...cardiac cells and the relationship between membrane...
...levels. 2. Describe the cardiac conduction system,...
...cardiac conduction system, the normal electrocardiogram (ECG)...
...nursing responsibilities for the patient who requires...
...responsibilities for the patient who requires cardiac...
...dysrhythmias arising from the sinoatrial (SA) node...
...9. Distinguish among the four conduction abnormalities,...
...nursing implications for the patient receiving these...
...implications for the patient receiving these therapies....
...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....
...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....
...is verified by the nurse at the...
...the nurse at the beginning of each...
...care of a patient who requires cardiac...
...strip analysis. E. Patient electrical safety 1....
...an ECG. F. Patient and family education...
...Electrical Conduction of the Heart Intrinsic electrical...
...Conduction Pathway 4. The Electrocardiogram (ECG) Represents...
...Care of a Patient Who Requires Cardiac...
...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...
...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...
...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...
...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...
...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...
...is dependent on patient symptomology and can...
...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...
...and describes the patient’s underlying cardiac rhythm...
...cardiac rhythm and the type of PVCs...
...major responsibility of the nurse is to...
...is to assess the patient for factors...
...to assess the patient for factors that...
...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,...
...vasopressin. If the patient remains pulseless, CPR...
...of electrical impulses. The patient is unconscious...
...electrical impulses. The patient is unconscious and...
...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...
...exhibited by the patient. c) Management of...
...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...
...heart block is the same as for...
...in conduction through the bundle of His...
...of ECG normal Patient usually asymptomatic No...
...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...
...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...
...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....
...synchronized with the patient’s heart rhythm. It...
...in an unstable patient. a) Nursing considerations....
...In preparation for the procedure, the nurse...
...for the procedure, the nurse obtains informed...
...consent and educates the patient as to...
...and educates the patient as to the...
...patient as to the purpose of the...
...the purpose of the cardioversion and what...
...in an unresponsive patient and ventricular fibrillation....
...again depending on the type of defibrillator...
...II Agents Block the effects of catecholamines....
...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...
...painful experience for the patient, who should...
...experience for the patient, who should be...
...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....
...electrical stimulation of the right ventricular or...
...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...
...to assuring the patient did not experience...
...experience complications from the central line placement...
...d) Caring for the transvenous pacing wire...
...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)....
...needs of the patient (Fig. 8-38). B....
...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...
...not sense the patient’s own cardiac electrical...
...more frequently. If the sensitivity is too...
...is too high, the pacemaker is better...
...able to sense the patient’s own cardiac...
...to sense the patient’s own cardiac electrical...
...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...
...cardiac arrest. 2. Patient education a) The...
...Patient education a) The patient is taught...
...education a) The patient is taught that...
...is taught that the ICD can “reorganize”...
...well as stimulate the heart. (Pacemaker action...
...Caring for a patient with a pacemaker...
...care, including preparing the patient for insertion...
...including preparing the patient for insertion of...
...electrical stimulus to the heart Used when...
...electrical stimulus to the myocardial cells Used...
...different areas of the heart. Most common...
...Classroom Activities Have the students practice identifying...
...ventricular contractions using the seven steps in...
...predisposing factors for the development of premature...
...Clinical Activities Have the students obtain ECG...
...predisposing factors for the development of ventricular...

...used to determine the need for mechanical...
...support. 2. Select the equipment necessary to...
...ventilation. 3. Describe the modes of mechanical...
...ventilation. 4. Explain the commonly monitored ventilator...
...support. 6. Discuss the major complications of...
...practice. 8. Describe the nursing care of...
...nursing care of the patient requiring ventilatory...
...care of the patient requiring ventilatory support....
...support. 9. Describe the process of weaning...
...of weaning a patient from mechanical ventilation...
...mechanical ventilation and the nurse’s role in...
...process. I. Determining the Need for Ventilatory...
...augment and support the ventilation portion of...
...ventilation portion of the respiratory process. Mechanical...
...ventilators place a patient at risk for...
...major complications, so the decision to place...
...to place a patient on a ventilator...
...to place a patient on a ventilator:...
...failure (AVF) is the most common indication...
...It is when the lungs are unable...
...oxygenation failure 1. The second major indication...
...60 mm Hg (the clinical definition of...
...support is needed. The most common tests...
...pulmonary physiology place the elderly at risk...
...in various sizes. The size to use...
...on age of patient. a) Choice of...
...obstruction 3. Securing the artificial airway a)...
...tube stabilizers are the preferred method of...
...method of securing the ET tube commonly...
...bite block if the oral route is...
...manometer to check the ET tube cuff...
...be used on the ventilator, a manual...
...on age of patient Different routes Other...
...obstruction 2. Securing the artificial airway Adhesive...
...pressure applied to the thorax by external...
...external means. a) Patient’s body is encased...
...Air pressure in the unit is reduced...
...air moves into the lungs. c) Negative...
...are delivered into the lungs. 2. Positive...
...Pre-set pressure augments the patient’s inspiratory effort...
...pressure augments the patient’s inspiratory effort as...
...as long as patient breathes at certain...
...pressure applied to the thorax by external...
...by external means. Patient’s body is encased...
...adjusted to meet the individual patient’s needs....
...meet the individual patient’s needs. The most...
...individual patient’s needs. The most commonly monitored...
...mL/kg may overdistend the alveoli, increasing pressure,...
...b) Volutrauma: increases the permeability of the...
...the permeability of the lungs’ microvasculature, which...
...(adult) based on the patient’s lung status...
...based on the patient’s lung status 3....
...intermittent hyperinflation of the lungs. B. Fraction...
...percent oxygen to the patient. C. Positive...
