[ Perrin 2 e IRM ] Chapter 1 What Is Critical Care? RESOURCE LIBRARY COMPANION WEBSITE Case St u d y : Critical Care Nursing Nursing Care Plan NCLEX Review Questions Media Links Media Link Applications Learning Outcome 1 Define critical care. Concepts for Lecture 1. Critical care is the direct delivery of medical care to a critica l ly ill or injured patient. The care is often delivered in a specialized unit with advanced technology available. This care is provided by a sp e cially trained team of professionals . 2. Critical care is defined by the Department of Health and Human Services (2001) as the “direct d e livery of medical care for a critically ill or injured patient. To be considered critical an illness or injury must acutely impair one or more vital organ systems such that a patient’s survival is jeopa r dized. Critical care is usually but not always given in a critical care area such as a coronary care unit, an intensive care unit, a respiratory care unit, or an emergency care unit.” PowerPoint Lecture Slides 1. Critical c are — “direct delivery of medical care for a critically ill or injured patient. To be considered critical an illness or injury must acutely impair one or more vital organ systems so that a patient’s survival is jeopardized” (Department of Health and Human Services, 2001). 2. Elements of critical illness or injury: • Impairment of one o r more vital organs • Patient survival jeopardized • Care given in specialty unit with specialized personnel and equipment Suggested Strategies for Classroom Experience Ask students to share examples of patient conditions that, according to the definition provided, would require critical care. Learning Outcome 2 State the three levels of care provided in critical care units. Concepts for Lecture 1. In 2003, the Society of Critical Care Medicine (SCCM) endorsed guidelines for critical care services base d on three levels of care. These guidelines suggested that each hospital provide a level of care appropriate to its mission and regional needs for critical care services because not all hospitals are able to meet the needs of all types of patients and severit ies of illness. 2. Level I critical care units possess sophisticated equipment . S pecialized nurses and physician specialists are continuously available. Care is comprehensive for a wide variety of disorders. Support services are readily available. These ICUs are usually located in teaching hospitals. 3. Level II units provide comprehensive care for most patients but may not be able to care for more complex t ypes of patients such as cardiothoracic surgical patients. These ICUs must have transfer arrangements in place so that care can be made available for the most complex patients if necessary. 4. Level III units provide initial stabilization of critically ill patients but have limited ability to provide comprehensive critical care. Patients who require routine care may remain at the facility but written transfer policies must be in place to provide options for critical care for those patients who need it. PowerPoint Lecture Slides 1. Three levels of care for critical care services are necessary . Not all hospitals are equipped to meet the needs of all patient types and severit ies of illness . 2. Level I Critical Care Units Most comprehensive care available Usually in teaching hospitals Specialty physicians, nurses, and equipment continuously available Comprehensive support services available 3. Level II Critical Care Units Limited care for some specific patients (ex: cardiothoracic surgical patients) Must have transfer plan to Level I facilities for patients with specific disorders for which the unit does not provide care 4. Level III Critical Care Units Provide initial stabilization of critically ill patients Limited ability to provide comprehensive critical care Should h ave written policies for patient transfer if required Suggested Strategies for Classroom Experience Discuss clinical facilities in use by students in your program. What attributes are obvious in the critical care units of these facilities? What level of care is provided at each? Learning Outcome 3 Compare and contrast “open” and “closed” critical care units. Concepts for Lecture 1. Critical care units may be “open” or “closed.” 2. In an open ICU , nurses, pharmacists, and respiratory therapists are based in the ICU but the physicians directing patient care may have other obligations. These physicians may or may not choose to consult an intensivist to assist with the management of their ICU patients. 3. In a closed ICU , patient care is provided by a dedicated ICU team that includes a critical care physician. The SCCM recommends that primary care physician s and consult ant s collaborate and use an intensivist to intervene and direct care in urgent and emergent situations. PowerPoint Lecture Slides 1. “Open” Unit • Nurses, pharmacists, and respiratory therapists are ICU - based • Physicians are not ICU - based — have other responsibilities • The primary physician may consult an intensivist to assist with patient management 2. “Closed” Unit • ICU team with critical care physician • Primary care physician and consultants collaborate • Intensivist is given authority to manage patient’s care in urgent and emergent situations Suggested Strategies for Classroom Experience Ask students to reflect upon the ICUs in the facilities in which they have clinical experience. Are the units open or closed? What attributes, specifically, indicate this status? Learning Outcome 4 Explain why critical care units are one of the most common sites for health care errors . C oncepts for Lecture 1. Critically ill patients require complex, carefully coordinated care. When a care pattern is complex, failure in one part of the system can unexpectedly affect another. Therefore , if anything goes wrong, and an error is identified, it can be difficult to prevent deterioration of the situation because of the extreme complexity of care in crit i cal care areas. 