Class Notes for High-Acuity Nursing, 7th Edition

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Instructor’s Resource Manual
For
High-Acuity Nursing
7th Edition
Kathleen Dorman Wagner, EdD, MSN, RN
Faculty Emerita, University of Kentucky College of Nursing
Melanie G. Hardin-Pierce, DNP, RN, APRN, ACNP-BC
Associate Professor of Nursing, University of Kentucky College of Nursing
Darlene Welsh, PhD, MSN, RN
Associate Professor of Nursing, University of Kentucky College of Nursing
Prepared by
Maria Baptiste, MSN, CCRN-CMC, APRN-BC, NP-C

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CHAPTER
1 High-Acuity Nursing
Objectives:
1. Discuss the various healthcare environments in which high-acuity patients receive care.
2. Identify the need for resource allocation and staffing strategies for high-acuity patients.
3. Examine the use of technology in high-acuity environments.
4. Identify the components of a healthy work environment.
5. Discuss the importance of patient safety in the high-acuity environment.
I. High-Acuity Environment
A. Historical perspective
1. Intensive care units (ICUs) were developed in the 1960s. Medical advances
resulted in the initiation of these units.
a) The implementation of CPR
b) Improved management of patients experiencing hypovolemia and shock
c) The implementation of emergency medical services
d) Technological advances that required close observation for effective use
e) The advancement of renal transplant services
f) The first ICUs were recovery rooms created for those postoperative
patients who required extra equipment and prolonged observation.
B. Determining the level of care needed
1. Systematic triage approach for high-acuity patients aids in giving the most
efficient and cost-effective care.
a) ICU
b) Intermediate care unit (IMC) or progressive care unit (PCU)
(1) Developed to manage those patients whose acute illness requires
less monitoring equipment and staffing than is provided in an ICU
(2) Ability to manage patients with moderate or potentially severe
physiological instability but who do not require artificial life
support
c) Medical–surgical acute care unit

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2. Nurses should use a prioritization model to triage and determine the level of
care needed by acutely ill patients. The model divides patient needs into four
categories:
a) Priority 1: The patient is acutely ill, requiring intensive treatments not
available outside of the intensive care unit.
b) Priority 2: The patient is seriously ill and has the potential to require
immediate medical interventions to prevent complications.
c) Priority 3: The patient is critically ill but has a limited chance for
recovery. There might be limits placed on the amount of life-saving
interventions that may be implemented.
d) Priority 4: This is a large category of patients. Their inclusion into the
ICU will depend on an individualized decision based on the appropriate
use of resources and current patient status.
C. Levels of intensive care units
1. The American College of Critical Care Medicine has identified three levels of
ICUs as determined by resources available to the hospital:
a) Level I: Hospitals with ICUs that provide comprehensive care for
patients with a wide range of disorders. Sophisticated equipment,
specialized nurses and healthcare providers, and comprehensive support
services.
b) Level II: Hospitals with ICUs that provide comprehensive care to most
critically ill patients.
c) Level III: Hospitals with ICUs that provide initial stabilization of
critically ill patients but are limited in their ability to provide
comprehensive care for all patients.
D. Profile of the high-acuity nurse
1. Able to analyze clinical situations
2. Makes decisions based on analysis
3. Rapidly intervenes to ensure optimal patient outcomes
4. Competent in detecting early signs of an impending complication
5. Role of the nurse in the management of the high-acuity environment:
a) Constant surveillance and monitoring to identify possible impending and
life-threatening complications
(1) Studies show that constant surveillance of patients by nurses
reduces mortality and complications.
II. Resource Allocation
A. Nurse staffing
1. Nurse–patient ratios

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a) Many interrelated factors have led to a shortage of nurses able and
willing to work with acutely ill patients. Factors linked to the nursing
shortage include:
(1) Hospital restructuring of nursing personnel reduced job
satisfaction, which resulted in nurses leaving the workforce.
(2) Aging of the registered nurse workforce
(3) Limited number of young adults choosing nursing as a career
(4) Increasing number of aging persons, resulting in an increase in
persons requiring acute care health services
(5) Increase in access to health care as a result of the Affordable
Care Act
(6) Legislation to support registered nurse-to-patient ratios and other
nurse–patient issues have been raised to the national level.
b) The reduction in the number of professional nurses has resulted in an
increase in the nurse–patient ratio.
c) The Academy of Medical Surgical Nurses (AMSN) does not support the
development of exact patient–nurse ratios.
d) The needs of the patient and the skill mix of the nursing staff must be
considered when making decisions about staffing patterns.
e) The first principle of staffing is to provide safe and effective patient care.
f) Unlicensed assistive personnel (UAP) can be used to provide direct care
under direct supervision of the professional nurse.
g) The professional nurse uses leadership skills to safely and legally
delegate tasks to the UAP.
2. Magnet status: recruiting and retaining nurses
a) Magnet designation is a status awarded to hospitals that demonstrate
successful recruitment and retention of professional nurses.
b) Magnet hospitals promote environments meant to attract and retain
professional nurses.
c) Nurses who work at Magnet hospitals are more involved in decision
making, report better relations with physicians, and have higher nurse-to-
patient ratios.
B. Decreasing resources, increasing care needs
1. Who Belongs in an ICU?
a) Deciding factors for ICU care are multifactorial and may include severity
of injury, futility of treatment and informed refusal, the need to provide
the quality of the dying and death experience, and family involvement.
b) The assignment of patients to units requires a close review of available
resources.

