complex test 1 book

Examples of Patient Safety Goals

-identify patients correctly: use at least two methods of patient identification, ensure correct patient identification for blood transfusion -improve communication among healthcare providers: report important results of tests and diagnostic procedures on a timely basis -use medication safely: label all medications and containers, including syringes and medicine cups. reduce harm associated with administration of anticoagulants. reconcile medications across the continuum of care -use alarms safely: ensure that alarms are audible and respond to them in a timely manner -prevent infection: comply with guidelines for hand hygiene, implement evidence based guideline stop prevent: infections with multi drug resistant organisms, central line associated bloodstream infections, surgical site infections, catheter associated urinary tract infections -identify safety risks: assess patient for suicidal risk -prevent complications associated with surgery and procedures: conduct a preprocedure verification process to ensure that surgery is done on the correct patient and site, mark the correct procedure site, preform a time out before the procedure to ensure that the correct patient, site, and procedure are identified

Advance Directives

An advance directive is a communication that specifies a person's preference about medical treatment should that person become incapacitated. Several types of advance directives exist, including DNR orders, allow-a-natural-death orders, living wills, healthcare proxies, and other legal documents. It is important for nurses to know whether a patient has an advance directive and that the directive be followed. To enhance advance directives and ensure common conversation and language, the Physician Orders for Life-Sustaining Treatment (POLST) has been promoted in many states. The POLST form is a medical order indicating a patient's wishes regarding treatments that are commonly used in a medical crisis. The POLST complements the advance directive and is not intended to replace it. The goal of POLST is a conversation with an emphasis on advanced care planning, shared decision making, and ensuring that a patient's end-of-life wishes are honored. The living will provides a mechanism by which individuals can authorize the withholding of specific treatments if they become incapacitated. Although living wills provide direction to caregivers, in some states living wills are not legally binding and are advisory. When completing a living will, individuals can add special instructions about end-of-life wishes. Individuals can change their directive at any time. The durable power of attorney for health care is more protective of patients' interests regarding medical treatment than is the living will. With a durable power of attorney for health care, patients legally designate an agent whom they trust, such as a family member or friend, to make decisions on their behalf should they become incapacitated. This person is called the healthcare surrogate or proxy. A durable power of attorney for health care allows the surrogate to make decisions whenever the patient is incapacitated, not just at the time of terminal illness. Some legal commentators recommend the joint use of a living will and a durable power of attorney to give added protection to a person's preferences about medical treatment. Ultimately, if self-determination and informed consent are to have real value, patients or their surrogates must be given an opportunity to consider options and to shape decisions that affect their life or death. Communication and shared decision making among the patient, family, and healthcare team regarding end-of-life issues are key. Unfortunately, this frequently does not happen before admission to a critical care unit. The critical care nurse must be part of the team that educates the patient and family so that they can determine and communicate end-of-life wishes. Some situations may result in moral distress for the nurse. A nurse who is unable to follow these legal documents because of personal or religious beliefs must ask to have the client reassigned to another nurse. For instance, some advance directives may call for withdrawing life support when certain conditions are met, and this may conflict with the nurse's personal or religious beliefs. Nurses who frequently ask to be reassigned to another client may need to consider another nursing specialty in which their beliefs do not conflict with advance directives.