2. The Institute of Medicine (IOM) postulates that technology increases errors for several reasons: • Technology changes tasks by shifting the workload and eliminating human decision making . • Although technology decreases workload during nonpeak hours, it often increases it during peak hours or during system failure ( e.g., when the computerized medication scanning device fails and documentation must be done on paper and then entered electronically later when the system is working). • When technology controls performance of tasks automatically, users no longer know how to perform functions without it ( e.g . , calculation of mcg/kg/min for drug doses) when the system fails. • Errors can occur when equipment is not standardized and demands precision for use ( e.g., ICU nurses use many different brands of IV pumps or ventilators) . 3. Safety of all patients is a concern, but safety for vulnerable, critically ill patients is paramount. In one 24 - hour examination of errors in ICU s worldwide, nearly 75% reported errors , including : • dislodgement of lines, catheters, and drains • medication errors • failure of infusion devices • failure or dysfunction of a ventilator • unplanned extubation while ventilator alarms were turned off 4. Since release of the IOM report To Err I s Human (2000), there has been a focus on identifying and correcting system problems that increase potential for errors so that risk for errors can be reduced. Recommendations for error reduction include: • utilizing constraints — an example of this is when the height, weight , and allergies of a patient must be on file to obtain a medication for the patient • installing forcing functions or system - level firewalls — for example, concentrated potassium chloride (KCl) is no longer available on hospital units • avoiding reliance on vigilance — forcing use of checklists, protocols , and rechecking with another professional ( e.g., time - outs prior to surgery and checking doses of insulin with another RN prior to administration) • simplifying and standardizing key processes 5. Providers can enhance safe, effective care and limit risks to critically ill patients by: • developing a multidisciplinary approach to patient care — C are should be delivered by a multidiscipl i nary team headed by a full - time critical - care - trained physician and consisting of at least an ICU nurse, a respiratory therapist, and a pharmacist. Ou t comes for patients are better when multidisciplinary teams collaborate and work well together. • encouraging a culture of safety — This encompasses seven essential properties: teamwork, evidence based practice, communication, patient - centered care, leadership, learning , and justice. In a critical care unit that has embraced a culture of safety, practitioners have a responsibil i ty to their patients to make their errors known, have them corrected, and share them with the p a tient, his family, and other practitioners. With practice improvement as the goal rather than punishment of the health care provider who committed the error, the reporting of the error promotes examination of factors that contributed to the error and changes in practice for the future. • instituting closed unit s — These are u nits in which only intensivists treat patients . • providing adequate staffing — This does not imply only looking at numbers of patients/nurse, but also to assigning a nurse with appropriate competencies to meet the needs of the assigned patients. • limiting work hours — The IOM recommends that nurses work no more than 60 hours per week and no more than 12 hours in any 24 - hour period. PowerPoint Lecture Slides 1. Technology increases errors because : • I t eliminate s need for human decision making • I t increase s worklo ad when it fails or is inadequate • N urses forget how to calculate drips without technolog y • E quipment is highly sophisticated, nonstandard , and demands precision for use 2. Technology can affect patient care • Nurse s may fail to touch patients • Best assessment occurs when nurses assess in addition to what technology provides • Technology can predispose to errors in delivery of care • Technology devices may fail and contribute to error (extubation, failure of infusion devices, etc.) 3. Patient safety strategies for preventio n and early detection of errors • utilizing constraints — height, weight , and allergies required before a medication can be obtained for the patient • installing forcing functions or system - level firewalls — concentrated potassium chloride (KCl) is no longer available on hospital units • avoiding reliance on vigilance — forcing use of checklists, protocols , and rechecking with another professional ( e.g., time - outs prior to surgery and checking doses of insulin with another RN prior to administration) • simplifying and standardizing key processes 4. Providers can enhance safe, effective care and limit risks to critically ill patients by: • developing a multidisciplinary approach to patient care • encouraging a culture of safety • instituting a closed unit • providing adequate staffing • limiting work hours Suggested Strategies for Classroom Experience Ask students why it is important to check insulin doses with another professional nurse prior to administration of the drug. (If necessary, remind them that insulin is considered a high - alert medication according to the Institute for Safe Medication Practices.) Ask students why it is important not to have concentrated potassium chloride available on the unit . What risks are involved with intravenous administration of this medication in particular? Learning Outcome 5 Describe the relationship between the patient and nurse in the AACN’s synergy model. Concepts for Lecture 1. The AACN believes that critical care nursing should be defined more by the needs of the p a tients and those of their families than by the environment in which care is delivered or the dia g noses of the patients. An underlying assumption of the s ynergy m odel is that optimal patient outcomes occur when patient and family needs are aligned with nurse competencies. PowerPoint Lecture Slides 1. Critical care nursing practice should be defined more by the needs of patients and those of their families than by the environment in which care is delivered or the diagnosis of the patients. Patient/Family Needs + Nurse Competencies = Optimal Patient Outcomes Suggested Strategies for Classroom Experience Ask students to think about why it would be preferable to have an expert critical care nurse care for a 78 - year - old fresh cardiothoracic surgical patient with a history of diabetes and chronic lung disease , wh ereas a competent critical care nurse might be assigned to a chronic postoperative cardiothoracic surgical patient. Learning Outcome 6 Discuss the competencies of critical care nurses as defined by the s ynergy model. Concepts for Lecture 1. According to the synergy model, critical care nurse competencies can be described along a continuum from competent to expert. These competencies include the following: • clinical inquiry — T he critical care nurse should provide care based on the best available evidence rather than tradition . • clinical judgment — T he nurse should engage in clinical reasoning according to his or her level of expertise. For example, a competent critical care nurse is able to collect and interpret basic information and then follow algorithms when providing care , wh ereas an expert nurse can see the “big picture” and anticipate patient needs. • caring — According to the AACN, this encompasses “nursing activities that create a compa s sionate, supportive, and therapeutic environment for patients and staff, with the aim of promo t ing comfort and preventing unnecessary suffering.” • advocacy — This refers to the nurse’s respect and support for the rights and beliefs of the critically ill patient (AACN). • systems thinking — The critical care nurse manages the existing environment and resources for the benefit of patients and their families. • facilitator of learning — T he nurse should facilitate both informal and formal learning for patients, families, and members of the health care team . • response to diversity — The nurse should be sensitive to diversity among patients and providers and incorporate appropriate cultural and spiritual values into care. • collaboration — The nurse will work with others in order to achieve optimal and realistic patient goals. PowerPoint Lecture Slides 1. According to the synergy model, critical care nurse competencies include the following: clinical inquiry clinical judgment caring advocacy systems thinking facilitator of learning response to diversity collaboration Suggested Strategies for Classroom Experience Divide the class into groups and assign each group one of the critical care nurse competencies from the synergy model. Ask each group to identify levels of function likely for the competent nurse and the expert nurse for the assigned competency. Learning Outcome 7 Describe ways to enhance communication and collaboration among members of the health care team. Concepts for Lecture 1. Optimum patient outcomes require communication and collaboration by a multidisciplinary team. Skilled communication includes determining appropriate content for the message and delivery of the content. One method of skilled communication advocated by the Institute for Healthcare Improv e ment (IHI) is the SBAR technique ( s ituation , b ackground , a ssessment , r ecommendation) . o S: Situation • I am calling about [ patient, name, location ] . • The problem I am calling about is [ the nurse states speci f ics ] . • I have assessed the patient personally. • Vital signs are _____ . • I am concerned about [ the nurse states what the specific co n cern is ] . o B: Background • The patient’s immediate history is _______. • The patient’s other physical findings are [ e.g., mental st a tus ] . • The patient’s treatments are [ e.g., oxygen ther a py ] . o A: Assessment ▪ This is what I think the problem is : _____________. ▪ Or, I’m not sure what the problem is but the patient is deter i orating. o R: Recommendation ▪ I suggest [ or request ] that you [ the nurse states the desired course of a c tion ] . 