end of life...
...care. 2. End-of-life care—the solution a) Palliative...
...(1) Increase comfort for patients and families...
...resuscitation efforts at the end of life:...
...decisions (1) In the later stages of...
...and heroic measures for patients who might...
...Nursing responsibilities at the end of life...
...Nurses must monitor for hypothermia (h) Warm...
...be given to the elderly patient population:...
...outcomes Greater risk for functional decline when...
...2. Hartford Institute for Geriatric Nursing (HIGN)...
...Nursing, funded by the John A. Hartford...
...issues Provides steps the nurse can follow...
...deliver better care for the older high-acuity...
...better care for the older high-acuity patient....
...adults. 3. End-of-life care—the problem In most...
...curative. Needs of the elderly person are...
...care. 4. End-of-life care—the solution • Palliative...
...Decisions about resuscitation for patients who might...
...Nursing responsibilities at the end of life:...
...summarizes changes in the central nervous system...
...nervous system in the older adult. Discuss...
...or have cared for. Suggestions for Clinical...
...cared for. Suggestions for Clinical Activities Visit...
...older seniors to the classroom. Specifically, meet...
...centenarian to appreciate the healthy seniors that...
...their health through the years, their secrets...
...years, their secrets for longevity, and their...
...administrator to visit the classroom). Ask about...
...classroom). Ask about the most common health...
...care problems of the elderly that they...
...this compares with the list of problems...
...Instructor’s Resource Manual for High-Acuity Nursing, 6th...

...Holistic Care of the Patient and Family...
...Objectives: 1. Discuss the impact of illness...
...of illness on the high-acuity patient and...
...2. Identify way the nurse can help...
...event. 3. Describe the principles of patient...
...family-centered care in the high-acuity environment as...
...policies. 4. Discuss the importance of awareness...
...diversity when caring for high-acuity patients. 5....
...patients. 5. Examine the role of palliative...
...palliative care in the high-acuity environment and...
...considered in caring for high-acuity patients. 6....
...Illnesses can cause the patients to experience...
...might respond to the losses by passing...
...Nursing considerations 1. The family is an...
...important part of the patient’s health outcome....
...must participate in the care and recovery...
...2a. Needs of the Family of the...
...the Family of the Patient with High-Acuity...
...Communication Requirements of the Family Openness Honesty...
...stress. Humor strengthens the bonds among the...
...the bonds among the patient, family, and...
...family, and nurse. The use of humor...
...facilitate sleep. (2) The vascular, muscular, and...
...encourages relaxation. (2) The patient is asked...
...soft tissues of the body using the...
...the body using the hands Can reduce...
...used to distract the patient from painful...
...a relationship with the patient facilitates trust...
...facilitates trust in the nurse and will...
...inhibit learning in the high-acuity patient. Obstacles...
...communication and pain. The nurse must meet...
...nurse must meet the physiological needs of...
...physiological needs of the patient before attempting...
...(3) Acknowledgement of the past (4) Optimal...
...a) Transfer of the patient to a...
...transfer anxiety in the patient or family....
...or family. b) The anxiety is the...
...The anxiety is the result of a...
...of care allowing the patient and family...
...promote success of the transfer. d) Moving...
...transfer. d) Moving the patient during daytime...
...care units in the United States have...
...are unrestricted. 2. The visiting activities of...
...care units: a) The rationales for these...
...a) The rationales for these limitations are...
...limitations are concerns for the risk of...
...are concerns for the risk of infection...
...of infection and for the emotional well-being...
...infection and for the emotional well-being of...
...emotional well-being of the child. b) In...
...child. b) In the event a family...
...is at risk for not recovering, exceptions...
...made to allow for “goodbyes” 3. Traditionally,...
...identified benefits of the presence of the...
...the presence of the family during CPR....
...during CPR. 4. The care delivery model...
...delivery model embraces the presence of the...
...the presence of the family members at...
...family members at the bedside: a) Nursing...
...provide education to the family members regarding...
...should carefully address the facility’s stance toward...
...Slides 1. Educating the High-Acuity Patient Goals...
...a relationship with the patient 2. Barriers...
...Barriers to Learning for the High-Acuity Patient...
...to Learning for the High-Acuity Patient Condition-related...
...making Acknowledgement of the past Optimal learning...
...based on: Concerns for the risk of...
...on: Concerns for the risk of infection...
...of infection Concerns for emotional well-being of...
...emotional well-being of the child Should be...
...Presence during CPR The ability of the...
...The ability of the family to grasp...
...family to grasp the seriousness of the...
...the seriousness of the patient’s illness. Family...
...everything was done for the patient. Families...
...was done for the patient. Families move...
...more positively through the grieving process. Removal...
...is happening to the patient. Families experience...
...sense of closure for families who lose...
...one. Facilitation of the grieving process by...
...letting them influence the care of patients...
...respect, and acceptance for the patient’s culture....
...and acceptance for the patient’s culture. c)...
...includes sensitivity to the culture, race, gender,...
...economic status of the patients. 2. Other...