enteral nutrition

Any patients who cannot meet their nutritional needs orally should be started on enteral nutrition in the first 24 to 48 hours. Studies evaluating early EN (within 24 hours) when compared to delayed EN found benefits associated with decreasing pneumonia, mortality, and critical care unit length of stay and maintaining the integrity of the GI tract. Exclusions to initiating early EN include diagnoses such as bowel obstruction, hemodynamic instability, GI bleeding, bowel ischemia, or intraabdominal hypertension. Traditionally, patients are kept NPO (nothing by mouth) from midnight prior to surgery until, at times, multiple days postoperatively. This is often due to waiting for the return of bowel function or resolution of postoperative ileus prior to beginning nutrition. Research suggests that reducing fasting times for procedures is associated with improvement in patient outcomes and nutrition status. Evidence has shown that a 2-hour fast for liquids and a 6-hour fast for solids is adequate time for gastric emptying to avoid pulmonary aspiration during general anesthesia. Research finds that resuming oral or enteral nutrition within 24 hours postoperatively not only is safe and tolerated but also improves recovery. Early initiation of gastric feeding may improve ileus and expedite the return of bowel function. I EN can be delivered by three methods: trophic, targeted hourly rate, and volume-based feeding (VBF). Trophic feeding provides patients with less than their estimated nutrition needs due to an actual or perceived risk of intolerance. In some cases, patients are started on trophic feeds and advanced to a goal volume or rate as tolerated. Trophic feeding rates are most often between 10 and 30 mL/h. In the targeted hourly rate method, a goal rate for EN administration is calculated based on the daily estimated nutritional need. Initiation of EN either occurs at a trophic rate and advances to the hourly goal or is initiated at the hourly goal rate. The rate is set and remains at the specified hourly volume (e.g., 45 mL/b). This method does not typically account for missed EN secondary to procedures, nursing care, or diagnostic tests; therefore the patient is at risk for suboptimal nutrition therapy. Certain tests or procedures may not require fasting; clarify with the practitioner who is ordering or performing procedures how long to hold EN or whether holding EN is necessary. Upon procedure completion, resume nutrition support promptly. Compensating for missed EN via VBF can help optimize the patient's nutrition status. Upon implementing the VBF method, the practitioner orders the appropriate EN as a goal volume to be infused over 24 hours. Increases in the hourly rate occur in response to interruptions in EN therapy, with the goal of compensating for gaps in EN therapy. For example, if the goal volume is 1200 mL and the patient's EN is held for 12 hours for a procedure, the patient has 12 hours remaining in the day to achieve the goal volume. Recalculate the rate of administration based on the remaining hours (1200 mL divided by 12 hours) and run the EN at 100 mL/h for the remainder of the day. In this method, patients receive more prescribed calories and protein when compared to the target hourly rate method. Enteral nutrition can be administered through a number of options, with the optimal access depending on the patient's acute and long-term nutrition support needs. Often the intubated patient receives an orogastric tube (OGT) for stomach decompression after intubation. The OGT can easily be transitioned from a decompressive device to EN access. Nasogastric tubes (NGTs) are another gastric tube option; however, NGTs increase the risk of sinusitis by 200% in intubated patients. The placement of all blindly inserted gastric tubes should be confirmed via radiographic study prior to use, then checked every 4 hours during continuous feeding based on external tube length. Patients at high risk for aspiration should have their feeding tube placed postpyloric in the small bowel given the reduction in aspiration and regurgitation. Small bowel feeding tubes (SBFTs) are safe and do not increase the likelihood of complications when compared to the gastric route. Use of SBFTs requires additional training to safely achieve postpyloric placement. Some institutions use a bedside electromagnetic placement device (EMPD) to assist with accurate placement. The EMPD tracks the location of the SBFT through the use of a stylet that emits an electromagnetic signal from its distal tip. The signal is then transformed to a tracing on the screen of the EMPD, which allows the nurse to determine the location and trajectory of the SBFT. The accuracy of EMPD-placed SBFTs by skilled nurses is upward of 97%, with some institutions eliminating radiographic confirmation; however, radiographic studies are still recommended for SBFT confirmation. Long-term (typically longer than 4 to 5 weeks) nutritional access is considered based on the patient's swallowing ability, aspiration risks, goals of care or wishes, and ability to meet nutritional requirements. Feeding tubes can be inserted externally through the stomach or jejunum. A percutaneous endoscopic gastrostomy (PEG) tube is inserted under local to moderate sedation, allowing enteral feedings to begin within 4 hours after placement. If a patient does not tolerate gastric feedings, a percutaneous endoscopic gastrojejunostomy (PEG) tube can be placed, allowing jejunal feeding and bypassing the stomach. The PEG portion is often used for medication administration to facilitate adequate absorption, and the PEG portion is used for continuous EN. Another postpyloric long-term feeding tube option is the surgically placed percutaneous endoscopic jejunostomy (PEJ) tube; however, endoscopic placement is available to certain patients based on clinical disposition. PEJ tubes have significantly better long-term patency than PEGJ tubes, which tend to recoil back into the stomach. During administration of EN, elevate the patient's head of bed to 30 degrees or higher to prevent aspiration. Placing the head of bed higher than 30 degrees requires frequent integumentary assessments and patient repositioning to reduce the risk of pressure injury. Whenever medications are administered via an enteral feeding tube, flush the tube with 30 ml of water before and after each medication is administered. Patients requiring fluid restriction may receive 15 mL for flush. If the patient's EN is to be placed on hold, flush the feeding tube to prevent a buildup of residue in the tube and reduce the risk of clogging. Liquid medication formulations are preferred for administration via the enteral feeding tube; however, they increase the risk of diarrhea, as many liquid medications use sorbitol as an excipient. If enough sorbitol is consumed, the sugar alcohol can have a laxative effect. Sustained-release medications must not be crushed and given via a feeding tube because of the potential for overdose. When administering EN via a feeding tube, collaborate with the pharmacist to ensure safe and effective medication administration. EN may require temporary discontinuation before and after medication administration. For example, current recommendations for administration of phenytoin are to stop enteral feedings 1 to 2 hours before and after dosing. This method may not always be optimal, especially for malnourished patients. Other options include monitoring and adjusting phenytoin dosages based on serum drug levels while the patient is receiving EN or transitioning the patient to IV therapy during continuous EN administration. Once EN is discontinued, the drug dosage or route of administration is readjusted. The location of enteral access in the alimentary tract may also affect bioavailability of some medications. In patients receiving medications via a small bowel or jejunostomy tube, care should be given to ensure that all medications are effectively absorbed in the small bowel. For example, antacid medications such as pantoprazole or famotidine are ineffective when administered directly into the small intestine given their mechanism of action. The administration of rivaroxaban distal to the stomach is not recommended, as this may decrease the patient's exposure to the medication." Open communication with the pharmacist and multiprofessional team to effectively reconcile the medication administration record will facilitate safe and effective therapy. Tolerance of Enteral Nutrition: Presence of bowel sounds in four quadrants, as determined by auscultation, Presence of bowel motility or bowel movements, Palpation of a soft abdomen, Percussion of the abdomen revealing tympanic findings. Signs of intolorance: Nausea or vomiting, Absent bowel sounds, Abdominal distension, Cramping, Diarrhea, consitpation, emesis

communication and conflict resolution

Clear, ongoing, and honest communication among the members of the healthcare team, the patient, and the family is a key factor in improving the quality of care for the dying patient in the critical care unit. Communication is also incredibly challenging, in part because of the complex nature of predicting prognosis with accuracy in a critically ill person. Significant differences in perception of the patient's prognosis for recovery have been identified among surrogates, physicians, and nurses. The most accurate prognostication occurs when physicians and nurses work together, emphasizing the need for a multiprofessional team approach. A shared decision-making model with clinicians and patients or their surrogates collaborating to determine patient prognosis and goals of care is recommended by critical care guidelines. A process-based method for resolving disputes between care teams and patients or their surrogates has been described and is supported by major nursing and critical care societies. Schedule regular conferences with the patient and family to facilitate communication and identify goals of care. During the conference, make the family feel comfortable talking about death and dying issues, focusing on how the patient likely would decide in the given situation if unable to communicate his or her wishes. Clarify what the family understands and answer any questions, allowing them to talk about the family member's life and medical history. Provide honest information about the patient's prognosis. Discuss goals for palliative care, emphasizing that patient comfort will be maintained. Use skills of effective communication such as reflection, empathy, and silence. Conclude with a plan and follow-up communication. guidelines for effective communication: -Present a clear and consistent message to the family. Mixed messages confuse families and patients, as do unfamiliar medical terms. The multiprofessional team needs to communicate and strive to reach agreement on goals of care and prognosis. -Allow ample time for family members to express themselves during family conferences. Ask about previous discussions or feelings of the patient regarding life-sustaining treatments. Aim for all (healthcare providers, patients, and families) to agree on the plan of treatment. The plan should be based on the known or perceived preferences of the patient. Arriving at such a plan through communication minimizes legal actions against providers, relieves patient and family anxiety, and provides an environment in which the patient is the focus of concern. -Emphasize that the patient will not be abandoned if the goals of care shift from aggressive therapy to "comfort" care (palliation) only. Let the patient and family know who is responsible for the care and that they can rely on those individuals to be present and available when needed. -Facilitate continuity of care. If a transfer to an alternative level of care, such as a hospice unit or ventilator unit, is required, ensure that all pertinent information is conveyed to the new providers. Details of the history, prognosis, care requirements, palliative interventions, and psychosocial needs should be part of the information transfer.