2. Two - Challenge Rule — Another method of skilled communication adopted from the airline industry . This rule can be used for managing situations in which members of the health care team do not listen even when information has been presented in an appropriate format . When following the two - challenge rule, a nurse who disagrees with another health care provider’s proposed intervention would respectfully state his concerns about the intervention twice then would seek a superior as soon as possible and explain his concerns. 3. Collaboration — This is the l ink between teamwork and patient outcomes in ICU . Collaboration is a process of sharing knowledge and responsibility for patient care. Many characteristics influence collaboration . PowerPoint Lecture Slides 1. Communication — Optimal patient care is not possible without skilled communication . 2. Skilled communication has two components — appropriate content for the message and delivery of the content. 3. SBAR Technique — provides process for determining what information is appropriate and delivering it in specific manner Situation — who you are calling about (patient name, location); state specific problem, patient assessment, and specific concern Background — patient’s immediate history, physical findings, and treatments Assessment — what you think the problem is ; if unsure , state that patient is deteriorating Recommendation — state or request desired course of action 4. Two - Challenge Rule — a rule for disagreement about the proposed course of action • Respectfully state concerns about the intervention twice; then seek help from supervisor. • Assertive communication — nurse should state disagreement and present concerns respectfully; speak with a bold voice. 5. Collaboration — th is is the link between teamwork and patient outcomes in ICU. • Collaboration is a process, not a single event. • Characteristics that influence collaboration: o Emotional maturity o Understanding the perspectives of others o Team goal is patient well - being o Negotiate respectfully o Manage conflict wisely — watch emotional responses Suggested Strategies for Classroom Experience Given a patient scenario, ask students to demonstrate use of SBAR communication to a health care provider. Ask students to describe what it means to them to “collaborate” on a project. Learning Outcome 8 Explain why some health care providers believe that critically ill patients cannot give informed consent. Concepts for Lecture 1. Obtaining i nformed consent has legal and ethical ramifications. When a patient gives consent, he agrees to the suggested treatment or procedure. Legally, if a nurse treats or touches a patient without consent, it is considered battery, even if the treatment is a p propriate and has no negative effects. Consent is usually implied rather than written for “routine” procedures such as turning, dressing changes, and most medication administration. 2. Th ere are th ree components of informed consent : • The decision must be made voluntarily . • The decision must be made by a competent adult . • The decision must be made by a competent adult who understands his condition and the possible treatments . This means that the patient’s decision must be an autonomous choice. The patient must be capable of rational thought and be able to recognize what the treatment involves. 3. Are critically ill patients able to make decisions? This is sometimes difficult to determine because the patient may be in severe pain, may be intubated, or may be very depressed. Determination of the patient’s capacity to give informed consent does not require a legal proceeding. It is a clinical judgment. To determine capacity, the nurse may ask: • Does the patient understand the medical condition? • Does the patient understand the options and the consequences of her decision? • If the patient refuses to give consent for the recommended treatment, is the refusal based on rational reasons? 4. Surrogate decisions : Occasionally, loss of capacity may be temporary, such as when a patient has been heavily medicated. When a patient is incapacitated, a surrogate health decision maker may be asked to consent for treatment of the patient. PowerPoint Lecture Slides 1. Three components of informed consent: • The decision to permit the treatment or procedure must be made voluntarily. • The decision to permit the treatment or procedure must be made by a competent adult. • The patient must understand his condition and the possible treatments. 2. An ICU patient may lack the capacity to give informed consent. Determination does not require legal proceeding — it is a clinical judgment. Loss of capacity may be temporary (pain medication). 3. To determine capacity , the health care provider may ask: • Does the patient understand the medical condition? • Does the patient understand the options and consequences of the decision? • If the patient refuses treatment, is refusal based on rational reasons? 