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

.
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

.
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

.
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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