...oxygen to the patient. C. Positive end-expiratory...
...provide pressure at the end of expiration,...
...mode: sensitive to patient’s inspiratory effort but...
...mandatory ventilation mode: Patient breathes spontaneously, with...
...breathes spontaneously, with the ventilator circuit doing...
...doing much of the work of breathing....
...pressure. Triggered by patient’s spontaneous breathing and...
...a) Advantages: Improved patient–ventilator synchrony, prevents respiratory...
...be initiated by patient or the ventilator....
...by patient or the ventilator. a) Advantages:...
...guaranteed VE, improved patient–ventilator synchrony, decreased risk...
...and out of the lungs in one...
...and rate are the two variables that...
...a leak in the system. H. High-pressure...
...alarm 1. Any patient action or problem...
...coughing, biting on the tube, or secretions...
...or secretions in the airway. I. Initial...
...be determined by the provider or the...
...the provider or the respiratory therapist. PowerPoint...
...mL/kg may overdistend the alveoli, increasing pressure,...
...Mechanical Ventilation 1. The use of positive...
...airway places a patient at risk for...
...prolonged periods. In the ICU, it is...
...as severe. a) The use of a...
...b) NIPPV requires the nurse to offer...
...nurse to offer the patient a combination...
...to offer the patient a combination of...
...best assure a patient’s success in using...
...is required. 2. The therapy should be...
...each step, giving the patient an opportunity...
...step, giving the patient an opportunity to...
...and adapt to the sensations of the...
...the sensations of the masks and air...
...6. With NIPPV, the nurse offers: Explanations...
...Pulmonary complications 1. The distribution of gases...
...of gases to the alveoli normally favors...
...alveoli normally favors the peripheral and dependent...
...increasing evidence that the pulmonary injury associated...
...Oxygen toxicity damages the endothelial lining of...
...endothelial lining of the lungs and decreases...
...related to bypassing the normal upper airway...
...warm and humidify the air. A. Nasal/oral...
...Nasal damage a) The airway can traumatize...
...and necrosis of the nares can develop...
...or erosion of the tracheal cartilage, is...
...becomes damaged from the presence of the...
...the presence of the tube, cuff, or...
...Laryngoscopy can identify the degree of problem,...
...Can develop as the stoma size is...
...VIII. Care of the Patient Requiring Mechanical...
...Care of the Patient Requiring Mechanical Ventilation...
...Mechanical Ventilation 1. The goals of nursing...
...1. Supporting a patient’s physiologic needs involves:...
...ventilation. d) Clearing the airway: (1) ABCs:...
...secretions. e) Protecting the airway. f) Supporting...
...removed by suctioning the artificial airway on...
...secretions: properly hydrating the patient is an...
...properly hydrating the patient is an important...
...or can plug the tip of the...
...the tip of the artificial airway. 3....
...5. Protection of the airway must be...
...taken to minimize the possibility of dislodgment,...
...nutrition: collaboration with the dietitian and provider...
...routine care, and the critical care environment...
...or sleeping high-acuity patient. 3. Communication and...
...and sensation a) The presence of an...
...artificial airway prevents the patient from communicating...
...airway prevents the patient from communicating verbally....
...Family support a) The psychosocial needs of...
...psychosocial needs of the patient’s family are...
...needs of the patient’s family are important,...
...are important, while the patient physical needs...
...important, while the patient physical needs being...
...being managed on the ventilator. PowerPoint Slides...
...Clearing and protecting the airway Supporting tissue...
...support IX. Weaning the Patient from the...
...IX. Weaning the Patient from the Mechanical...
...the Patient from the Mechanical Ventilator 1....
...is rapid when the reason for ventilation...
...wean a) Initial patient screening b) Comprehensive...
...screening b) Comprehensive patient screening 2. Alternative...
...cm H2O B. The weaning process: Duration...
...weaning (short term): Patient is placed on...
...manual weaning C. The weaning process: Methods...
...schedule of disconnecting the patient from the...
...of disconnecting the patient from the mechanical...
...the patient from the mechanical ventilator for...
...less traumatic for the patient because it...
...traumatic for the patient because it does...
...intermittent removal from the ventilator. D. Special...
...older adults 1. The elderly are at...
...is determined that the patient can sustain...
...determined that the patient can sustain spontaneous...
...Terminal weaning is the intentional removal of...
...intentional removal of the mechanical ventilator when...
...mechanical ventilator when the patient is expected...
...ventilator when the patient is expected to...
...without it. b) The nurse closely monitors...
...nurse closely monitors the patient’s status and...
...closely monitors the patient’s status and provides...
...is rapid when the reason for ventilation...
...wean depends on the physiologic and psychological...
...psychological status of patient. 3. Bedside tests,...
...can help assess patient’s readiness: Rapid shallow...
...students to explain the similarities and differences...
...demonstrating to a patient how to use...
...students to describe the various complications that...
...students to participate. The rest of the...
...The rest of the class will observe...
...observe and critique the interaction. The selected...
...critique the interaction. The selected student group...
...demonstrate communication with the patient who is...
...communication with the patient who is receiving...
...one student as the patient, another the...
...student as the patient, another the significant...
...the patient, another the significant other, and...
...significant other, and the last student will...
...will act as the nurse Ask students...
...students to review the role of the...
...the role of the nurse when caring...
...when caring for the patient after extubation....
...caring for the patient after extubation. Review...
...after extubation. Review the phenomena of oxygen...
...toxicity. What are the signs and symptoms?...
...are associated with the disorder? What actions...
...What actions can the nurse perform in...
...in prevention of the disorder? Suggestions for...
...students to describe the complications that can...