Informed Consent

Consent problems arise because patients are experiencing acute, life- threatening illnesses that interfere with their ability to make decisions about treatment or participation in a clinical research study. The doctrine of informed consent is based on the principle of autonomy; competent adults have the right to self-determination or to make decisions regarding their acceptance or rejection of treatment.

Withholding, Limiting, or Withdrawing Therapy

Decisions to withdraw, withhold, or limit treatment should be made with multiprofessional team and family participation using a shared decision-making model. Appropriate withdrawal, limiting, or withholding of therapy does not constitute euthanasia or assisted suicide. Minimal moral distress on the part of the healthcare team, patients, and families should result if generally accepted ethical and legal principles are followed during this process. A growing number of states have endorsed the use of a standardized end-of-life order set for inpatient or outpatient use, known as Physician (or Provider) Orders for Life-Sustaining Treatment (POLST). This form is designed to be mutually agreed on between the provider and patient or surrogate and clearly specifies the kind of care the patient prefers at the end-of-life. Preparing patients (if conscious) and families for what will likely occur during the withdrawal process is key to alleviating anxiety and undue distress. Anticipate patient symptoms, such as dyspnea during ventilator withdrawal, and medicate to alleviate such symptoms even if high doses of medications are required. Assess pain using a validated pain scale such as the Critical-Care Pain Observation Tool (COT) and assess agitation using either the Sedation-Agitation Scale (SAS) or the Richmond Agitation-Sedation Scale (RASS). Assess the patient's response (e.g., comfort) to determine how much medication is appropriate in a given situation and titrate therapy as needed to relieve emotional and physical distress, even if such dosing hastens the death of the patient as a secondary effect. Commonly used medication regimens include morphine sulfate or other opioids for pain or dyspnea and IV benzodiazepines for anxiolysis. Pharmacological management of life support withdrawal is critical in ensuring a peaceful death for both patient and family.

pain assessment

Factors that alter verbal communication in critically ill patients include endotracheal intubation, altered level of consciousness, restraints, sedation, and therapeutic paralysis. Optimal pain assessment in adult critical care settings is essential because nurses often underrate and undermedicate the patient's pain. Inaccurate pain assessments and resulting inadequate treatment of pain in critically ill adults can lead to significant physiological consequences. Assessment involves the collection of the patient's self-report of the pain experience as well as behavioral markers. If a patient can respond, ask the patient to describe the pain or anxiety being experienced or to provide a numeric score to indicate the level of pain or anxiety. Observe behavioral or physiological cues of pain. As part of the assessment of pain and anxiety, note what procedures cause pain and evaluate the effectiveness of interventions to prevent or relieve pain and anxiety. When patients exhibit signs of anxiety or agitation, identify and treat the potential cause, such as hypoxemia, hypoglycemia, hypotension, pain, and withdrawal from alcohol and drugs. When possible, ask patients about any herbal remedies they use as complementary and alternative medical therapies and whether they take them along with prescription or over-the-counter medications. These products may lead to adverse herb-drug interactions, especially in older adults who are more likely to be taking multiple drugs. To assess pain, ask the patient to identify several characteristics associated with the pain: precipitating cause, severity, location (including radiation to other sites), duration, and any alleviating or aggravating factors. Patients with chronic pain conditions, such as arthritis, may be able to provide a detailed list of effective pain remedies that may be useful to implement. One tool used in assessing the patient with chest pain is the PQRST method. The PQRST method is a mnemonic the nurse can use to ensure that all chest pain characteristics are documented. P-Provocation or position. What precipitated the chest pain symptoms, and where in the chest area is the pain located? Q-Quality. Is the pain sharp, dull, crushing? R-Radiation. Does the pain travel to other parts of the body? S- Severity or symptoms associated with the pain. The patient is asked to rate the pain on a numeric scale and to describe what other symptoms are present. T-Timing or triggers for the pain. Is the pain constant or intermittent, and does it occur with certain activities? One of the most common methods used to determine pain severity is to ask patients to rate their pain on a numbered scale such as 0 to 10 (administered either verbally or visually). Reassess the pain score after medications or other pain-relieving measures have been provided. Some institutions require nurses to intervene for a pain score greater than a pre-designated number. Use the pain rating method only with patients who are cognitively aware of their surroundings and can follow simple commands. It is possible for patients with mild to moderate dementia to self-report pain, but this ability decreases with progression of the disease. Numeric rating is not an appropriate method to assess pain in patients who are disoriented or have severe cognitive impairment. Another widely used subjective pain measurement tool is the Visual Analog Scale (VAS). The VAS is a 10-cm line that looks similar to a timeline. The scale may be drawn horizontally or vertically, and it may or may not be numbered. If numbered, 0 indicates no pain, whereas 10 indicates the most pain. To use the VAS, hold up the scale and ask the patient to point to the level of pain on the line. If the patient is able to communicate in writing, the patient can place an "X" on the VAS with a pencil. The VAS can also be used to evaluate a patient's level of anxiety, with 0 representing no anxiety and 10 representing the most anxiety. The VAS is used only with patients who are alert and able to follow directions. It is imperative to identify ways to communicate effectively with patients who have limited communication abilities. Several writing tablets and computer applications (app) are available for patients to use to communicate their pain level. The ICU Patient Communicator app by the SCCMS was designed to assist critical care providers to communicate with patients who are unable to speak because of mechanical ventilation, hearing loss, or speech limitations. The ICU Patient Communicator app allows patients to identify where on the body they are feeling sensations, as well as the severity of those sensations. Pain, itching, and nausea can be identified in exact locations on the body and rated on a scale of 0 to 10 for severity. Assessment of pain in the noncommunicative patient requires identification of an optimal pain scale using the behavioral-physiological tools. The PADIS guidelines recommend use of behavioral assessment tools in critically ill adults unable to self-report pain and in whom behaviors are observable. Vital signs are not valid indicators for pain and should be used only as cues to initiate further assessment. Observe behaviors using either the Behavioral Pain Scale in intubated (BPS) or nonintubated (BPS-NI) patients or the Critical-Care Pain Observation Tool (CPOT). Both tools demonstrate the greatest validity and reliability for monitoring pain in noncommunicative patients. As appropriate, involve the family in the pain assessment process. Widely used and validated, the BPS was developed to assess pain in the critically ill adult who is nonverbal and unable to communicate (Table 6.2). The BPS, comprising the original BPS and the BPS-NI, includes three behavioral indicators: facial expression, movement of upper limbs, and compliance with ventilation for intubated patients, or vocalization for nonintubated patients. Each indicator is rated from 1 to 4, with a total BPS score ranging from 3 to 12. The CPOT includes four behavioral categories: facial expression, body movements, muscle tension, and compliance with the ventilator for intubated patients or vocalization for extubated patients. Items in each category are scored from 0 to 2, with a total CPOT score ranging from 0 to 8.

