| Essential core of practice for the registered nurse | Nursing Process |
| Stages of Assessment Process | 1. Prearrival Assessment
2. Admission Quick Check
3. Comprehensive Initial Assessment
4. Ongoing Assessment |
| Is it possible to proceed with traditional methods of assessment (i.e. complete evaluation of the patient's history and a comprehensive physical exam of all body systems) in a critical care setting? | No, because the patient may be experiencing life-threatening problems during admission |
| Factors in gathering of psychosocial, physical, spiritual, economic and lifestyle | a. Interviewing the patient and/or family members
b. Reviewing past medical history and records
c. Completing a physical examination and reviewing current patient data |
| What approach must be used in assessing a critical care patient? | a specific assessment approach that recognizes the complexities of the nature of critical illness will be presented |
| Main importance in assessing a critical care patient | What is important is developing competence in assessing critically ill patients and their families in a consistent and systematic approach. (This way, we do not miss out on subtle signs or details that may point to an actual or potential problem or change in patient status.) |
| What is the purpose of technology in assessment? | Technology is there to augment information obtained from direct assessment of the patient. |
| Standard approaches in assessing patients | the head-to-toe approach and the body systems approach |
| Standard approaches in assessing critical care patients | combination of the two (head-to-toe approach and the body systems) approach applied in a “top-to-bottom” manner. |
| This stage begins the moment the nurse receives notification about the upcoming admission of the patient. | Prearrival Assessment |
| This assessment is a quick overview of the adequacy of ventilation and perfusion to ensure early intervention for any life-threatening situations | Admission Quick Check (“just the basics”) |
| ABCDE Acronym | Airway; Breathing; Circulation, Cerebral perfusion & Chief complaint; Drugs and Diagnostic Test; Equipment |
| This assessment is done as soon as possible, with the timing determined by the degree of physiologic stability and emergent treatment needs of the patient. | Comprehensive initial Assessment |
| What is the Comprehensive initial assessment if the patient is being admitted directly to the intensive care unit (ICU) from outside the hospital? | The comprehensive assessment is an in-depth assessment of the past medical and social history and a complete physical examination of each body system |
| What is the Comprehensive initial assessment if the patient is being transferred to the ICU from within the hospital? | The comprehensive assessment includes a review of the admission assessment data and comparison to the current state of the patient. |
| This assessment is an abbreviated version of the comprehensive initial assessment, is performed at varying intervals according to unit protocol and the individual needs of the patient | Ongoing Assessment |
| If a patient is unable to cooperate in terms of supplying information needed for assessment, who may be the other sourse? | family members or friends |
| Is pivotal in the prevention and/or early treatment for complications associated with critical illness. | Careful physical assessment on admission to the critical care unit |
| Prearrival Assessment | - abbreviated report on pt (age, gender, chief compliant, dx, pertinent hx, physiologic status, invasive devices, equipment and status of lab/dx tests)
- allergies
- complete room setup, verification of proper equipment functioning
- DNR status
- isolation status |
| Admission Quick Check Assessment | - gen appearance (consciousness)
- airway; patency; position of artificial airway if present
- breathing: quantity & quality of respirations; breath sounds; presence of spontaneous breathing
- circulation & cerebral perfusion: ECG; BP; peripheral pulses & CRT; skin, color, temp, moisture; presence of bleeding; LOC
- chief complaint: primary body system; associated symptoms
- equipment: patency of vascular & drainage systems; appropriate functioning & labeling of all equipment connected to pt |
| Common Diagnostic Tests Obtained During Admission Quick Check Assessment | Serum electrolytes
Glucose
Complete blood count with platelets
Coagulation studies
Arterial blood gases
Chest x-ray
ECG |
| Basis on which the nursing care plan is developed. | Analysis / Diagnosis |
| The nursing care plan details planning and outcomes by | a. Assigning priorities, if the patient has multiple nursing diagnoses
b. Setting short- and long-term goals that are patient oriented and measurable
c. Including assessment and diagnosis details
d. Stating appropriate nursing interventions and corresponding medical orders
e. Utilizing a standardized or computerized care plan or clinical pathway as a guideline, if appropriate |
| What type of plan of care is used particularly for critically ill patients? | An inter-professional plan of care would be the most useful approach to ensure coordination of the care of the patient and to improve achievement of targeted clinical outcomes |
| A set of expectations for the major components of care a patient receives during the hospitalization to manage a specific medical or surgical problem | inter-professional plan of care |
| Benefits of inter-professional plan of care | • Improved patient outcomes (e.g., survival rates)
• Increased quality and continuity of care
• Improved communication and collaboration
• Identification of hospital system problems
• Coordination of necessary services and reduced duplication
• Prioritization of activities |
| Typical Features of the format of inter-professional plans of care | • Patient goals (e.g., pain control, activity level, absence of complications)
• Assessment and evaluation
• Consultations
• Diagnostic studies
• Medications
• Nutrition
• Activity
• Education
• Discharge planning |
| Why must ongoing plans of care and safety initiatives developed by nurses be incorporated? | Since acutely ill patient conditions can change abruptly, hence constant awareness and vigilance is imperative even when the patient appears to be stable or improving |
| Major concern when providing care to critically ill patients | Prevention of complications associated with critical illness |
| Most common complications | • Physiologic instability
• Venous thromboembolism (VTE)
• Hospital-acquired infections
• Pressure injury
• Sleep pattern disturbance
• Psychosocial impact (delirium, anxiety, depression) |
| Performance of the interventions noted in the plan of care | Implementation of Care |
| performance of nursing care according to the care plan by | a. Properly documenting the care provided to the patient
b. Performing treatment in a way that minimizes complications and life-threatening issues
c. Involving patients, families, caregivers, and other members of the healthcare team as their abilities and patient safety allow |
| Implementation of care for physiologic instability | Perform ongoing assessments and monitoring of critically ill patients to immediately identify physiologic changes and to ensure that the patient is progressing toward identified patient outcomes. |
| Implementation of care for Venous thromboembolism (VTE) | - Avoid placing intravenous access in the groin site or lower limbs as this limits mobility and may impede blood flow and can therefore increase the risk for VTE
- Ensure adequate hydration.