...students to perform the procedure. During the...
...the procedure. During the postconference period, discuss...
...postconference period, discuss the actions taken. What...
...What signs did the patient exhibit when...
...signs did the patient exhibit when suctioning...
...took place after the suction procedures? Wagner...

...Acute Pain in the High-Acuity Patient Objectives:...
...in the High-Acuity Patient Objectives: 1. Explain...
...Objectives: 1. Explain the multidimensional nature of...
...issues related to the under treatment of...
...acute pain in the high-acuity adult patient...
...the high-acuity adult patient 5. Demonstrate effective...
...of pain for the high-acuity adult patient....
...the high-acuity adult patient. 6. Perform focused...
...focused assessments of the patient receiving opioid...
...assessments of the patient receiving opioid drug...
...populations. 8. Discuss the nursing management of...
...sedation populations. I. The Multifaceted Nature of...
...acute pain 1. The International Association for...
...International Association for the Study of Pain...
...its presence. (4) Patient’s report of pain...
...real to that patient 3. Defining acute...
...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,...
...Can decrease the patient’s pain threshold, causing...
...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...
...refers to the patient’s subjective experience surrounding...
...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...
...Unknown whether the patient’s ability to perceive...
...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...
...International Association for the Study of Pain...
...prove its presence. Patient’s report of pain...
...real to that patient. 3. The first...
...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....
...in the High-Acuity Patient A. Potential sources...
...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,...
...pain Imaginable.” (3) Patient self-reports the level...
...(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)...
...from which the patient chooses. (3) Most...
...proven NRS is the 0–10 scale. (4)...
...within any of the pain dimensions (2)...
...Using a list, the patient chooses the...
...a list, the patient chooses the adjective...
...the patient chooses the adjective that best...
...that best describes the pain: (a) E.g.,...
...choose words from the middle. d) Wong-Baker...
...to 10 (4) Patient points to the...
...Patient points to the face that represents...
...face that represents the current level of...
...pain 2. Adapting the Unidimensional Pain Assessment...
...Assessment Tool for the Severely Ill Patient...
...the Severely Ill Patient Patients may be...
...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...
...Assessment provides the patient with a means...
...means to expresses the affective and evaluative...
...evaluative aspects of the pain experience. a)...
...descriptive words. d) Patient’s word choice determines...
...from which category the pain is originating...
...of pain in the adult with altered...
...Patients rely on the nurse to advocate...
...c) Review of the patient’s medical history...
...Review of the patient’s medical history provides...
...pain adapt to the stress response. (2)...
...frequently subjectively interpret the patient’s self-report of...
...subjectively interpret the patient’s self-report of pain....
...attitudes frequently alter the assessment of pain....
...inappropriate use of the self-report tools. d)...
...self-report tools. d) The patient might be...
...tools. d) The patient might be using...
...coping skills. e) The patient’s use of...
...skills. e) The patient’s use of distraction...
...pain scales use patient behaviors (cues) to...
...(cues) to indicate the presence of pain....
...with stimulation of the sympathetic nervous system...
...pain assessment tools Patient rates a single...
...useful in evaluating the effectiveness of interventions...
...Multidimensional assessment tools Patient expresses the affective...
...tools Patient expresses the affective and evaluative...
...evaluative aspects of the pain experience. Work...
...“worst pain imaginable.” Patient self-reports the level...
...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...
...from which the patient chooses. Most common...
...proven NRS is the 0–10 scale. 6....
...within any of the pain dimensions. Useful...
...Using a list, the patient chooses the...
...a list, the patient chooses the adjective...
...the patient chooses the adjective that best...
...that best describes the pain. Potential disadvantages....
...0 to 10 Patient points to the...
...Patient points to the face that represents...
...face that represents the current level of...
...pain 8. Adapt the scale for the...
...the scale for the severely ill patient....
...the severely ill patient. Patients might be...
...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....
...of descriptive words. Patient’s word choice determines...
...from which category the pain is originating....
...Patients rely on the nurse to advocate...
...them. Review of the patient’s medical history...
...Review of the patient’s medical history provides...
...pain scales use patient behaviors (cues) to...
...(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....
...guidelines). (1) Intravenous patient-controlled analgesia (PCA) (a)...
...analgesia (PCA) (a) Patient can self-dose intravenously...
...intrathecal (3) Intermittent patient-controlled epidural (PCEA) or...
...Continuous infusion plus patient-controlled opioid alone or...
...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...
...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...
...absorption. 9. Intravenous patient-controlled analgesia (PCA) Patient...
...patient-controlled analgesia (PCA) Patient can self-dose intravenously....
...or intrathecal Intermittent patient-controlled epidural or intrathecal...
...Continuous infusion plus patient-controlled opioid alone or...
...of analgesic. Minimizes the potential for side...
...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....
...catheter placed in the pleural space. Local...
...physical adaptation of the body to the...
...the body to the presence of opioids...
...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)...
...observation of the patient’s response. (1) Sedation...
...are administered before the patient complains of...
...administered before the patient complains of pain....
...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...
...should closely observe patient’s response. 9. Effective...
...based on effects the drug is having....
...A. Assessment 1. Patient variables a) Age...
...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...
...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...
...to adequately reflect patient status, monitoring of...
...Nursing interventions 1. The plan of care...
...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...
...required if the patient develops severe respiratory...
...respiratory depression. b) The half-life of naloxone...
...time during which the patient may be...
...during which the patient may be in...
...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...
...care of each patient. PowerPoint Slides 1....
...Slides 1. Assessment Patient variables Iatrogenic (therapy)...
...analgesia POSS and the RASS 3. Use...
...Working collaboratively with the prescribing health care...