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c) Age and seriousness of illness can be controversial variables in the
assignment of intensive care beds. Severity scales are models used to
determine which patients will benefit most from intensive care services.
d) Ethical, economic, and legal considerations must be addressed with
regard to ICU care.
e) Patient death in a high-acuity area consumes significant resources.
f) Each patient’s end-of-life care is subjective and different; therefore, cost
alone cannot be used to justify the use of healthcare resources.
III. Use of Technology in High-Acuity Environments
A. Benefits
1. The use of technology in the intensive care unit allows for close monitoring of
the unstable patient and can limit complications.
2. The technology is a primary incentive for placement in the intensive care unit.
3. The use of computers can provide a programmed approach to guide decision
making by providing decision-making trees.
4. Programs are available to diagnose patient conditions. Handheld devices can be
used to provide bedside reference guides.
5. Nurses must be able to use technology but also recognize its limitations.
B. Patient depersonalization
1. Difficulties arise when machines become the focus of care of the high-acuity
patient.
2. Technology must be used to enhance care, not take the place of a nurse’s
personal knowledge, observation skills, and senses.
3. Technology may evoke fear in patients and contribute to their anxiety about
their recovery process.
C. Overload and overreliance issues
1. The potential for increased stress on the nurse as a result of information
overload.
2. Alarm fatigue is one result of overload and overreliance on technology.
3. Support of patient well-being can be lost to the lure of technology.
D. Finding a balance
1. The skilled nurse who practices in a high-acuity setting must be able to bridge
the gap between complex technology and the art of caring.
2. Appropriate training in the use of technology prevents technology from
becoming the focus of care.
3. Nurses are at risk for becoming overly dependent on technology.
IV. Healthy Work Environment

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A. Healthy work environment
1. The American Association of Critical-Care Nurses (AACN) has identified six
standards needed to sustain a healthy work environment. These standards are:
a) Skilled communication
b) True collaboration
c) Effective decision making
d) Appropriate staffing
e) Meaningful recognition
f) Authentic leadership
B. Stress, burnout, and compassion fatigue
1. Burnout is a term used to describe feelings of personal and professional
frustration, dissatisfaction, job insecurities, and emotional and physical
exertion.
2. Causes for burnout:
a) Nursing shortages, long work hours, and a loss of concentration,
managerial unresponsiveness, lack of team support
b) Stress caused by exposure to patients experiencing pain and suffering
c) Feelings of powerlessness
d) Repeated exposure to pain and traumatic loss
3. Compassion fatigue describes the inability to reenergize because of the loss of
compassion energy expended on others.
a) Compassion fatigue results from stress nurses experience from daily
relationships with patients and families.
C. Coping with stress, burnout, and compassion fatigue
1. Factors that improve a nurse’s ability to cope with stress are a positive social
climate, managerial support, and staff cohesiveness.
2. Critical incident stress debriefings (CISD) help to promote coping with special
situations.
3. A sense of community allows the nurse the ability to share both stresses and
joys.
V. Ensuring Patient Safety in High-Acuity Environments
A. The culture
1. Studies have linked a relationship among work conditions, teamwork, and
patient outcomes:
a) High levels of teamwork have been associated with a decreased length of
stay and decreased mortality.
B. Patient safety

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1. The Joint Commission (TJC) is an accrediting organization that seeks to
improve patient safety through an accreditation process.
a) TJC developed National Patient Safety Goals for acute care hospitals.
b) To receive accreditation, the applying organization must develop and
provide evidence that it is meeting the outlined safety goals.
C. Technology and patient safety
1. Computerized systems are used to prevent errors.
a) The computerized provider order entry (CPOE) systems
(1) Used to block incorrect medication orders; warn of drug
interactions, allergies, and overdoses; provide current drug
information; and alert one to similar drug names
b) The barcode medication administration (BCMA)
(1) Allows nurses to scan their badges and then the patient
wristbands to access medications profiled for that specific patient
c) Smartphones allow for text messaging, email retrieval, and the use of
clinical apps
D. Other factors contributing to patient safety
1. Patient safety can be promoted with factors other than technology.
2. A strong educational foundation and solid orientation will help the high-acuity
nurse provide a safe environment.
3. Performance standards, specialty certification, culture of respect and
professionalism, and strong physician–nurse relationships are among the
factors that contribute to patient safety.
VI. Clinical Reasoning Checkpoint
Case 1: RM is a 64-year-old with stage 4 metastatic colon cancer. She presents to the emergency
department with shortness of breath. A chest x-ray reveals right lower lobe pneumonia. She is
admitted to the hospital. She has advance directives that include no intubation or CPR.
1. Is RM a candidate for admission to the ICU? Why or why not?
2. Using the Society of Critical Care Medicine (SCCM) prioritization model, identify the
patient’s priority level for ICU placement.
Case 2: A patient with a history of new-onset seizures is admitted to a level III ICU. A diagnosis of
brain tumor is made, and surgery will be required. The healthcare provider (HCP) informs the patient
that he needs to be transferred to another hospital that has a level I ICU.
3. After the HCP leaves the room, the patient says he doesn’t understand why he needs to be
transferred. As his nurse, explain the reason for the need for transfer.
Case 3: You would like to work in a high-acuity unit that has a healthy practice environment that
supports quality patient care and high levels of nurse satisfaction. You are aware of the six standards
identified by AACN that are critical to creating and sustaining a healthy work environment.