...competence 1. In the quest for developing...
...In the quest for developing cultural competence,...
...developing cultural competence, the nurse must give...
...will prevent stereotyping. The nurse must assess...
...must be in the language and at...
...language and at the level needed by...
...level needed by the patient. Judgment cannot...
...be made concerning the patient’s choices. The...
...the patient’s choices. The CRASH (culture, respect,...
...Economic status 2. The CRASH Model Consider...
...suffering and improving the quality of life....
...and symptoms. c) The program includes members...
...care models allow the needs of patients...
...manner. e) Needs for palliative care are...
...a) Cancer is the most common disorder...
...palliative care exist for the high-acuity-care patient....
...care exist for the high-acuity-care patient. b)...
...difficult to make the transition from a...
...palliative nature. c) The limited collaboration and...
...needed to facilitate the patient’s progression to...
...care path. b) The team will consist...
...will consist of the high-acuity nurse and...
...High-Acuity Settings: a) The Patient Self-Determination Act...
...advanced directives. b) The American Association of...
...and appreciation of the collaborative role of...
...team members. c) The Patient Self-Determination Act...
...Power of Attorney for health care 2....
...term implies that the patient is dying...
...done to keep the patient comfortable and...
...comfortable and allow the dying process to...
...occur naturally. (2) The goal of AND...
...individuals already in the workforce as well...
...Fragmented care 5. The Palliative Care Team...
...spiritual needs Includes the high-acuity nurse and...
...Conferences are instrumental The care plan must...
...be comprehensive 6. The Patient Self-Determination Act...
...Act Part of the Omnibus Budget Reconciliation...
...given information about the right to formulate...
...(power of attorney for health care) 7....
...unnecessary suffering Allow for nature to take...
...Environmental characteristics of the high-acuity care unit...
...significant impact on the patient. b) The...
...the patient. b) The patient is at...
...is at risk for both sensory overload...
...and deprivation. c) The individual’s normal stimuli...
...are interrupted, and the senses simultaneously are...
...unresponsive are at the greatest risk for...
...the greatest risk for this difficulty, known...
...alterations (SPAs). e) The nurse must recognize...
...nurse must recognize the stressors presented by...
...stressors presented by the environment and promote...
...unnecessary noises: (1) The Environmental Protection Agency...
...disorganized thinking. b) The nurse must assess...
...assess and identify the cause of the...
...the cause of the delirium. c) Causes...
...vary. Once determined, the underlying causes must...
...are compromised in the high-acuity unit. b)...
...high-acuity unit. b) The changes in the...
...The changes in the light/dark cycle, pain,...
...are caused by the inability to speak....
...be closely reviewed for messages. d) When...
...d) When caring for the patient who...
...When caring for the patient who cannot...
...who cannot speak, the nurse must act...
...patient advocate. (1) The nurse will need...
...to provide support for the decision of...
...provide support for the decision of the...
...the decision of the patient or designated...
...with those of the health care provider...
...by Environmental Stressors The aged population Very...
...2. Role of the Nurse Caring for...
...the Nurse Caring for the High-Acuity Patient...
...Nurse Caring for the High-Acuity Patient Assess...
...High-Acuity Patient Assess the patient’s normal environmental...
...Environmental Stimuli and the Unconscious Patient An...
...An assessment of the normal stimuli for...
...the normal stimuli for the unconscious patient...
...normal stimuli for the unconscious patient must...
...must be completed. The nurse might need...
...about normal stimuli for the patient. 5a....
...normal stimuli for the patient. 5a. Delirium...
...5d. Role of the Nurse Caring for...
...the Nurse Caring for the Patient Experiencing...
...Nurse Caring for the Patient Experiencing Delirium...
...6a. Alterations of the Rest and Sleep...
...with changes in the light/dark cycle Causes:...
...6b. Alterations of the Rest and Sleep...
...to prevent SPA. The inability to verbally...
...behaviors needed. 8. The Patient Who Cannot...
...Nurse must represent the patient or patient...
...X. References Suggestions for Classroom Activities Ask...
...in-class review. Divide the class into small...
...care plans addressing the education needs of...
...education needs of the acutely ill patient....
...a short time for the exercise. Once...
...short time for the exercise. Once complete,...
...Once complete, ask the student groups to...
...their work with the entire class. Having...
...entire class. Having the correct learning environment...
...correct learning environment for educating for the...
...environment for educating for the acutely ill...
...for educating for the acutely ill patient...
...their concepts of the optimal learning environment....
...learning environment. Suggestions for Clinical Activities Discuss...
...Clinical Activities Discuss the implications of ensuring...
...high acuity. During the clinical post conference,...
...post conference, ask the students to determine...
...which Suchman stage the patient they cared...
...patient they cared for was demonstrating. Invite...
...to visit with the clinical group. Ask...
...clinical group. Ask the massage therapist to...
...therapist to discuss the use of massage...
...use of massage for patients experiencing pain....
...Instructor’s Resource Manual for High-Acuity Nursing, 6th...