...large doses Decreasing the mean doses of...
...Management in Special Patient Populations A. Pharmacology...
...1. Several important patient-focused factors influence acute...
...metabolized primarily in the liver. b) Kidneys...
...b) Kidneys have the major responsibility for...
...be reduced and the patient monitored closely....
...reduced and the patient monitored closely. C....
...C. Management of the tolerant patient with...
...of the tolerant patient with superimposed acute...
...1. Management of the tolerant patient with...
...of the tolerant patient with superimposed acute...
...b) Consider a patient’s home routine opioid...
...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)...
...when appropriate. D. The known active or...
...substance abuser as patient 1. An ethical...
...(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...
...symptoms e) Consider the impact of tolerance...
...analgesics that have the same pharmacologic basis...
...pharmacologic basis as the abused drug. b)...
...1. Several important patient-focused factors influence acute...
...2. Pharmacology and the effect of aging...
...metabolized primarily in the liver. Kidneys have...
...liver. Kidneys have the major responsibility for...
...be reduced and the patient monitored closely....
...reduced and the patient monitored closely. 6....
...monitored closely. 6. The opioid-tolerant patient—management of...
...6. The opioid-tolerant patient—management of the tolerant...
...opioid-tolerant patient—management of the tolerant patient with...
...of the tolerant patient with superimposed acute...
...tolerance. Consider a patient’s home routine opioid...
...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...
...withdrawal symptoms Consider the impact of tolerance...
...analgesics that have the same pharmacologic basis...
...pharmacologic basis as the abused drug. Choose...
...b) Used when patient cooperation is needed...
...agents (IV). d) Patient has an altered...
...of consciousness. e) Patient maintains a patent...
...clear understanding of the different stages of...
...leads to increased patient safety. b) Ramsey...
...assesses sedation in the intensive care unit....
...conscious sedation a) Patient who is moderately...
...uncomfortable procedures. b) Patient can breathe spontaneously,...
...being performed outside the operating room. C....
...Nursing management of the patient undergoing moderate...
...management of the patient undergoing moderate sedation...
...unstable) 2. Before the procedure a) Before...
...procedure a) Before the conscious sedation procedure:...
...b) Verify that the patient has given...
...Verify that the patient has given informed...
...c) Verify that the physician has explained...
...physician has explained the procedure to the...
...the procedure to the patient. (1) E.g.,...
...procedure to the patient. (1) E.g., medications,...
...Do not leave the patient unattended or...
...not leave the patient unattended or compromise...
...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...
...b) Monitor the patient’s level of consciousness...
...neurovascular status. d) Patient might report amnesia,...
...memories. e) No patient should be sent...
...it’s necessary for the patient to go,...
...necessary for the patient to go, the...
...patient to go, the nurse must accompany....
...intravenous lines. c) The patient’s level of...
...lines. c) The patient’s level of pain...
...as indicated by the patient’s condition. E....
...indicated by the patient’s condition. E. Possible...
...conscious sedation. b) The nurse must be...
...to rescue a patient who progresses to...
...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....
...procedure if the patient is oversedated. 2....
...relaxation. Used when patient cooperation is needed....
...administering pharmacological agents. Patient has an altered...
...level of consciousness. Patient maintains patent airway,...
...leads to increased patient safety. Ramsey Sedation...
...assesses sedation in the ICU. Sedation definitions....
...of conscious sedation Patient can tolerate uncomfortable...
...tolerate uncomfortable procedures. Patient can breathe, cough,...
...training 5. Before the conscious sedation procedure:...
...sedation procedure: Verify the patient has given...
...procedure: Verify the patient has given informed...
...informed consent. Verify the physician has explained...
...physician has explained the procedure. Do not...
...Do not leave the patient unattended. Have...
...not leave the patient unattended. Have knowledge...
...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...
...procedure): Monitor the patient’s LOC and vital...
...and neurovascular status. Patient might report amnesia,...
...hangover, memories. No patient should be sent...
...separate IV lines. Patient’s level of pain...
...sedation. Rescue a patient who progresses to...
...does not meet the standard. Do not...
...continue procedure if patient is oversedated. 11....
...Classroom Activities Read the original AHCPR guideline...
...definition document. Discuss the AHCPR guideline definitions...
...or thoughts on the undertreatment of pain,...
...have personally experienced the undertreatment of pain—and...
...are found within the class? Suggestions for...
...pain. Ask about the four common misconceptions...
...play out in the actual clinical setting—how...
...avoided, etc. Obtain the pain management policies...
...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...

...Acute Pain in the High-Acuity Patient Objectives:...
...in the High-Acuity Patient Objectives: 1. Explain...
...Objectives: 1. Explain the multidimensional nature of...
...issues related to the under treatment of...
...acute pain in the high-acuity adult patient...
...the high-acuity adult patient 5. Demonstrate effective...
...of pain for the high-acuity adult patient....
...the high-acuity adult patient. 6. Perform focused...
...focused assessments of the patient receiving opioid...
...assessments of the patient receiving opioid drug...
...populations. 8. Discuss the nursing management of...
...sedation populations. I. The Multifaceted Nature of...
...acute pain 1. The International Association for...
...International Association for the Study of Pain...
...its presence. (4) Patient’s report of pain...
...real to that patient 3. Defining acute...
...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,...
...Can decrease the patient’s pain threshold, causing...
...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...
...refers to the patient’s subjective experience surrounding...
...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...
...Unknown whether the patient’s ability to perceive...
...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...
...International Association for the Study of Pain...
...prove its presence. Patient’s report of pain...
...real to that patient. 3. The first...
...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....
...in the High-Acuity Patient A. Potential sources...