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4. Provide at least one example of how you might see each of the six standards operationalized
in the high-acuity unit.
VII. Post-Test / Chapter 1 Review
Chapter 1 Question: ch01_01
Question: The ICU nurse receives a call from the medical–surgical unit requesting transfer of a
patient to the ICU. The patient is in acute respiratory failure and requires mechanical ventilation. He
will require vasoactive drugs to help manage his profound hypotension. Based on the SCCM
prioritization model, what is this patient’s priority for ICU placement?
Answer:
1. Priority 1
Rationale:
1. This patient is unstable and requires treatment and monitoring that cannot be provided outside the
ICU (new mechanical ventilation and vasoactive infusions). This condition meets the criteria for
Priority 1 admission.
Chapter 1 Question: ch01_02
Question: A nurse is interviewing for a position in a community hospital. Hospital brochures
describe a Level III ICU. Which statement describes the resources that the nurse would expect in this
hospital?
Answer:
3. Staff in the unit can provide initial stabilization of patients for transfer to more advanced care.
Rationale:
3. A Level III ICU provides initial stabilization of patients.
Chapter 1 Question: ch01_03
Question: A hospital has been working to achieve Magnet status. Which statements by an ICU nurse
reflect the benefits of Magnet status? (Select all that apply.)
Answer:
1. “I feel more ownership in the decisions being made to run the unit.”
4. “Taking care of one less patient each shift makes such a difference.”
Rationale:
1. Nurses who work in Magnet hospitals are more involved in decision making, which increases their
ownership of the decisions.
4. Improved nurse–patient ratios are a benefit of work toward Magnet status.
Chapter 1 Question: ch01_04
Question: In the middle of a shift a nurse comes to the manager to discuss the acuity level and
number of patients he has been assigned. Which statement would the manager interpret as indicating
the nurse needs further education about nurse–patient ratios?
Answer:
2. “Our professional organizations would not approve of exceeding their recommended ratios.”

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Rationale:
2. AACN and AMSN do not set recommended ratios.
Chapter 1 Question: ch01_05
Question: New, fairly complex monitoring devices have been purchased to replace current monitors
in the ICU. How should the nurse manager plan to introduce this equipment to the unit?
Answer:
2. Require that all nurses caring for patients on this monitor have extensive training on its use.
Rationale:
2. All nurses who will use this equipment must be trained in its use before caring for a patient on the
monitor.
Chapter 1 Question: ch01_06
Question: What is the best advice that an experienced ICU nurse can offer to new nurses on how to
remain focused on the patient?
Answer:
3. “Try to arrange equipment so that you have ample opportunity to use the power of your touch with
the patient.”
Rationale:
3. Touch helps to personalize the patient for the nurse. Touch also helps to reduce anxiety in the
patient.
Chapter 1 Question: ch01_07
Question: A coworker has become increasingly withdrawn from social activities on the unit. She is
often late for work and is ambivalent about warnings from the nurse manager. She has become hostile
and negative about proposed changes in the unit. The nurse should recognize that the coworker is
exhibiting symptoms of which condition?
Answer:
1. Burnout
Rationale:
1. Ambivalence, withdrawal, hostility, and negativity are all symptoms of burnout.
Chapter 1 Question: ch01_08
Question: The nurse manager has made a commitment to improve the health of the ICU work
environment. Which activities will help meet that goal? (Select all that apply.)
Answer:
1. Make every effort to assign patients so that their needs match the nurse’s strengths.
3. Engage the hospital nurse executive in efforts to improve the health of the entire environment.
5. Communicate in a clear and effective manner.
Rationale:
1. Matching patient need to nurse strength reflects appropriate staffing, which is one of the AACN

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standards for a healthy work environment.
3. The manager should demonstrate and encourage authentic leadership, embracing healthy living and
environmental strategies.
5. Skilled communication is one of the AACN standards for a healthy work environment.
Chapter 1 Question: ch01_09
Question: The hospital is planning to implement a CPOE system. One of the nurses says, “I don’t see
how that is going to help.” Which statement by another nurse is a good response to this concern?
Answer:
3. “Actually, hospitals that have used these systems generally see error reduction.”
Rationale:
3. CPOE systems have been found to reduce error.
Chapter 1 Question: ch01_10
Question: The high-acuity unit’s operations council is seeking suggestions concerning the use of
technology to prevent errors on the unit. What statements by nurses are good responses to this
request? (Select all that apply.)
Answer:
1. “Barcode medication administration (BCMA) has been shown to reduce medication errors.”
5. “If we had smartphones, we could look up so much information.”
Rationale:
1. BCMA systems do reduce medication errors.
5. Smartphones do allow for quick and convenient access to data.
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IX. Suggestions for Classroom Activities
• Develop three to four patient scenarios. Lead a class discussion as to whether the patients being
referenced are suitable for the ICU, IMC, or general medical–surgical unit.
• Determine the students’ interest level. Ask the students if they are considering a nursing career in
an ICU, an IMC, or a generalized medical–surgical care unit. What factors do the students cite as
the reasons behind their choices?
• Contact a local clinical facility. Ask to have a copy of its policies concerning the steps taken
when the intensive care units are filled to capacity.
• Ask students to identify behaviors associated with professional burnout. Lead the discussion on
recognizing burnout and coping with the high-acuity nursing environment.
X. Suggestions for Clinical Activities
• During the clinical postconference, ask the students to evaluate whether their assigned patients
were appropriate for the ICU, IMC, or general medical–surgical care unit.
• Lead a class discussion to determine potential factors that would lead to a patient’s being
considered a Priority 4 patient.
• Provide the clinical group rotation opportunities to the ICU and the IMC. Ask the students to
develop a listing of the noted differences between the units.

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CHAPTER
2 Holistic Care of the Patient and
Family
Objectives:
1. Describe the impact of illness on the high-acuity patient and family.
2. Identify ways the nurse can help high-acuity patients cope with an illness and/or injury event.
3. Describe the principles of patient- and family-centered care in the high-acuity environment as it
relates to educational needs of visitation and policies.
4. Explain the importance of awareness of cultural diversity when caring for high-acuity patients.
5. Identify environmental stressors, their impact on high-acuity patients, and strategies to alleviate
those stressors.
I. Impact of Acute Illness on Patient and Family
A. Kübler-Ross’s Stages of Grief
1. Illnesses can cause the patient and family to experience loss of health, loss of
limb, disfigurement, or necessary change in lifestyle that may alter the patient’s
self-image and self-esteem. Patients may respond to losses in certain
predictable phases. According to Kübler-Ross and Kessler, these stages of grief
are:
a) Denial: The diagnosis does not have an emotional meaning.
b) Anger: The patient rejects diagnosis.
c) Bargaining: The patient attempts to regain control.
d) Depression: The patient accepts the diagnosis.
e) Acceptance: The patient’s identity is changed.
B. Nursing considerations
1. The family is an important part of the patient’s health outcome.
2. The family is defined by the patient and may not be the traditional nuclear
family.
3. High-acuity units are now more inclusive family environments.
4. Patients need information, comfort, support, assurance, and accessibility.