4. Surrogate decisions: • Some states allow next of kin to make decision. • Some states require health care proxy or durable power of attorney — advance directive or court appointed . • Two ethical modes for surrogate decisions: • Best interest standard — decision maker decides what he or she believes is in the best interest of the patient • Substituted judgment — surrogate decides what he or she thinks patient would have decided if able to make the decision Suggested Strategies for Classroom Experience Ask students to consider a situation in which they may be asked to be a surrogate decision maker for someone. Ask them to discuss their feelings and concerns about using the “ best interest standard ” versus the “ substituted judgment ” standard. Which seems more comfortable to them? Why? Learning Outcome 9 Analyze why moral distress might be a significant concern for critical care nurses. Concepts for Lecture 1. Critical care nurses have the potential to develop moral distress or compassion fatigue as a result of being placed continually in situations with high levels of complexity, uncertainty , and decisional authority . 2. Moral distress has been defined as when a nurse would know the right thing to do, but would not do it because of institutional constraints or personal authority. Critical care nurses are often in situations associated with high levels of moral distress — such as when nurses are required to provide aggressive care to patients whom they do not believe will benefit from the care. 3. Moral distress impacts health care. Nurses leave ICU s , they lose the capacity to care for patients, and they experience physiological and psychological problems. 4. The AACN developed a public policy statement in which t he 4 A’s to rise above moral distress (ask, affirm, assess, act ) are described. 5. Conscientious refusal of an assignment is an option if the nurse believes he cannot ethically perform an action he is being asked to perform. The nurse , however, should consider administrative repercussions for his refusal. It is possible that administration w ill fully support the decision ; however, it is also possible that the nurse may be dismissed from the nursing position. Therefore, this option should be taken only after careful consideration of influence on the patient/family, the nurse, and the institution. 6. Compassion fatigue is a response to caring for people who are suffering . It can be traumatizing for the care provider. Symptoms may include: • Intrusive thoughts or images of patients’ situations or traumas • Difficulty separating work life from personal life • Lowered tolerance for frustration and/or outbursts of anger or rage • Dread of working with certain patients • Depression • Increase in ineffective and/or self - destructive self - soothing b e haviors • Hypervigilance • Decreased functioning in nonprofessional situ a tions • Loss of hope 7. Standards for self - care to establish and maintain wellness for care providers : • Make a commitment to self - care • Develop strategies to let go of work • Develop strategies for rest and relaxation • Plan strategies for daily stress reduction PowerPoint Lecture Slides 1. Moral d istress — distress suffered by nurse s from being involved in patient situations that they perceive to be morally wrong 2. Situations contributing to moral distress: • Aggressive care to patients who m nurses perceive would not benefit from the care • Feeling s of powerlessness • Nurse unable to find meaning in patient or family suffering 3. Moral distress has impact on health care • N urses leave ICU s • N urses lo se the capacity to care for patients • N urses experience physiological and psychological problems 4. Compassion f atigue — a “state of tension and preoccupation with the suffering of those being helped that is traumatizing for the helper” (Figley, 2005) 5. Symptoms of compassion fatigue: • Difficulty separating work from personal life • Intrusive thoughts/image s of patient situations/trauma • Lowered frustration tolerance — outbursts of anger • Dread working with certain patients — depression • Increase in ineffective and self - destructive behaviors • Hypervigilance • Decreased functioning in nonprofessional situations • Loss of hope 6 . Standards for self - care to establish and maintain wellness: • Make a commitment to self - care • Develop strategies to let go of work • Develop strategies for rest and relaxation • Plan strategies for daily stress reduction Suggested Strategies for Classroom Experience Ask students if they have ever interacted with a staff nurse who may have been suffering from compassion fatigue. What attributes made the students believe this to be the case? Ask students to develop a plan for avoidance of compassion fatigue and maintaining wellness for a critical care nurse. List the suggestions on the board for discussion. Learning Objective 10 Prioritize measures a nurse might utilize to prevent compassion fatigue. Concepts for Lecture 1. The American Nurses Association (ANA) Code of Ethics indicates that “The nurse owes the same duties to self as others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.” 