...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,...
...pain Imaginable.” (3) Patient self-reports the level...
...(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)...
...from which the patient chooses. (3) Most...
...proven NRS is the 0–10 scale. (4)...
...within any of the pain dimensions (2)...
...Using a list, the patient chooses the...
...a list, the patient chooses the adjective...
...the patient chooses the adjective that best...
...that best describes the pain: (a) E.g.,...
...choose words from the middle. d) Wong-Baker...
...to 10 (4) Patient points to the...
...Patient points to the face that represents...
...face that represents the current level of...
...pain 2. Adapting the Unidimensional Pain Assessment...
...Assessment Tool for the Severely Ill Patient...
...the Severely Ill Patient Patients may be...
...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...
...Assessment provides the patient with a means...
...means to expresses the affective and evaluative...
...evaluative aspects of the pain experience. a)...
...descriptive words. d) Patient’s word choice determines...
...from which category the pain is originating...
...of pain in the adult with altered...
...Patients rely on the nurse to advocate...
...c) Review of the patient’s medical history...
...Review of the patient’s medical history provides...
...pain adapt to the stress response. (2)...
...frequently subjectively interpret the patient’s self-report of...
...subjectively interpret the patient’s self-report of pain....
...attitudes frequently alter the assessment of pain....
...inappropriate use of the self-report tools. d)...
...self-report tools. d) The patient might be...
...tools. d) The patient might be using...
...coping skills. e) The patient’s use of...
...skills. e) The patient’s use of distraction...
...pain scales use patient behaviors (cues) to...
...(cues) to indicate the presence of pain....
...with stimulation of the sympathetic nervous system...
...pain assessment tools Patient rates a single...
...useful in evaluating the effectiveness of interventions...
...Multidimensional assessment tools Patient expresses the affective...
...tools Patient expresses the affective and evaluative...
...evaluative aspects of the pain experience. Work...
...“worst pain imaginable.” Patient self-reports the level...
...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...
...from which the patient chooses. Most common...
...proven NRS is the 0–10 scale. 6....
...within any of the pain dimensions. Useful...
...Using a list, the patient chooses the...
...a list, the patient chooses the adjective...
...the patient chooses the adjective that best...
...that best describes the pain. Potential disadvantages....
...0 to 10 Patient points to the...
...Patient points to the face that represents...
...face that represents the current level of...
...pain 8. Adapt the scale for the...
...the scale for the severely ill patient....
...the severely ill patient. Patients might be...
...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....
...of descriptive words. Patient’s word choice determines...
...from which category the pain is originating....
...Patients rely on the nurse to advocate...
...them. Review of the patient’s medical history...
...Review of the patient’s medical history provides...
...pain scales use patient behaviors (cues) to...
...(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....
...guidelines). (1) Intravenous patient-controlled analgesia (PCA) (a)...
...analgesia (PCA) (a) Patient can self-dose intravenously...
...intrathecal (3) Intermittent patient-controlled epidural (PCEA) or...
...Continuous infusion plus patient-controlled opioid alone or...
...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...
...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...
...absorption. 9. Intravenous patient-controlled analgesia (PCA) Patient...
...patient-controlled analgesia (PCA) Patient can self-dose intravenously....
...or intrathecal Intermittent patient-controlled epidural or intrathecal...
...Continuous infusion plus patient-controlled opioid alone or...
...of analgesic. Minimizes the potential for side...
...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....
...catheter placed in the pleural space. Local...
...physical adaptation of the body to the...
...the body to the presence of opioids...
...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)...
...observation of the patient’s response. (1) Sedation...
...are administered before the patient complains of...
...administered before the patient complains of pain....
...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...
...should closely observe patient’s response. 9. Effective...
...based on effects the drug is having....
...A. Assessment 1. Patient variables a) Age...
...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...
...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...
...to adequately reflect patient status, monitoring of...
...Nursing interventions 1. The plan of care...
...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...
...required if the patient develops severe respiratory...
...respiratory depression. b) The half-life of naloxone...
...time during which the patient may be...
...during which the patient may be in...
...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...
...care of each patient. PowerPoint Slides 1....
...Slides 1. Assessment Patient variables Iatrogenic (therapy)...
...analgesia POSS and the RASS 3. Use...
...Working collaboratively with the prescribing health care...
...large doses Decreasing the mean doses of...
...Management in Special Patient Populations A. Pharmacology...
...1. Several important patient-focused factors influence acute...
...metabolized primarily in the liver. b) Kidneys...
...b) Kidneys have the major responsibility for...
...be reduced and the patient monitored closely....
...reduced and the patient monitored closely. C....
...C. Management of the tolerant patient with...
...of the tolerant patient with superimposed acute...
...1. Management of the tolerant patient with...
...of the tolerant patient with superimposed acute...
...b) Consider a patient’s home routine opioid...
...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)...
...when appropriate. D. The known active or...
...substance abuser as patient 1. An ethical...
...(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...
...symptoms e) Consider the impact of tolerance...
...analgesics that have the same pharmacologic basis...
...pharmacologic basis as the abused drug. b)...
...1. Several important patient-focused factors influence acute...
...2. Pharmacology and the effect of aging...
...metabolized primarily in the liver. Kidneys have...
...liver. Kidneys have the major responsibility for...
...be reduced and the patient monitored closely....
...reduced and the patient monitored closely. 6....
...monitored closely. 6. The opioid-tolerant patient—management of...
...6. The opioid-tolerant patient—management of the tolerant...
...opioid-tolerant patient—management of the tolerant patient with...
...of the tolerant patient with superimposed acute...
...tolerance. Consider a patient’s home routine opioid...