Family members of the critically ill patient: Family Needs

Family members report that they need assurance and stress reduction." They also report being fatigued, stressed, and needing frequent updates on patient status. Addressing stress and coping of family members is important. If family members perceive stress, it may increase the workload of the nurse to address that stress. Knowledge of interventions that are known to be effective in reducing stress and promoting coping of family members enables the critical care nurse to create a plan of care that assists both patients and their families. Some family members may be demanding or disruptive, or they may insist on constant vigilance from the nursing staff. These behaviors may reflect a sense of loss of control or possibly memories of an adverse outcome during a previous hospitalization. Recognize these factors as the reason for observed behaviors and determine the best way to communicate and intervene. Family members often want confirmation that everything is being done for the patient, which may be challenging. Establish a partnership with the family built on mutual respect as well as credibility, competence, and compassion. One strategy is to encourage family members to assist in patient assessment (e.g., identify changes) and participate in selected aspects of the patient's care. Depending on institutional policy, it may be possible to enlist family members to help with tasks such as oral care, hygiene, range-of-motion exercises, or repositioning the patient. These activities give family members a sense of purpose and control, as well as potentially providing an additional layer of safety when the nurse is unavailable. A "family bundle" to provide a structure for planning and carrying out family care was developed and tested with positive results

what 2 strategies have been introduced to improve patient safety

IHI bundles- evidence based best practices that are done as a whole to improve outcomes, and research is being done to evaluate their effectiveness rapid response teams or medical emergency teams- expertise to assess and manage patients whose conditions are deteriorating and to provide early intervention and improve outcomes

Family members of the critically ill patient: Visitation

Many critical care units have relaxed or eliminated restrictions on visiting hours. This greatly improves patient and family satisfaction, although some nurses remain reluctant to change. Nurses may view family-centered care and open or expanded visitation as challenging or stressful; however, administrative support can help nurses to adjust and improve their job satisfaction. Reasons cited for opposition to liberal visitation include the presumed increased physiological stress for the patient, family interference with the provision of care, and physical and mental exhaustion of family and friends. An additional concern is that family members will be intrusive, creating burdens for nurses; however, concerns about negative outcomes of liberalized visitation are unfounded Contrary to traditional thinking, it was well documented more than 30 years ago that family presence frequently has no effect on the patient's condition and at times the effect is positive, such as decreased intracranial pressures or blood pressures, or an increased heart rate in a bradycardic patient. Although practice is changing and research is limited, many institutions prohibit visitation by children. The American Association of Critical-Care Nurses (AACN) recommends welcoming children who are supervised by an adult family member. A unit culture change may need to occur to make child visitation a reality. Nurses need to be engaged, and the visiting child needs individual guidance and follow-up." Visitaton provides children with an opportunity to learn about their loved one and provides support during times of uncertainty. Animal-assisted therapy may also be beneficial to a patient's recovery. Some critical care units have extended visitation to include pet therapy. These institutions have policies that permit the family pet or designated therapy animals to visit the patient. Nurses can assist in promoting policy changes to affect open-visitation policies. Unit-based councils and staff-led research are helpful to create change in the visitation policies. A significant benefit of a liberal visitation policy is its positive effect on the opinions of both patients and families regarding the quality of nursing care. When combined with family sup-port, as demonstrated by the nurses' caring behaviors and inter-actions, liberal visitation is influential in shaping the critical care experience for both patients and families.

Moral Distress and Moral Resilience

Moral distress occurs when the nurse knows the ethically appropriate action to take but is unable to act on it or when the nurse acts in a manner contrary to personal and professional values. Nurses with moral distress are sick more often, suffer burnout, and disengage from their work environment, leading to increased turnover and even career changes. Moral resilience is defined as the ability of nurses to rebalance and resolve ethical incongruency both personally and organizationally when faced with ethical dilemmas.