- Administer low-dose heparin as prescribed as a preventive measure. |
| Implementation of care for Hospital-acquired infections | - Standard precautions, aka “universal precautions” or “body substance isolation” must be observed and practiced
- Maintaining blood sugar levels for both diabetic and non-diabetic patients
- Replace peripheral IV lines as recommended by the Centers of Disease Control and Prevention (CDC).
- All catheters inserted in an emergency situation are to be replaced as soon as possible or within 48 hours
- Dressings are to be kept dry and intact, and should be changed at the first signs of becoming damp, soiled, or loosened
- hand hygiene |
| Implementation of care for Pressure injury | - reposition the patient at least every two hours
- use pressure-reduction mattresses
- elevate heels off the bed with pillows under the calves or use heel protectors
- elbow pads may also be used
- use a skin care protocol with ointment barriers, especially for patients who are incontinent. |
| Implementation of care for Sleep pattern disturbance | • Be sensitive to the factors that affect a patient’s sleep
• Instituting a nighttime sleep protocol where patients are untouched but still closely monitored from 1 to 5 AM is one way to eliminate hourly disturbances to the patient.
• Assess patient's usual sleep patterns
• Minimize effects of an underlying disease process as much as possible (e.g., reduce fever, eliminate pain, and minimize metabolic disturbances)
• Avoid medications that disturb sleep patterns
• Consult with providers to continue behavioral medications as appropriate
• Mimic patients' usual bedtime routine as much as possible
• Minimize environmental impact on sleep as much as possible |
| Factors contributing to sleep disturbances in critical care | - Illness (metabolic changes, underlying disease, pain, anxiety, fear, delirium)
- Medications (analgesics, antidepressants, beta-blockers, bronchodilators, benzodiazepines, corticosteroids)
- environment (noise, staff conversations, television/radio, equipment alarms, frequent care interruptions, lighting, lack of usual bedtime routine, room temp, uncomfortable sleep surface) |
| Implementation of care for Psychosocial impact (delirium, anxiety, depression) | a. Keep stressors to a minimum.
b. Encourage family participation in care.
c. Promote a proper sleep-wake cycle.
d. Encourage communication, questions, and honest and positive feedback.
e. Empower the patient to participate in decisions as appropriate.
f. Provide patient and family education about unit expectations and rules, procedures, medications, and the patient’s physical condition.
g. Ensure pain relief and comfort
h. Provide continuity for care providers.
i. Make available the patient’s usual sensory and physical aids, such as glasses, hearing aids, dentures, as these may help prevent confusion. |
| may be evidenced by disorientation, confusion, perceptual disturbances, restlessness, distractibility, and sleep-wake cycle disturbances | Delirium |
| Medications that may also predispose a patient to delirium | 1. Prochlorperazine
2. Diphenhydramine
3. Famotidine
4. Benzodiazepines
5. Opioids
6. Antiarrhythmic medications |
| Implementation of care for Depression | - to educate the patient and family that most depressions that result during critical illness is not unusual and may be only temporary.
- If the family or patient have negative distortions about the illness and treatment, it is wise to correct, clarify, and reassure with realistic information to promote a more hopeful outcome
- If you suspect the patient may be suicidal, do clarify with the patient. Oftentimes, when the patient communicates he is feeling suicidal it is a cover for wanting to discuss fear, pain, or loneliness
- For further evaluation and intervention, a psychiatric referral is in order. |
| predispose the critically ill patient to depression | social isolation, recent loss, pessimism, financial pressures, history of mood disorder, alcohol or substance abuse/withdrawal, previous suicide attempts, and pain. |
| Implementation of care for Anxiety | - Applying both pharmacologic and non-pharmacologic interventions may alleviate the problem |
| goals of pharmacologic therapy for anxiety | to titrate the drug dose to maintain the patient’s cognition and ability to interact with the people around them, to complement pain control, and to assist in promoting sleep |
| Non-pharmacologic interventions for anxiety | to decrease or control anxiety include breathing techniques, muscle relaxation, imagery, preparatory information, distraction techniques, and use of previous coping methods |
| can result from medical disorders and can cause distress to the patient and family, which may exacerbate the medical condition. | Anxiety and panic-like symptoms |
| Why is it essential to provide information regarding diagnosis, prognosis, treatments and procedures? | This helps allay fears and concerns, or at least, puts them into perspective. Through client education, the patient and their family are better able to take a more proactive role in the plan of care. |
| the nurse takes the opportunity of teaching moments when the learner is able to comprehend and synthesize the information to be shared | learning readiness |
| A good method to find out if the learner comprehends the information is to ask the patient or family member to relay in their own words what they learned. | teach-back |
| Why is creating and implementing inter-professional plans of care important? | improves communication and collaboration in achieving optimal patient outcomes |
| designed to facilitate documentation, since they have programs and pages for numerous situations that happen in critical care units | Electronic medical records (EMRs) and electronic medication administration records (EMARs |
| rule of documentation in ICU | “If it was not documented, it was not done” |