...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...
...withdrawal symptoms Consider the impact of tolerance...
...analgesics that have the same pharmacologic basis...
...pharmacologic basis as the abused drug. Choose...
...b) Used when patient cooperation is needed...
...agents (IV). d) Patient has an altered...
...of consciousness. e) Patient maintains a patent...
...clear understanding of the different stages of...
...leads to increased patient safety. b) Ramsey...
...assesses sedation in the intensive care unit....
...conscious sedation a) Patient who is moderately...
...uncomfortable procedures. b) Patient can breathe spontaneously,...
...being performed outside the operating room. C....
...Nursing management of the patient undergoing moderate...
...management of the patient undergoing moderate sedation...
...unstable) 2. Before the procedure a) Before...
...procedure a) Before the conscious sedation procedure:...
...b) Verify that the patient has given...
...Verify that the patient has given informed...
...c) Verify that the physician has explained...
...physician has explained the procedure to the...
...the procedure to the patient. (1) E.g.,...
...procedure to the patient. (1) E.g., medications,...
...Do not leave the patient unattended or...
...not leave the patient unattended or compromise...
...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...
...b) Monitor the patient’s level of consciousness...
...neurovascular status. d) Patient might report amnesia,...
...memories. e) No patient should be sent...
...it’s necessary for the patient to go,...
...necessary for the patient to go, the...
...patient to go, the nurse must accompany....
...intravenous lines. c) The patient’s level of...
...lines. c) The patient’s level of pain...
...as indicated by the patient’s condition. E....
...indicated by the patient’s condition. E. Possible...
...conscious sedation. b) The nurse must be...
...to rescue a patient who progresses to...
...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....
...procedure if the patient is oversedated. 2....
...relaxation. Used when patient cooperation is needed....
...administering pharmacological agents. Patient has an altered...
...level of consciousness. Patient maintains patent airway,...
...leads to increased patient safety. Ramsey Sedation...
...assesses sedation in the ICU. Sedation definitions....
...of conscious sedation Patient can tolerate uncomfortable...
...tolerate uncomfortable procedures. Patient can breathe, cough,...
...training 5. Before the conscious sedation procedure:...
...sedation procedure: Verify the patient has given...
...procedure: Verify the patient has given informed...
...informed consent. Verify the physician has explained...
...physician has explained the procedure. Do not...
...Do not leave the patient unattended. Have...
...not leave the patient unattended. Have knowledge...
...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...
...procedure): Monitor the patient’s LOC and vital...
...and neurovascular status. Patient might report amnesia,...
...hangover, memories. No patient should be sent...
...separate IV lines. Patient’s level of pain...
...sedation. Rescue a patient who progresses to...
...does not meet the standard. Do not...
...continue procedure if patient is oversedated. 11....
...Classroom Activities Read the original AHCPR guideline...
...definition document. Discuss the AHCPR guideline definitions...
...or thoughts on the undertreatment of pain,...
...have personally experienced the undertreatment of pain—and...
...are found within the class? Suggestions for...
...pain. Ask about the four common misconceptions...
...play out in the actual clinical setting—how...
...avoided, etc. Obtain the pain management policies...
...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...

...Holistic Care of the Patient and Family...
...Care of the Patient and Family Objectives:...
...Objectives: 1. Discuss the impact of illness...
...of illness on the high-acuity patient and...
...on the high-acuity patient and family. 2....
...2. Identify way the nurse can help...
...event. 3. Describe the principles of patient...
...the principles of patient and family-centered care...
...family-centered care in the high-acuity environment as...
...policies. 4. Discuss the importance of awareness...
...patients. 5. Examine the role of palliative...
...palliative care in the high-acuity environment and...
...Acute Illness on Patient and Family A....
...Illnesses can cause the patients to experience...
...might respond to the losses by passing...
...meaning. b) Denial: Patient rejects diagnosis. c)...
...accepted. e) Resolution: Patient’s identity is changed....
...Nursing considerations 1. The family is an...
...important part of the patient’s health outcome....
...part of the patient’s health outcome. 2....
...must participate in the care and recovery...
...2a. Needs of the Family of the...
...the Family of the Patient with High-Acuity...
...Family of the Patient with High-Acuity Illness...
...Communication Requirements of the Family Openness Honesty...
...stress. Humor strengthens the bonds among the...
...the bonds among the patient, family, and...
...bonds among the patient, family, and nurse....
...family, and nurse. The use of humor...
...facilitate sleep. (2) The vascular, muscular, and...
...encourages relaxation. (2) The patient is asked...
...relaxation. (2) The patient is asked to...
...soft tissues of the body using the...
...the body using the hands Can reduce...
...used to distract the patient from painful...
...to distract the patient from painful events...
...or treatments III. Patient- and Family-Centered Care...
...a relationship with the patient facilitates trust...
...relationship with the patient facilitates trust in...
...facilitates trust in the nurse and will...
...inhibit learning in the high-acuity patient. Obstacles...
...in the high-acuity patient. Obstacles to education...
...communication and pain. The nurse must meet...
...nurse must meet the physiological needs of...
...physiological needs of the patient before attempting...
...needs of the patient before attempting to...
...(3) Acknowledgement of the past (4) Optimal...
...a) Transfer of the patient to a...
...Transfer of the patient to a less-acute...
...transfer anxiety in the patient or family....
...anxiety in the patient or family. b)...
...or family. b) The anxiety is the...
...The anxiety is the result of a...
...of care allowing the patient and family...
...care allowing the patient and family to...
...promote success of the transfer. d) Moving...
...transfer. d) Moving the patient during daytime...
...d) Moving the patient during daytime hours...