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5. Proactive communication in the form of family meetings beginning early in the
patient’s ICU stay contributes to family-centered plan of care.
II. Coping with Acute Illness
A. Complementary and Alternative Therapies (CAT)
1. Numerous strategies are used to help patients cope with psychological and
physical illness–related stressors. Complementary and alternative therapies that
can help reduce stress include:
a) Aromatherapy
(1) Use of oils to reduce stress and anxiety. Oils may be inhaled and
used to enhance massage. Commonly used oils include lavender
and jasmine.
b) Therapeutic Humor
(1) Humor is used to relieve stress. Humor strengthens the bonds
among the patient, family, and nurse. The use of humor is tricky
during a serious illness.
c) Massage Therapy and Therapeutic Touch
(1) Massage can help promote relaxation, reduce anxiety, and
facilitate sleep.
(2) The vascular, muscular, and nervous systems are positively
affected by massage.
(3) Massage is an acceptable tool to manage pain. Conditions that do
not indicate massage therapy include advanced osteoporosis,
bone fractures, burns, deep vein thrombosis,
eczema, phlebitis, and skin infections.
d) Guided Imagery
(1) Guided imagery is a technique that encourages relaxation.
(2) The patient is asked to focus on positive thoughts and
experiences.
III. Patient- and Family-centered Care
A. Educational needs of patients and families
1. Health literacy
a) Health literacy is the degree to which patients and families have the
ability to obtain, process, and understand basic health information to
make informed decisions about their healthcare.
b) Health literacy includes the ability to:
(1) Communicate with members of the health team
(2) Complete complex forms

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(3) Understand concepts related to risks.
c) Some groups at risk for low levels of health literacy include: patients
older than 65 years of age, members of minority groups, immigrants,
those of a lower socioeconomic status, or those suffering from chronic
illnesses.
d) Patients with low health literacy are at risk for negative outcomes.
e) Educational needs of the patient and family include:
(1) Information about progress
(2) Informed decision making
(3) Acknowledgment of the past
(4) Optimal learning environment
(5) Orientations to routines and care
(6) Motivation
f) The nurse should use return demonstration and teach-back techniques to
supplement patient and family education as appropriate.
2. Transfer anxiety
a) Transfer anxiety is the mixed-emotional experience of the patient and
family as the patient is transferred from a secure to an unfamiliar
environment.
b) A plan of care allowing the patient and family to ask questions will
promote success of the transfer.
c) Activities that promote reducing transfer anxiety include:
(1) Moving the patient during daytime hours
(2) Receiving information about unit routines and new equipment
(3) Introducing the receiving nurse before the transfer
B. Visitation policies
1. Many intensive care units in the United States have restrictive visiting policies:
a) Studies indicate that patients prefer open visitation policies.
b) Patients demonstrate reduced risks of cardiovascular complications,
decreased mortality, and anxiety levels when their visiting hours are
unrestricted.
2. The visiting activities of children often are restricted in intensive care units:
a) The rationales for these limitations are concerns for the risk of infection
and for the emotional well-being of the child.
b) In the event a family member is at risk for not recovering, exceptions
should be made to allow for “goodbyes.”
3. Historically, family members have been restricted from their loved ones during
invasive procedures and cardiopulmonary resuscitation:

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a) Studies reveal that many facilities do not have policies restricting family
presence during CPR.
b) Benefits of family presence during CPR include:
(1) Increasing family awareness of resuscitation efforts
(2) The family is able to say goodbye.
(3) Gaining a sense of control
(4) The ability to preserve the patient’s dignity
(5) Gaining a sense of closure
(6) Decreasing family members’ experience of posttraumatic stress
disorder.
4. The care delivery model embraces the presence of the family members at the
bedside:
a) Nursing staff should provide education to the family members regarding
what to expect and actions that should be taken.
b) Hospital policies should carefully address the facility’s stance toward
visitors exhibiting negative behaviors.
IV. Cultural Diversity
A. Cultural competence
1. Cultural Assessment
a) Knowledge of a patient’s cultural background is required to provide
excellent care.
b) The nurse should observe or ask culture-specific questions in order to
understand the patient’s culture.
c) The nurse should be aware of possible hindrances to communication
including interpretation and speech.
(1) The nurse should use short units of speech.
(2) Simple language
(3) Observe for nonverbal cues
2. Other Sources of Diversity
a) Immigrants and refugees may have specific health beliefs and practices.
b) Racial and ethnic considerations must be taken into account.
c) Socioeconomic status
d) Sexual orientation
B. Developing Cultural Competence
1. In the quest for developing cultural competence, the nurse must give
consideration to individual characteristics. This will prevent stereotyping. The
nurse must assess and affirm differences. Educational materials provided must