Emotional and Psychological Care of the Patient and Family

Needs are as variable as family situations, so carefully assess what the patient's and family's needs are instead of making assumptions about what they ought to be. Use nonjudgmental assessment, being keenly aware of the patient's and family's personal feelings or values about the situation. The results of this assessment determine priorities in this dimension of care. Keep in mind that "family" can consist of many different persons in an individual's life. It may include unmarried life partners same or opposite sex, close friends, and "aunts "uncles," or "cousins" who may have no legal relationship to the patient. For some families, spiritual counseling from pastoral care services might be a priority. For others, the need may be for statistics documenting their loved one's chances of survival with a particular diagnosis. One common need is receiving clear, consistent, and accurate information about the patients condition, what to expect during the withdrawal and dying process (if applicable), and reassurance that the patient will not suffer during the dying process. Coordinating the communication process between the patient, the family, and the healthcare team contributes to building family resilience in the critical care setting and is a key nursing role. Other nursing activities that promote family resilience include managing expectations to ensure a realistic understanding of condition and prognosis and supporting the patient's or surrogate's decision-making process. Many institutions have bereavement counselors with extensive training in assisting patients and families through the dying process and its aftermath. Social workers, spiritual care providers, and licensed mental health professionals frequently can assist in meeting the needs of families. Spiritual care providers can be an essential element of end-of-life care, and their presence is valued by nurses, patients, and families. Maintaining the patient's dignity during the dying process is of the utmost importance. Make time to listen to family accounts of the patient's life before the illness or injury and acknowledge the patient's individuality and humanity. Use a calm manner and voice, maintain a quiet and private environment, and allow unrestricted family presence with the patient before, during, and after the patient's death. Provide items for family comfort, such as tissues, refreshments, and chairs. When no words seem appropriate, maintain a respectful, conscious presence. The patient's death may be a relatively routine part of your work experience, but keep in mind that family members will likely remember the situation, your actions, and those of the healthcare team for many years. Nursing interventions to support the family at the end-of-life: -Assess patient's and family members' understanding of the condition and prognosis to address educational needs -Educate family members about what will happen when life support is withdrawn to decrease their fear of the unknown -Assure family members that the patient will not suffer -Assure family members that the patient will not be abandoned -Provide for any needed emotional support and spiritual care resources, such as grief counselors and spiritual care providers -Facilitate physician communication with the family -Provide for visitation and presence of family and extended family, most family members do not want the patient to die alone

Family members of the critically ill patient: family assessment

Once the patient has been admitted to the critical care unit, an assessment of the family provides valuable information for development of the plan of care. Obtain essential information during the admission assessment, and gather additional information throughout the hospital stay. Structured tools are available to assess the family but are not consistently used in everyday practice; however, concepts incorporated into tools can guide the nursing assessment. The structural, developmental, and functional categories described in the Calgary Family Assessment Model provide a useful way to gather information about the family. Structural assessment is done on admission, and it identifies immediate family, extended family, and the decision makers. Other aspects of family structure include ethnicity, race, religion, and spirituality. Designating a spokesperson for primary communication with the family members is beneficial. The developmental assessment includes information related to the family's developmental stages and tasks. The functional assessment reveals how family members function and behave in relation to one another. In today's diverse society, it is important to assess the influence of culture and spirituality on both the patient and family. Especially important are beliefs about health and healing, cultural and spiritual practices, personal space and touch preferences, social organization, and the role of the family. Identify the primary language used for verbal and written communication. Use hospital-designated language interpreters when communicating with non-English speakers. Interpreters also serve as cultural guides to facilitate communication and understanding of the critical care experience. A simple approach to cultural and spiritual assessment is to ask three questions that can easily be adapted for most situations: (1) What are your specific religious and spiritual practices? (2) What are your beliefs about illness and death? (3) What is most important to you and your family at this time? An early, proactive approach is advised when assessing a patient's family. Observe the family; interact with them; and note significant facts such as the patient's role, family coping strategies, and socioeconomic issues. The family assessment may reveal whether the family members are angry, feeling guilty, or have unaddressed concerns regarding the patient's condition and care. An illness within the family may also uncover underlying conflicts among family members, especially when family members are estranged or have other unresolved issues. Once an assessment is completed, concisely record the collected data to identify key information related to family assessment that is shared among all healthcare team members caring for the patient.

Parenteral Nutrition

PN is a form of nutrition that supplies protein, fat, minerals, electrolytes, and carbohydrates via the IV route. In patients where EN is contraindicated due to the structure or function of the alimentary tract (e.g., discontinuity, obstruction, hy-peremesis gravidarum), assess patients early for the provision of PN. A multiprofessional approach to PN implementation may reduce the associated risks, including hyperglycemia, electrolyte imbalances, immune suppression, increased oxidative stress, and potential infectious morbidity. PN should be withheld for the first 7 days of a critical care admission if the patient is at low nutrition risk and EN is not feasible. If the patient cannot receive EN and is found to be severely malnourished or have a high nutritional risk, initiate PN as soon as possible after admission. In patients receiving EN, consider PN after 7 to 10 days of EN therapy if nutritional goals are not being met. Do not use PN unnecessarily, as its initiation and the treatment itself are not without risks. How-ever, if PN is indicated, initiate the nutrition early to maximize benefits. If possible, consider trophic feeds to reduce the risk of sepsis and wean the patient from PN as soon as possible. There are two types of PN, total and peripheral, with total parenteral nutrition (TPN) being more common given the concentrated dosing and lower fluid volume. Peripheral parenteral nutrition (PPN) is not indicated for use in the adult population. PPN does not provide full nutrition support to patients and has the risk of compromising peripheral veins. TPN involves the administration of a highly concentrated dextrose solution (210%) with a high osmolarity (>900 mOsm/L). Due to the high concentration of dextrose, patients receiving TPN have an increased risk of hyperglycemia and require frequent glucose monitoring and management. The caustic nature of the hyperosmolar fluid requires central venous access through a peripherally inserted central catheter (PICC), port, or central venous access located in the subclavian, jugular or femoral veins. Central venous access increases the patient's risk for a nosocomial infection (i.e., central line-associated bloodstream infection [CLABSI]). Decrease risk to the patient by implementing CLABSI prevention bundles and adhering to hand hygiene practices. Lipids or fatty acids are infused with TPN to prevent essential fatty acid deficiency. Provision of lipids should not exceed 30% of a patient's total calorie intake from TPN. In patients receiving lipids, monitor triglyceride levels and withhold lipids if levels are elevated. Some medications use lipids as an emulsifier (e.g., the sedative propofol), and lipids are often held until discontinuation of these medications to prevent hypertriglyceridemia. Lipids can be infused concurrently with TPN or separately. Use a dedicated port in the central venous access device to administer TPN and lipids. Preferably, do not administer other medications via the same port as TPN. Monitor and evaluate electrolytes closely in patients receiving TPN, as these patients high nutrition risk predisposes them to refeeding syndrome. Refeeding syndrome is a potentially life-threatening electrolyte fluctuation in response to aggressive administration of nutrition therapy in a previously malnourished patient. The guidelines recommend a slow titration of TPN to feeding goal over a 3- to 4-day period in at-risk patients. Electrolyte monitoring and repletion is especially important, and in severe cases of refeeding, nutrition support has to be reduced to allow adequate electrolyte repletion. If TPN is discontinued abruptly, monitor for signs and symptoms of hypoglycemia. Ideally, a patient who has been receiving TPN is transitioned to EN. Upon initiation of EN, ensure that the patient is receiving more than 80% of estimated caloric needs from EN or an oral diet prior to discontinuing PN.