...care units in the United States have...
...are unrestricted. 2. The visiting activities of...
...care units: a) The rationales for these...
...are concerns for the risk of infection...
...infection and for the emotional well-being of...
...emotional well-being of the child. b) In...
...child. b) In the event a family...
...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...
...Educating the High-Acuity Patient Goals Reduce stress...
...a relationship with the patient 2. Barriers...
...relationship with the patient 2. Barriers to...
...to Learning for the High-Acuity Patient Condition-related...
...for the High-Acuity Patient Condition-related fatigue Communication...
...Families Information about patient progress Informed decision...
...making Acknowledgement of the past Optimal learning...
...care unit Affects patient and family Tips...
...Provide information to patient and family Encourage...
...Encourage questions from patient and family Transfer...
...on: Concerns for the risk of infection...
...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...
...seriousness of the patient’s illness. Family members...
...was done for the patient. Families move...
...done for the patient. Families move more...
...more positively through the grieving process. Removal...
...is happening to the patient. Families experience...
...happening to the patient. Families experience less...
...one. Facilitation of the grieving process by...
...letting them influence the care of patients...
...and acceptance for the patient’s culture. c)...
...acceptance for the patient’s culture. c) Cultural...
...includes sensitivity to the culture, race, gender,...
...economic status of the patients. 2. Other...
...competence 1. In the quest for developing...
...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...
...needed by the patient. Judgment cannot be...
...be made concerning the patient’s choices. The...
...made concerning the patient’s choices. The CRASH...
...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...
...a) Cancer is the most common disorder...
...care exist for the high-acuity-care patient. b)...
...for the high-acuity-care patient. b) It is...
...difficult to make the transition from a...
...palliative nature. c) The limited collaboration and...
...needed to facilitate the patient’s progression to...
...to facilitate the patient’s progression to a...
...care path. b) The team will consist...
...will consist of the high-acuity nurse and...
...High-Acuity Settings: a) The Patient Self-Determination Act...
...Settings: a) The Patient Self-Determination Act requires...
...advanced directives. b) The American Association of...
...and appreciation of the collaborative role of...
...team members. c) The Patient Self-Determination Act...
...members. c) The Patient Self-Determination Act requires...
...term implies that the patient is dying...
...implies that the patient is dying and...
...done to keep the patient comfortable and...
...to keep the patient comfortable and allow...
...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...
...comprehensive 6. The Patient Self-Determination Act Part...
...Act Part of the Omnibus Budget Reconciliation...
...given information about the right to formulate...
...Environmental characteristics of the high-acuity care unit...
...significant impact on the patient. b) The...
...impact on the patient. b) The patient...
...the patient. b) The patient is at...
...patient. b) The patient is at risk...
...and deprivation. c) The individual’s normal stimuli...
...are interrupted, and the senses simultaneously are...
...unresponsive are at the greatest risk for...
...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....
...When caring for the patient who cannot...
...caring for the patient who cannot speak,...
...who cannot speak, the nurse must act...
...act as a patient advocate. (1) The...
...patient advocate. (1) The nurse will need...
...provide support for the decision of the...
...the decision of the patient or designated...
...decision of the patient or designated surrogate....
...with those of the health care provider...
...by Environmental Stressors The aged population Very...
...2. Role of the Nurse Caring for...
...Nurse Caring for the High-Acuity Patient Assess...
...for the High-Acuity Patient Assess the patient’s...
...High-Acuity Patient Assess the patient’s normal environmental...
...Patient Assess the patient’s normal environmental stimuli...
...Environmental Stimuli and the Unconscious Patient An...
...and the Unconscious Patient An assessment of...
...An assessment of the normal stimuli for...
...normal stimuli for the unconscious patient must...
...for the unconscious patient must be completed....
...must be completed. The nurse might need...
...normal stimuli for the patient. 5a. Delirium...
...stimuli for the patient. 5a. Delirium Sensory...
...5d. Role of the Nurse Caring for...
...Nurse Caring for the Patient Experiencing Delirium...
...Caring for the Patient Experiencing Delirium Assess...
...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...
...needed. 8. The Patient Who Cannot Speak...
...Nurses must be patient advocates. Nurse must...
...Nurse must represent the patient or patient...
...must represent the patient or patient representative:...
...the patient or patient representative: Choices may...
...in-class review. Divide the class into small...
...care plans addressing the education needs of...
...education needs of the acutely ill patient....
...the acutely ill patient. Allow only a...
...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...
...for educating for the acutely ill patient...
...the acutely ill patient is crucial. Ask...
...their concepts of the optimal learning environment....
...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...
...Suchman stage the patient they cared for...
...to visit with the clinical group. Ask...
...clinical group. Ask the massage therapist to...
...therapist to discuss the use of massage...

...Objectives: 1. Discuss the various health care...
...care. 2. Identify the need for resource...
...patients. 3. Examine the use of technology...
...environments. 4. Identify the components of a...
...environment. 5. Discuss the importance of patient...
...the importance of patient safety in the...
...patient safety in the high-acuity environment. I....
...were developed in the 1960s. Medical advances...
...advances resulted in the initiation of these...
...these units. a) The implementation of CPR...
...and shock c) The implementation of emergency...
...Technological advances e) The advancement of renal...
...services B. Determining the level of care...
...aids in giving the most efficient and...
...Ability to manage the potentially serious health...
...care needs of the patient whose condition...
...needs of the patient whose condition is...
...too complex for the traditional medical-surgical floor...
...triage and determine the level of care...
...acutely ill patients. The model divides patient...
...The model divides patient needs into four...
...a) Priority 1: The patient is acutely...