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be in the language and at the level needed by the patient. Judgment cannot be
made concerning the patient’s choices. The CRASH (culture, respect,
assess/affirm, sensitivity/self-awareness, and humility) model is often used:
a) Consider culture.
b) Show respect.
c) Assess and affirm differences.
d) Show sensitivity and self-awareness.
V. Environmental Stressors
A. Sensory–perceptual alterations (SPA)
1. Sensory overload and deprivation
a) Sensory overload occurs when patient is exposed to noise for continuous
periods.
b) Excessive noise affects the patient’s as well as the nurse’s physical and
physiological state, contributing to caregiver stress and delivery of
quality patient care.
c) The World Health Organization recommends that in a patient’s room
noise level should not exceed 35 dBA.
2. Delirium
a) Delirium involves an acute onset of fluctuating awareness, impaired
ability to attend to environmental stimuli, and disorganized thinking.
b) Delirium is preceded by anxiety and restlessness.
c) The nurse must assess and identify the underlying cause of the delirium.
3. Sleep deprivation
a) Normal rest and sleep are compromised in the high-acuity unit.
b) The changes in the light/dark cycle, pain, and environmental stimuli are
related factors.
c) Sedating hypnotics may be helpful but are associated with falls, delirium,
and functional decline especially in elderly patients.
B. Interventions to decrease sensory–perceptual alterations
1. Prevent sleep deprivation
a) Two hours of uninterrupted sleep is necessary to promote rapid eye
movement (REM), which promotes protein anabolism, restores the
immune system, and promotes healing.
b) Some interventions to prevent sleep deprivation include:
(1) Pain control
(2) Relaxing music or earplugs
(3) Placing pagers on vibrate

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(4) Turning down volume on overhead announcement systems
(5) Decreasing alarm volumes with caution
(6) Adjusting light levels
(7) Encouraging other services to return after rest period
(8) Limiting visitation during rest periods
(9) Mental preparation for quiet time
(10) Planning the patient’s daily schedule to include quiet
time.
2. Facilitate communications
a) Communication with mechanically ventilated patients is needed to
prevent SPA.
b) Nonverbal behaviors will vary and must be closely reviewed for
messages.
(1) Nonverbal cues include elevated heart rate and blood pressure,
facial expression, hand gestures, moving legs.
c) When caring for the patient who cannot speak, the nurse should provide
a means of communication appropriate to the patient’s ability such as
large markers or pens, an alpha board, or using a coded eye-blink system.
VI. Clinical Reasoning Checkpoint
This values clarification exercise is designed to help the learner explore personal values in relation to
the profession of nursing and bioethical issues. By reflecting on personal values, we gain a better
understanding of what factors may limit our ability to reason clearly and of when we may not be
suitable for the role of patient advocate.
Values Clarification Exercise
Directions: To the left of each statement, place the number that best explains your position: 1 =
mostly agree, 2 = somewhat agree, 3 = neutral, 4 = somewhat disagree, 5 = mostly disagree.
_____ 1. Infants with severe handicaps ought to be left to die.
_____ 2. Extraordinary medical treatment is always indicated.
_____ 3. My role as a nurse is to always resuscitate patients who could benefit from it, no matter what
has been decided previously.
_____ 4. I must follow physician’s orders.
_____ 5. Older patients should be allowed to die with dignity.
_____ 6. Medical technology has advanced the quality of life.
_____ 7. Children should not be involved in giving consent for treatments.
_____ 8. Families ought to make decisions about life or death situations without involving the patient.

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_____ 9. Children should participate in human experimentation that is not harmful even if it is of no
benefit to them.
_____ 10. Prisoners should participate in scientific experiments to repay society for their wrongdoing.
_____ 11. Women should seek medical care from female physicians to avoid potential discrimination.
_____ 12. Children whose parents refuse medical care for them should be removed from their
families through court action.
_____ 13. Research using fetuses should be pursued vigorously.
_____ 14. Life-support systems should be discontinued after several days of flat
electroencephalograms.
_____ 15. Health professionals are a scarce resource in many parts of the country.
_____ 16. Nursing is a subservient profession, especially to the medical profession.
_____ 17. As a nurse, I must relinquish my personal philosophy to support the philosophies of others.
_____ 18. All patients, regardless of differences, should be treated in a humane way.
_____ 19. I should give mouth-to-mouth resuscitation to a derelict if he needs it.
_____ 20. A child who is disabled has value.
_____ 21. All forms of human life have value.
_____ 22. I should be involved in decision making regarding ethical issues in practice.
_____ 23. Committees should decide who receives scarce resources, such as kidneys.
_____ 24. Patients’ individual rights should be more important than the rights of society at large.
_____ 25. A person has the right to make a living will.
_____ 26. Underdeveloped countries should be given health and financial support by developed
countries.
_____ 27. I should support all the positions on ethical issues taken by my professional association.
_____ 28. The care component of nursing practice is not as important as the cure component of
medical practice.
_____ 29. The nurse’s primary role in decision making on ethical issues is to implement the selected
alternative.
_____ 30. I feel afraid when caring for a patient who is dying.
_____ 31. Children who have disabilities should be institutionalized.
_____ 32. Patients in mental health institutions and prisons should be given behavior modification
therapy to make them conform to societal norms.
_____ 33. Personal possessions of patients should be removed to guarantee safekeeping during
hospitalization.
_____ 34. Patients should have access to their own health information.
_____ 35. Withholding health information fosters the patient’s recovery.
_____ 36. A patient with kidney failure is always able to get kidney dialysis when needed.
_____ 37. Society should bear the cost of extraordinary medical interventions.
_____ 38. Confidentiality is an important part of the nurse’s role.