barriers to effective handoff communication

Physical setting: background noise, lack of privacy, interruptions Social setting: organizational hierarchy and status issues Language: differences between people of varying racial and ethnic backgrounds or geographical areas Communication medium: limitations of communications via telephone, e-mail, paper, or computerized records versus face-to-face

Family members of the critically ill patient: communication

Receiving information and feeling safe are predominant, complementary needs of critically ill patients and their family members. Of all the members of the critical care team, nurses spend the most time at the bedside and as such are usually the first to hear about any perceived unmet needs of family members. Frequent updates on the patient's condition, anticipated therapies or procedures, and goals of the critical care team are an easy and effective way to allay anxiety while building a relationship of mutual trust. Lack of communication is a principal complaint when families are dissatisfied with care. Facilitate communication by providing a simple, honest report of the patient's condition, free of medical jargon. A follow-up assessment to gauge the family's level of understanding helps to tailor the care plan accordingly. Scheduled rounds between the healthcare team and the family assist in maintaining open communication. A predetermined routine for these rounds provides an opportunity for the team to update the family on the patient's condition and answer questions posed by the family. It also provides time to identify goals for care and treatment to facilitate shared decision making. Scheduled family conferences provide a similar opportunity to facilitate communication. Family conferences may be held at the bedside or in a conference room, depending on space available and family needs. If possible, hold a preconference among team members to ensure that consistent messages are delivered during the family conference. Empathetic communication is important during rounds and family conferences. The VALUE mnemonic is a useful tool to enhance communication with family members of critically ill patients. Value what the family tells you Acknowledge family emotions Listen to the family members Understand the patient as a person Elicit (ask) questions of family members

SBAR

S- state what is presently happening B- circumstances leading up to the situation A- state what you think is the problem R- recommendation to correct the problem delivers information in a way that is brief and action oriented. other strategies to improve handoff include using checklists to prompt and document essential information, and training all personnel in effective communication techniques. the strategy developed by the airline industry to improve communication and safety is crew resource management. the crm monitors others actions by double checking, verifying, and when necessary correcting inaccurate or ambiguous information

The critically ill patient

Stressors related to treatment and the critical care environment can lead to anxiety, fear, insecurity, isolation, and loneliness.', Stressors that have been identified by patients when recalling their critical care experience are Difficult communication, Pain, Thirst, Difficulty swallowing, Anxiety, Lack of control, Depression, Fear, Lack of family, Feelings of dread, Discomfort, Difficulty sleeping, Loneliness, Thoughts of dying, Physical restraint. The cumulative effect of these stressors can promote anxiety and agitation, and in some cases it leads to the development of delirium and posttraumatic stress disorder (PTSD). One effective intervention is to group together nursing activities and medical procedures to maximize resting periods. Even if patients are sedated or unconscious, it is important to remember that many patients can still hear, understand, and respond emotionally to what is being said. Make every effort to talk to patients, regardless of their ability to interact. Reorient patients to time and place, update them on their progress, and remind them that they are safe and have family and people nearby who care about their well-being. Increase pleasant sensory input by encouraging family members to speak to and touch the patient. Reorient the patient every 2 to 4 hours, and address the patient directly to minimize disorientation. Instead of repeatedly questioning the patient (e.g., "Do you know what day it is? Do you know where you are?"), incorporate this content into normal conversation (e.g., "It's 8 o'clock in the morning on the fifth of September. You are still in the critical care unit. Your family will be here to see you in about 10 minutes."). Do not discuss other patients and personnel in the patient's room because such information can increase confusion and contribute to sensory overload. Place objects that facilitate orientation, such as a clock or a calendar, within the patient's visual field. Ask family members to bring personal and meaningful items from home to assist in reorienting the patient. These items also humanize the patient and help staff to recognize that the patient has a unique personality and should be treated accordingly. Promoting rest and sleep are other important nursing interventions. Sleep is frequently interrupted by such activities as blood draws, physician visits, medication administration, and frequent assessment. Multiple healthcare providers are involved in patient care, and their interventions are often determined by when staff are available rather than when the timing is ideal for the patient. Bundling nonpharmacological interventions such as removing noxious stimuli and increasing comfort are effective ways to promote rest and sleep. Simply asking the patient or family about sleep preferences is another intervention. Promote day-night cycles by positioning the patient near natural light during the day and reducing light levels in the patient's room at night. Reduce noise during the nighttime hours. Stress and anxiety for the critically ill patient are caused by pain, discomfort, and many other factors. Critical care nurses are in the position to pinpoint exactly what stresses their patients, and they can minimize many of these stresses. Provide high-quality nursing care, offered with humanity and delivered professionally. Explain procedures or interventions before they are performed, plan care so that the patient has quality time with family members, encourage decision making, and facilitate communication.