...Priority 1: The patient is acutely ill,...
...available outside of the intensive care unit....
...b) Priority 2: The patient is seriously...
...Priority 2: The patient is seriously ill...
...ill and has the potential to require...
...c) Priority 3: The patient is critically...
...Priority 3: The patient is critically ill...
...limits placed on the amount of life-saving...
...Their inclusion into the ICU will depend...
...decision based on the appropriate use of...
...resources and current patient status. C. Levels...
...care units 1. The American College of...
...resources available to the hospital: a) Level...
...D. Profile of the high-acuity nurse 1....
...to ensure optimal patient outcomes. 4. Competent...
...5. Role of the nurse in the...
...the nurse in the management of the...
...the management of the high-acuity environment: a)...
...environment: a) Review the patient’s clinical condition...
...a) Review the patient’s clinical condition and...
...too complex for the traditional medical surgical...
...terminally ill 4. The Registered Nurse in...
...Continual assessment of the patient’s status Implementation...
...assessment of the patient’s status Implementation of...
...status Implementation of the plan of care...
...Nurse staffing 1. Nurse-patient ratios a) Many...
...Factors linked to the nursing shortage include:...
...in nurses leaving the workforce (2) Aging...
...(2) Aging of the registered nurse workforce...
...health services b) The reduction in the...
...The reduction in the number of professional...
...an increase in the nurse–patient ratio. c)...
...increase in the nurse–patient ratio. c) The...
...nurse–patient ratio. c) The Academy of Medical...
...does not support the development of exact...
...development of exact patient–nurse ratios. 2. Magnet...
...are attractive to the retention of professional...
...direct care. a) The UAP provides care...
...provides care under the direction of the...
...the direction of the professional nurse. B....
...an ICU? a) The health care needs...
...care needs of the patient and the...
...needs of the patient and the skill...
...the patient and the skill mix available...
...available must be the deciding factors. b)...
...deciding factors. b) The assignment of patients...
...those patients requiring the greatest level of...
...cared for in the intensive care unit....
...controversial variables in the assignment of intensive...
...1. Nursing Shortage The nursing shortage has...
...Factors linked to the nursing shortage include:...
...satisfaction Aging of the nursing workforce Limited...
...as a career The increasing number of...
...health services 2. Nurse–Patient Ratios Linked to...
...care Work under the direct supervision of...
...direct supervision of the professional nurse 5....
...of Resources and Patient Bed Assignments Goals...
...Goals involve ensuring the most favorable use...
...A. Benefits 1. The use of technology...
...of technology in the intensive care unit...
...close monitoring of the patient. 2. The...
...monitoring of the patient. 2. The technology...
...the patient. 2. The technology is a...
...for placement in the intensive care unit....
...care unit. 3. The use of computers...
...available to diagnose patient conditions. Handheld devices...
...reference guides. B. Patient depersonalization 1. Difficulties...
...when machines become the focus of care...
...of care of the high-acuity patient. 2....
...of the high-acuity patient. 2. Technical devices...
...impediments to touching the patient. 3. Little...
...to touching the patient. 3. Little surface...
...overreliance issues 1. The potential for increased...
...increased stress on the nurse as a...
...on technology by the nurse. D. Finding...
...a Balance 1. The skilled nurse who...
...able to bridge the gap between complex...
...complex technology and the art of caring....
...of Technology in the ICU Allows for...
...close monitoring of the patient Provides a...
...monitoring of the patient Provides a programmed...
...programs to diagnose patient disorders Source of...
...Technology Depersonalization of the patient Overload Over-reliance...
...Depersonalization of the patient Overload Over-reliance IV....
...work environment 1. The American Association of...
...of community allows the nurse the ability...
...allows the nurse the ability to share...
...factors that improve the ability of the...
...the ability of the nurse to manage...
...debriefings V. Ensuring Patient Safety in High-Acuity...
...High-Acuity Environments A. The culture 1. Studies...
...conditions, teamwork, and patient outcomes: a) High...
...decreased mortality. 2. The current culture is...
...care errors. B. Patient safety 1. The...
...Patient safety 1. The Joint Commission (TJC)...
...seeks to improve patient safety through an...
...TJC developed National Patient Safety Goals for...
...To receive accreditation, the applying organization must...
...it is meeting the outlined safety goals....
...C. Technology and patient safety 1. Computerized...
...prevent errors a) The computerized provider order...
...drug names b) The barcode point-of-care (BPOC)...
...badges and then the patient wristbands to...
...and then the patient wristbands to access...
...factors contributing to patient safety 1. Patient...
...patient safety 1. Patient safety can be...
...orientation will help the high-acuity nurse provide...
...systems improvement. 2. The Joint Commission (TJC)...
...seeking to improve patient safety. Developed National...
...safety. Developed National Patient Safety Goals. Acute...
...Elements That Promote Patient Safety Strong educational...
...three to four patient scenarios. Lead a...
...as to whether the patients being referenced...
...are suitable to the ICU, IMC, or...
...medical–surgical unit. Determine the students’ interest level....
...interest level. Ask the students if they...
...What factors do the students cite as...
...students cite as the reasons behind their...
...its policies concerning the steps taken when...
...steps taken when the intensive care units...
...Clinical Activities During the clinical post conference,...
...post conference, ask the students to evaluate...
...were appropriate for the ICU, IMC, or...
...lead to a patient’s being considered a...
...a Priority 4 patient. Provide the clinical...
...4 patient. Provide the clinical group rotation...
...rotation opportunities to the ICU and the...
...the ICU and the IMC. Ask the...
...the IMC. Ask the students to develop...
...a listing of the noted differences between...
...noted differences between the units. Wagner et...