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_____ 39. As a nurse, I should value responsibility.
_____ 40. Nurses have a right to withhold information to facilitate nursing research on human
subjects.
_____ 41. The patient who refuses treatment should be dropped from the health supervision of an
agency or professional.
_____ 42. Transplantations should be done whenever needed.
Personal Application
1. Add the number of 1s, 2s, 3s, 4s, and 5s that you have.
2. How many statements do you have clear ideas (1s and 5s) about?
3. Do these outweigh the number of ambivalent (neutral) statements you listed?
4. Look at the statements that you agree with (1s and 2s). Is there a relationship between the
statements that influenced your responses (e.g., age of patient, patient acuity)?
5. Look at the statements that you disagree with (4s and 5s). Is there a relationship between these
statements that influenced your responses?
6. Analyze the following cluster of statements. Is there any consistency in the way you rated these
statements? What variables influenced your decision?
Cluster 5, 8, 14, 25, 30: Relates to issues pertaining to death
Cluster 3, 4, 16, 17, 22, 27, 28, 29, 38: Relates to the profession of nursing
Cluster 2, 6, 14, 36, 37, 42: Relates to issues raised by advanced technology
Cluster 1, 7, 9, 12, 20, 31: Relates to children
Cluster 9, 10, 13, 40: Relates to human experimentation
Cluster 3, 7, 8, 11, 12, 18, 19, 21, 24, 25, 33, 34, 35, 38, 41: Relates to patients’ rights
Cluster 9, 10, 24, 26, 32, 37: Relates to society’s rights
Cluster 15, 23, 36: Relates to allocation of resources
Cluster 3, 4, 17, 18, 19, 22, 27, 29, 39: Relates to perceptions of obligations
VII. Post-Test / Chapter 2 Review
Chapter 2 Question: ch02_01
Question: A client is crying about a below-knee amputation sustained as a pedestrian in a pedestrian–
vehicle crash. She expresses fears about ambulating in physical therapy. The nurse interprets this
situation as a sign that the client is in which stage of grief?
Answer:
3. Depression
Answer: 3
Rationale:
3. In the depression phase, the client may be sad and have frequent crying episodes. Fears about the
future are revealed.

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Chapter 2 Question: ch02_02
Question: A client was recently admitted to the ICU after a myocardial infarction. The family wants
to meet with the nurse. The nurse prepares for this meeting with the knowledge that at this stage of
illness the family most needs which things? Select all that apply.
Answer:
1. Frequent updates on the client’s condition
2. Rationale for interventions being started
Rationale:
1. The communication between those providing care and the family is of primary importance. The
family members need to know how their loved one is progressing and need frequent updates.
2. The family members need to know the purpose of the activities surrounding their loved one. Many
interventions are frightening, and rationales help the family to cope.
Chapter 2 Question: ch02_03
Question: The nurse is considering use of a complementary and alternative therapy (CAT) to help a
client cope with the pain associated with burn treatment. The nurse designs this plan with full
consideration that which CAT is a risky strategy?
Answer:
1. Humor
Rationale:
1. Humor is a very individual perception and is not thought to be appropriate during critical illness by
some clients or nurses. When it is thoughtfully used, it can be very helpful as distraction.
Chapter 2 Question: ch02_04
Question: High-acuity clients have a right to know and understand what procedures are being done to
and for them. The nurse sets which initial goals when teaching the client about these procedures?
Select all that apply.
Answer:
1. To decrease the client’s stress
2. To promote the client’s comfort
Rationale:
1. Initially teaching is done to decrease stress levels in the client and family.
2. Initially teaching is done to promote comfort.
Chapter 2 Question: ch02_05
Question: The nurse is conducting an admission assessment on a client who is an immigrant to the
United States. How would the nurse demonstrate cultural competence when caring for this client?
Answer:
1. Consider that the client’s culture may differ significantly from that of the nurse.
2. Be respectful of the client and the family when providing care.
3. When cultural differences are assessed, confirm their presence with the client or family.
5. Be aware of the impact of cultural differences on the nurse.

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Rationale:
1. The nurse should always consider culture.
2. The nurse who is culturally competent shows respect for the client and family.
3. The nurse should not just assume that cultural differences exist but should confirm their presence
by asking sensitive questions.
5. The nurse must be self-aware.
Chapter 2 Question: ch02_06
Question: A client has been an active participant in all aspects of hospitalization. This morning the
client seems confused and has difficulty completing a form documenting consent to a procedure to be
done tomorrow. What nursing actions are indicated? (Select all that apply.)
Answer:
3. Review the client’s most recent laboratory results.
4. Assess the client for other findings of depression.
Rationale:
3. Alterations in blood chemistry constitute a frequent etiology for delirium.
4. Clients who are depressed may have a decline in health literacy and may show signs of delirium.
Chapter 2 Question: ch02_07
Question: A 79-year-old client had a colon resection with colostomy 2 days ago for adenocarcinoma.
She has had a patient-controlled analgesia pump for pain management. Since yesterday she has
become increasingly anxious and agitated. Today she is suddenly yelling out for help, is combative,
and has pulled out her nasogastric tube. The nurse should recognize that this client is exhibiting
symptoms of which condition?
Answer:
1. Delirium
Rationale:
1. Delirium is a sensory–perceptual alteration that can occur in high-acuity clients. It is more likely in
older clients and is often preceded by increasing anxiety and agitation.
Chapter 2 Question: ch02_08
Question: The hospital supports open visitation throughout the facility. Family members visiting in
the coronary care unit have been noisy and disruptive even after being asked to keep down the level
of their voices. What nursing action is indicated?
Answer:
1. Ask the visitors to leave the unit.
Rationale:
1. The nurse’s first responsibility is to the clients in the unit. If family members are disturbing others
and do not modify behavior when asked, they should be asked to leave the unit.
Chapter 2 Question: ch02_09
Question: A client in the ICU speaks only broken English. The nurse has been unsuccessful in
understanding the client, and it is apparent the client does not understand the nurse. How should the
nurse proceed?