Cardiopulmonary Resuscitation Decisions

The goals of resuscitation are to preserve life, restore health, relieve suffering, limit disability, and respect the individual's decision, rights, and privacy. Frequently, ethical questions arise about the use of CPR and emergency cardiac care because such treatment may conflict with a patient's desires or best interests. The critical care nurse should be guided by scientifically proven data, patient preferences, and ethical and cultural norms. The American Heart Association has developed guidelines to assist practitioners in making the difficult decision to provide or withhold emergency cardiovascular care. The generally accepted position is that resuscitation should cease if the physician determines that efforts are futile or hopeless. Futility constitutes sufficient reason for either withholding or ceasing extraordinary treatments. Withholding or stopping extraordinary resuscitation efforts is ethically and legally appropriate if patients or surrogates have previously made their preferences known through advance directives. It is also acceptable if the physician determines that resuscitation is futile or has discussed the situation with the patient, family, or surrogate as appropriate and there is mutual agreement not to resuscitate in the event of cardiopulmonary arrest. For the nurse not to initiate the resuscitation, a do not resuscitate (DNR) order must be written. Most physicians also write supporting documentation regarding the order in the progress notes, such as conversations held with the patient and family members. There is growing evidence that family presence during resuscitation and invasive procedures helps not only families but also the healthcare team. Family presence during resuscitation and invasive procedures is supported by professional organizations, including the Emergency Nurses Association, the AACN, and the American Heart Association. A large, multisite, descripted study found no differences in implementation of resuscitation events with and without the family present. I Current recommendations are for institutions to establish a process for allowing families who wish to be present to do so. This includes designating a trained clinician or chaplain to support the family throughout the process.

The critical care environment

The resultant high stress levels are compounded by the often unrelenting sensory stimulation of light and noise, loss of privacy, lack of nonclinical physical contact, and emotional and physical pain. Issues related to the environment include sensory over-load, noise, and sensory deprivation. Noise and light are listed among the stimuli that patients, families, and nurses view as stressors. The noise level alone is enough stimulation to cause patient discomfort and sleep deprivation, and it is a major factor contributing to sensory overload. Both sleep disruption and delirium in the critically ill are related to noise levels. Phlebotomy procedures are another sensory disturbance frequently encountered by patients in critical care units given the acuity of their situation.' The World Health Organization established guidelines for hospital noise levels that recommend levels no greater than 30 dB in daytime and 40 dB at night. Yet noise levels in hospitals routinely exceed those recommended, and efforts to reduce noise are not extremely successful due to the variety of noise sources. Sensory disturbances also affect nurses, often leading to increased stress, emotional exhaustion, burnout, and fatigue, as well as to difficult communication and distractions, which may contribute to medical errors. In addition, loud conversations may compromise patient confidentiality. Several strategies can reduce noise within the acute care environment: reducing the volume of technical equipment, adjusting alarm volume when possible, organizing workflow to promote efficiency rather than multiple interruptions, closing patient doors, placing patients in private rooms, and installing sound-absorbing textiles." Designate a private place for communication with family members and close the door during conversations that may be overheard by others. Avoid excessive or loud talking, answer phones quickly, and readily assess alarms on medical devices. Alarm sounds can be lowered, staff can use lower voices, and doors can sometimes be closed, but these interventions have limited effect on the noise level in the critical care unit. The layout of the unit and transport of patients to and from the unit are examples of sources of noise that often cannot be altered. Providing "sedative" music is another strategy to reduce anxiety and discomfort associated with increased noise levels Music is an inexpensive and easy-to-use therapy that reduces stress as indicated by lower cortisol levels, heart rate, and blood pressure in patients receiving the therapy rather than the control. Despite the potential for sensory overload, patients can also experience sensory deprivation in an environment that is very different from their usual surroundings. Sensory deprivation is associated with an increase in perceptual disturbances such as hallucinations, especially in older adults. Provide stimulation by interacting with and orienting the patient, and encourage visitation of friends and family. Post family photos within the patient's sight, and provide music or television that the patient usually enjoys. Lighting is another issue in the critical care environment, Adequate and appropriate exposure to light is a therapeutic modality for the health of both patients and staff. Inadequate or poorly placed lighting makes it more difficult to read medical records and medication labels and complicates accurate physical assessment of patients. In addition, the constant artificial lighting present in most critical care units tends to override patients' natural circadian rhythms. Constant artificial lighting has detrimental effects on healthy individuals and has even more of an impact on critically ill patients. Simple measures such as designing rooms to take advantage of natural light can reduce depression, improve sleep quality, and enhance pain management. It is important for members of the healthcare team to work with architects and other planners to design a safe and healing environment. Best practices for design of critical care units include private rooms with items such as natural light, views of nature, adequate room for visitors, and noise-reducing features. It is also important when designing or adapting a unit to meet the comfort needs of family members and promote rest should they wish to remain in a patient's room.

Elements of Informed Consent

Three primary elements must be present for a person's consent or decline of medical treatment or research participation to be considered valid: competence, voluntariness, and disclosure of information. Competence (or capacity) refers to a person's ability to understand information regarding a proposed medical or nursing treatment. Competence is a legal term and is determined in court. Healthcare providers evaluate mental capacity. The ability of patients to understand relevant information is an essential prerequisite to their participation in the decision-making process and should be carefully evaluated as part of the informed consent process. Patients providing informed consent should be free from severe pain and depression. Critically ill patients usually do not have the mental capacity to provide informed consent because of the severe nature of their illness or their treatment (e.g., sedation). If the patient is not mentally capable of providing consent, informed consent is obtained from the designated healthcare surrogate or legal authorized representative (proxy). State law governs consent issues, and legal counsel should be consulted for specific questions. Consent must be given voluntarily, without coercion or fraud, for the consent to be legally binding. This includes freedom from pressure from family members, healthcare providers, and payers. Persons who consent should base their decision on sufficient knowledge. Basic information considered necessary for decision making includes the following: A diagnosis of the patient's specific health problem and condition. The nature, duration, and purpose of the proposed treatment or procedures. The probable outcome of any medical or nursing intervention. The benefits of medical or nursing interventions. The potential risks that are generally considered common or hazardous. Alternative treatments and their feasibility. Short-term and long-term prognoses if the proposed treatment or treatments are not provided. Informed consent is not a form. It is a process that entails the exchange of information between the healthcare provider and the patient or patient's proxy. Frequently, critical care nurses are asked to witness the consent process for procedures and tests. Critical care nurses should serve as advocates for the patient and ensure that the informed consent process has been completed per legal standards and institutional policy. Critical care nurses may provide additional patient education to support decision making, but the process of obtaining informed consent is a physician obligation.