2. The s tandards of self - care for caregivers w ere developed to ensure that care providers do no harm to themselves when helping to treat others and to encourage providers to attend to their own physical, emotional, and spiritual needs so that they can ensure high - quality services to those who rely on them. 3. Strategies to prevent compassion fatigue : • Enhance physical well - being (tension, sleep, food and drink intake) • Enhance psychological well - being (relaxation methods, balance between work and play, use stress reduction methods) • Enhance social/interpersonal well - being (identify five supportive people at work to call on, know when to get personal and professional help) • Enhance professional well - being (establish boundaries and set limits, balance home and work responsibilities, generate a feeling of self - satisfaction from work achievements) PowerPoint Lecture Slides 1. Standards of self - care for caregivers • T o ensure that care providers do no harm to themselves when helping to treat others • T o encourage providers to attend to their own physical, emotional, and spiritual needs so that they can ensure high - quality services to those who rely on them 2. Strategies to prevent compassion fatigue: • Enhance physical well - being • Enhance psychological well - being • Enhance social/interpersonal well - being • Enhance professional well - being Suggested Strategies for Classroom Experience Ask class members to develop a plan for self - care for a critical care nurse. Encourage them to think about physical, psychological, social/interpersonal, and professional aspects of self - care. [ Perrin 2 e IRM ] Chapter 2 Care of the Critically Ill Patient RESOURCE LIBRARY COMPANION WEBSITE NCLEX Review Questions Media Links Media Link Applications IMAGE LIBRARY Table 2 - 1 Description of the Critical Care Pain Observation Tool Table 2 - 2 American Association of Critical Care Nurses Sedation Assessment Scale Table 2 - 3 Ventilator Adjusted Motor Assessment Scoring Scale (VAMASS) Table 2 - 4 CAM - ICU Worksheet Table 2 - 5 Body Mass Index (BMI) Calculation Table 2 - 6 Harris - Benedict Equations for Calculating Basal Energy Expenditure (BEE) Learning Outcome 1 Explain the characteristics of the critically ill patient described in the AACN s ynergy m odel. Concepts for Lecture 1. Critically ill patients are at high risk for life - threatening problems, and nurses must often focus on specific life - sustaining trea t ments. However, critically ill patients have basic needs as well. 2. The American Association of Critical Care Nurses (AACN) defines critically ill patients as “those who are at high risk for actual or potential life threatening health problems. The more critically ill the patient is, the more likely he or she is to be highly vulnerable, unstable and complex, thereby requiring intense and vigilant nursing care.” 3. According to the synergy model (Figure 2 - 1), the AACN postulates that when the needs of the patient and family drive the competencies r e quired by the nurse, optimal patient outcomes can be achieved. Further , the model identifies eight patient characteristics that can be scored along the health - illness continuum: • Resiliency: “The ability to bounce back quickly after insult.” • Vulnerability: “Susceptibility to actual or potential stressors.” • Stability: “The ability to maintain a steady state equilibrium.” • Complexity: “The intricate entanglement of two or more systems (e.g., body, family).” • Predictability: “A characteristic that allows one to predict a certain course of events or course of illness.” • Resource availability: “Extent of resources the patient, family, and community bring to the situation.” • Participation in care: “Extent to which patient and/or family engage in care.” • Participation in decision making: “Extent to which patient and/or family engage in decision making.” PowerPoint Lecture Slides 1. Characteristics of c ritically i ll p atients ( s ynergy m odel) • Resiliency • Vulnerability • Stability • Complexity • Predictability • Resource availability • Participation in care • Participation in decision making Suggested Strategies for Classroom Learning Considering each of the characteristics of critically ill patients, ask students to think about and describe patients they have encountered who exhibit these characteristics at both ends of the continuum. Discuss implications for care based on possession of these characteristics. Learning Outcome 2 Discuss the concerns expressed by critically ill patients. Concepts for Lecture 1. Critical care nurses have long focused on creating environments conducive to the comfort and healing of their patients. To that end, nurses have tried to limit stressors for their patients. However, research has indicated that what nurses thought would be stressful for patients varied considerably from what patients reported to be stressful to them. 2. Patients described as the most stressful to them: • being thirsty • having tubes in the mouth and nose • not being able to communicate • being restricted by tubes/lines • being unable to sleep • not being able to control themselves PowerPoint Lecture Slides 1. Stressors reported by critically ill patients • being thirsty • having tubes in the mouth and nose • not being able to communicate • being restricted by tubes/lines • being unable to sleep • not being able to control themselves