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Answer:
4. Call social services and request an interpreter.
Rationale:
4. Social services should have a list of interpreters who will provide this service.
Chapter 2 Question: ch02_10
Question: A client has developed confusion while in the ICU. Medical reasons for the confusion
have been ruled out and a diagnosis of sensory–perceptual alterations made. What should the nurse
tell visitors about this client?
Answer:
2. Talk about familiar and calming things while in the room.
Rationale:
2. Visitors can help to reorient the client by talking about familiar and calming things.
VIII. References
Agency for Healthcare Research and Quality (AHRQ). (2013). Guide to patient and family
engagement in hospital quality and safety. Retrieved October 7, 2015, from
http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/index.html
Allen, D. (2014). Laughter really can be the best medicine. Nursing Standard, 28(32), 24–25.
doi:10.7748/ns2014.04.28.32.24.s28
American Nurses Association (ANA). (2015). Code of ethics for nurses. Retrieved January 11, 2017,
from http://www.nursingworld.org/codeofethics
Andrews, L., Silva, S., Kaplan, S., & Zimbro, K. (2015). Delirium monitoring and patient outcomes
in a general intensive care unit. American Journal of Critical Care, 24(1), 48–56.
doi:10.4037/ajcc2015740
Berglund, B., Lindvall, T., & Schwela, D. H. (1999). Guidelines for community noise. Retrieved
January 11, 2017, from http://apps.who.int/iris/handle/10665/66217
Burhenn, P., Olausson, J., Villegas, G., & Kravits, K. (2014). Guided imagery for pain control.
Clinical Journal of Oncology Nursing, 18(5), 501–503. doi:10.1188/14.CJON.501-503
Chevillon, C., Hellyar, M., Madani, C., Kerr, K., & Kim, S. (2015). Preoperative education on
postoperative delirium, anxiety, and knowledge in pulmonary thromboendarterectomy clients,
American Journal of Critical Care, 24(2), 164–171. doi:10.4037/ajcc2015658
Crider, J., & Pate, M. (2011). Helping children say goodbye to loved ones in adult and pediatric
intensive care units: Certified child life specialist–critical care nurse partnership. AACN Advanced
Critical Care, 22(2), 109–112.

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Culturally competent nursing care and promoting diversity in our nursing workforce. (2015).
Michigan Nurse, 88(3), 7–11.
Cypress, B. (2013). Transfer out of intensive care: An evidence-based literature review. Dimensions
of Critical Care Nursing, 32(5), 244–261. doi:10.1097/DCC.0b013e3182a07646
Ernst, E., Pittler, M., & Wider, B. (Eds.). (2006). The desktop guide to complementary and alternative
medicine: An evidence-based approach (2nd ed.). St. Louis, MO: Mosby/Edinburgh, Scotland:
Elsevier.
Fink, R., Makic, M., Poteet, A. W., & Oman, K. (2015). The ventilated patient’s experience.
Dimensions of Critical Care Nursing, 34(5), 301–308. doi:10.1097/DCC.0000000000000128
Gay, E., Pronovost, P., Bassett, R., & Nelson, J. (2009). The intensive care unit family meetings:
Making it happen. Journal of Critical Care, 24(4), 629.e1–629.e12.
Hart, A., Hardin, S., Townsend, A., Ramsey, S., & Mahrle-Henson, A. (2013). Critical care visitation:
Nurse and family preference. Dimensions of Critical Care Nursing, 32(6), 289–299. doi:10.1097/01.
DCC.0000434515.58265.7d
Hart, P., & Mareno, M. (2013). Cultural challenges and barriers through the voices of nurses. Journal
of Clinical Nursing, 23, 2223–2233. doi:10.1111/jocn.12500
Ingram, R., & Kautz, D. (2012). When the patient and family just do not get it: Overcoming low
health literacy in critical care. Dimensions of Critical Care Nursing, 3(1), 25–30.
doi:10.1097/DCC.0b013e31823a5471
Institute for Patient- and Family-Centered Care. (n.d.). Core concepts of patient- and family-centered
care. Retrieved November 28, 2016, from http://www.ipfcc.org/pdf/CoreConcepts.pdf
Karadag, E., Samancioglu, S., Ozden, D., & Bakir, E. (2015). Effects of aromatherapy on sleep
quality and anxiety of clients. Nursing in Critical Care, 20(5), 1–8. doi:10.1111/nicc.12198
Kodali, S., Stametz, R., Bengier, A., Clarke, D., Layon, A., & Darer, J. (2014). Family experience
with intensive care unit care: Association of self-reported family conferences and family satisfaction.
Journal of Critical Care, 29(4), 641–644. doi:10.1016/j.jcrc.2014.03.012
Kramlich, D. (2014). Introduction to complementary, alternative and traditional therapies. Critical
Care Nurse, 34(6), 50–56. doi:10.4037/ccn2014807
Kübler-Ross, E. K., & Kessler, D. (2005). On grief and grieving: Finding the meaning of grief
through the five stages of loss. New York, NY: Scribner.
Lipson, J., Dibble, S., & Minarik, P. (Eds.). (2001). Culture & nursing care: A pocket guide. San
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Marchand, L. (2014). Integrative and complementary therapies for clients with advanced cancer.
Annals of Palliative Medicine, 3(3), 160–171. doi:10.3978/j.issn.2224-5820.2014.07.01
Martorella, G., Boitor, M., Michaud, C., & Gélinas, C. (2014). Feasibility and acceptability of hand
massage therapy for pain management of postoperative cardiac surgery clients in the intensive care
unit. Heart & Lung, 43(5), 437–444. doi:10.1016/j.hrtlng.2014.06.047
Mattox, E. (2010). Identifying vulnerable patients at heightened risk for medical error. Critical Care
Nurse, 30(2), 61–69.
Nilsen, M., Happ, M., Donovan, H., Barnato, A., Hoffman, L., & Sereika, S. (2014). Adaptation of a
communication interaction behavior instrument for use in mechanically ventilated, nonvocal older
adults. Nursing Research, 63(1), 3–13. doi:10.1097/NNR.0000000000000012
Palazzo, M. O. (2001). Teaching in crisis. Patient and family education in critical care. Critical Care
Clinics of North America, 13, 83–92.
Polster, D. (2015). Information: Tools for success. Nursing, 45(5), 42–49.
doi:10.1097/01.NURSE.0000463652.55908.75
Riemer, H., Mates, J., Ryan, L., & Schleder, B. (2015). Decreased stress levels in nurses: A benefit of
quiet time. American Journal of Critical Care, 24(5), 396–402. doi:10.4037/ajcc2015706
Ritmala-Castren, M., Virtanen, I., Leivo, S., Kaukonen, K., & Leino-Kilpi, H. (2015). Sleep and
nursing care activities in an intensive care unit. Nursing and Health Sciences, 17, 354–361.
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Rust, G., Kondwani, K., Martinez, R., Dansie, R., Wong, W., Fry-Johnson, Y., . . . Strothers, H.
(2006). A crash-course in cultural competence. Ethnicity and Disease, 16(2, suppl. 3), 29–36.
Sendelbach, S., & Funk, M. (2013). Alarm fatigue, a patient safety concern. Advanced Critical Care,
24(4), 378–386. doi:10.1097/NCI.0b013e3182a903f9
Steele, S., & Harmon, V. (1983). Values clarification in nursing. Norwalk, CT: Appleton-Century
Crofts.
Zavotsky, K., McCoy, J., Bell, G., Haussman, K., Joiner, J., Marcoux, K., . . . & Tortajada, D. (2014).
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IX. Suggestions for Classroom Activities
• Ask each student to develop two study questions based on Kübler-Ross’s stages of grief. Use
these questions as part of an in-class review.
• Ask students to pair off and develop a form of nonverbal communication.