Discharge From Critical Care and Quality of Life After Critical Care

Transfer or discharge from the critical care unit is stressful for both patient and family. As a result of transfer from the critical care unit to another unit or area, patients and families may experience physiological or psychological disturbances, referred to as relocation stress. They may also feel a sense of abandonment and fear losing the security of the higher level of care afforded in the critical care unit. Anticipate the stress associated with transfer and provide interventions that reduce these stressors. Survivors of critical illness experience many problems, but the three reported most often are disability and weakness, psychiatric pathologies, and cognitive dysfunction. Collectively, these symptoms are deemed post-intensive care syndrome, or PICS. Postdischarge therapy may be required to address PICS. Both patients and family members also have an increased risk of developing PTSD after a critical care experience. Once home, the demands of follow-up care place an enormous burden on family members, who may be ill-prepared or unwilling to shoulder such a burden. Discharge planning and patient teaching are essential nursing interventions to improve patient and family outcomes. Ongoing family involvement and teaching, beginning at admission and continuing throughout the hospital stay, are crucial interventions. Initiate patient education early and continue it throughout the patient's hospitalization. With the healthcare team, develop a comprehensive discharge plan that includes scheduled follow-up phone calls for ongoing assessment, reevaluation, and support. One technique used to facilitate teaching and learning is the teach-back method, in which patients and family members are asked to repeat the information and instructions they have been given.

Other Commonly Withheld Therapies

Vasopressors, antibiotics, blood and blood products, dialysis, and nutritional support are other common therapies that may be ethically withheld when goals of treatment shift to palliation instead of cure. Because of the increase in the use of cardiovascular implantable electronic devices, such as cardioverter-defibrillators, address the deactivation of these devices as appropriate before withdrawing or withholding ventilation or other therapies that may result in cardiac arrest.

Hospice Referral

When it has been determined that aggressive medical care interventions will be withheld or withdrawn, it may be appropriate to initiate a referral to a hospice care provider. Hospice is a model of care that emphasizes comfort rather than cure and views dying as a normal human process. It is a philosophy of care rather than a specific place and can be provided in various care settings, as dictated by patient needs. Hospice care for the critically ill patient is usually provided in an inpatient setting and can include withdrawal of ventilator support or other therapies. For patients who are less dependent on technologies for survival, the dying process occasionally may be managed in the patient's home with multiprofessional team support. Referral to hospice may provide a more supportive and tranquil environment for the patient during the dying process. Should such a transfer occur, it is crucial to ensure a smooth transition and good communication between the critical care staff, the receiving hospice provider, the patient, and the family.

Although most rapid response are initiated by health care team members, who is often empowered to activate the rapid response teams if needed?

patient and family members

Quality & Safety Education for Nurses (QSEN) core competencies

patient centered care, evidence based practice, safety, teamwork and collaboration, quality improvement, informatics

Healthy work environment: collaboration

create a culture of safety defined as a nonhierarchical culture in which all members have the opportunity and the duty to ensure safe and effective care. One strategy for collaboration is the implementation of multiprofessional bedside rounds one or two times per shift. Intensivist-led rounds and daily goal setting are recommended to address patient care issues and adherence to recommended guidelines and bundles of care. Such rounds improve communication, collaboration, and patient outcomes. It is important to include family members in patient rounds to facilitate communication and involvement. Some teams schedule regular afternoon rounds focused on communication with the family, whereas others include family in routine rounds. Visualization of goals via standardized data on whiteboards or glass doors of the patient's room is helpful in facilitating communication among the healthcare team and with family members. Conducting morning briefings before interdisciplinary rounds is another strategy to improve communication, collaboration, and patient safety. Suggested content of the morning briefings includes answers to three questions: (1) What happened during the night that the team needs to know (e.g., adverse events, admissions)? (2) Where should rounds begin (e.g., the sickest patient who needs the most attention)? and (3) What potential problems have been identified for the day (e.g., staffing, procedures)?

Healthy work environment: communication

patient- centered communication improves the patients experience. the goal is to elicit more information from patient. ask tell ask- strategy is used to encourage nurses to assess concerns before providing more information especially when discussing stressful issues with patients and families tell me more- tool is used to encourage information sharing in challenging situations communication breakdowns occur during handoff situations, when patient information is being transfered or exchanged. common handoff situations include nursing and physician shift reports and patient transfers.

evidence-based practice

research studies are created by quality of evidence. The AACN scale is used for rating. meta-analysis is the highest level. the next highest is derived from the randomized control trial. after evidence is rated, recommendations for practice are provided. nurses can get involved in research by participating in unit based journal clubs to review studies and rate their quality

Mechanisms to Address Ethical Concerns

situations in which ethic consultation may be considered: -Disagreement or conflict exists on whether to pursue aggressive lite-sustaining treatment, such as cardiopulmonary resuscitation, in a seriously ill patient or to emphasize comfort and palliative care -The family demands life-sustaining treatment, such as mechanical ventilation or tube feeding, which the physician and nurses consider futile -Competing family members are present and want to make critical decisions on behalf of the patient -A seriously ill patient is incapacitated and does not have a surrogate deci sion maker or an advance directive