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• Having the correct learning environment for educating the acutely ill patient is crucial. Ask
students to list their concepts of the optimal learning environment.
X. Suggestions for Clinical Activities
• Discuss the implications of ensuring that patients report all complementary and alternative
therapies being used. How and where should these therapies be documented?
• During clinical, assign students to patients who are considered to be high acuity. During the
clinical postconference, ask the students to determine which of Kübler-Ross’s stages of grief the
patient they cared for demonstrated.
• Invite a massage therapist to visit with the clinical group. Ask the massage therapist to discuss the
use of massage for patients experiencing pain.

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CHAPTER
3 Palliative and End-of-life Care
Objectives:
1. Examine the role of palliative care for the high-acuity patient and family.
2. Identify ways the nurse can facilitate therapeutic communication for palliative care to help high-
acuity patients and their families cope with an illness and/or injury event.
3. Describe the assessment and management of pain and other symptoms typically experienced by
high-acuity patients.
4. Discuss nursing competencies to provide high-acuity nursing care for patients at the end of life
and their families, including bereavement services.
5. Identify professional stressors, their impact on high-acuity nurses, and strategies to alleviate
those stressors.
I. Palliative Care
Palliative care should be offered to patients early in the occurrences of a serious or life-threatening
illness or injury or when emotional symptoms are interfering with treatment and/or quality of life.
Unfortunately, palliative care is more likely to be suggested as patients move into the last stages of
illness. Palliative care should not be initiated because cure-oriented care is not considered appropriate
but instead should be offered as a comfort care approach. The high-acuity nurse provides care that is
comprehensive, including addressing the patient's physiological status, his comfort needs, and the
comfort needs of the patient's family.
A. Defining Palliative Care
1. Palliative care is an interdisciplinary approach to relieve suffering and improve
quality of life.
2. It is important for the high-acuity nurse to explain to patients and to their
families that palliative care may be provided at the same time as medical
treatment is directed toward a cure.
3. The National Consensus Projects (NCP) Clinical Practice Guidelines for
quality palliative care advocates standardizing care with the goal of improving
palliative care. The NCP defines eight domains of palliative care:
a) Structure and processes of care
b) Physical aspects of care
c) Psychological and psychiatric aspects of care

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.
d) Social aspects of care
e) Spiritual, religious, and existential aspects of care
f) Cultural aspects of care
g) Care of the patient at the end of life
h) Ethical and legal aspects of care
B. Palliative Care in High-Acuity Settings
1. High-Acuity Patients and Palliative Care
a) Unmet needs of dying patients and concerns about the cost of high-acuity
care and limited bed availability have fostered the growth of palliative
care in the hospital setting.
b) Palliative care is a systematic approach to patient care in the ICU that
provides an extra layer of support to critically ill patients and their
families.
c) The goal of palliative care is to improve quality of life through numerous
components provided by different services as well as the support of the
organization.
2. Barriers to Providing Palliative Care
a) Barriers to palliative care may stem from patients, families, and in some
cases members of the healthcare team having inflated expectations of the
outcomes of medical therapies.
b) Barriers to the delivery of palliative care include misunderstandings,
difficulties with initiating discussions regarding palliative care, and in
some cases cultural issues.
c) Excellent communication is necessary to provide patients with consistent
and effective care including palliative care.
d) Healthcare professionals must be educated and trained in all aspects of
palliative care.
e) Health professional education in palliative care should include
limitations of critical care therapies, embracing treatment goals that are
attainable, and the benefits of palliative interventions.
II. Communication and Decision Making
A. Establishing goals of care for the high-acuity patient receiving palliative care includes the
input of other team members for a multidisciplinary approach to formulating a plan to
meet the patient's psychological, social, cultural, and spiritual needs.
1. Use of the Quality and Safety Education for Nurses (QSEN) quality
improvement care and communication bundle helps to standardize the time
frame in which the multidisciplinary team communicates and administers
particular services.

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Class Notes for High-Acuity Nursing, 7th Edition

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