480- Complex Exam 1; Module 1 (Introduction to Complex Care)

AACN strategies to promote a healthy work environment for nurses: Standard 6 >Authentic Leadership

*-Nurse leaders must fully embrace the imperative of an HWE, authentically live it, and engage others in its achievement* >provide support for and access to educational programs to ensure that nurse leaders develop and enhance knowledge and abilities in skilled communication, effective decision making, true collaboration, meaningful recognition, and ensuring resources to achieve appropriate staffing >demonstrate an understanding of the requirements and dynamics at the point of care and within this context successfully translate the vision of an HWE >excel at generating visible enthusiasm for achieving the standards that create and sustain HWEs >lead the design of systems necessary to effectively implement and sustain standards for HWEs >ensure that nurse leaders are appropriately positioned in their pivotal role in creating and sustaining HWEs; including participation in key decision-making forums, access to essential information, and the authority to make necessary decisions >facilitate the efforts of nurse leaders to create and sustain an HWE by providing the necessary time and financial and human resources >provide a formal co-mentoring program for all nurse leaders; actively engage in the co-mentoring program >role-model skilled communication, true collaboration, effective decision making, meaningful recognition, and authentic leadership >include the leadership contribution to creating and sustaining an HWE as a criterion in each nurse leader's performance appraisal; demonstrate sustained leadership in creating and sustaining an HWE to achieve professional advancement >mutually and objectively evaluate the impact of leadership processes and decisions on the organization's progress toward creating and sustaining an HWE

AACN strategies to promote a healthy work environment for nurses: Standard 1 >Skilled Communication

*-Nurses must be as proficient in communication skills as they are in clinical skills* >provide team members with support for and access to education programs that develop critical communication skills including self-awareness, inquiry/dialogue, conflict management, negotiation, advocacy, and listening >focus on finding solutions and achieving desirable outcomes >seek to protect and advance collaborative relationships among colleagues >invite and hear all relevant perspectives >call on goodwill and mutual respect to build consensus and arrive at common understanding >demonstrate congruence between words and actions, holding others accountable for doing the same >establish zero-tolerance policies and enforce them to address and eliminate abuse and disrespectful behavior in the workplace >establish formal structures and processes that ensure effective information sharing among patients, families, and the healthcare team >have access to appropriate communication technologies and are proficient in their use >establish systems that require individuals and teams to formally evaluate the impact of communication on clinical, financial, and work environment outcomes >include communication as a criterion in its formal performance appraisal system, and team members demonstrate skilled communication to qualify for professional advancement

AACN strategies to promote a healthy work environment for nurses: Standard 5 >Meaningful Recognition

*-Nurses must be recognized and must recognize others for the value each brings to the work of the organization* >have a comprehensive system in place that includes formal processes and structured forums that ensure a sustainable focus on recognizing all team members for their contributions and the value they bring to the work of the organization >establish a systematic process for all team members to learn about the institution's recognition system and how to participate by recognizing the contributions of colleagues and the value they bring to the organization >recognition system that reaches from the bedside to the board table, ensuring individuals receive recognition consistent with their personal definition of meaning, fulfillment, development, and advancement at every stage of their professional career >include processes that validate that recognition is meaningful to those being acknowledged >understand that everyone is responsible for playing an active role in the organization's recognition program and meaningfully recognizing contributions >regularly and comprehensively evaluates its recognition system, ensuring effective programs that help to move the organization toward a sustainable culture of excellence that values meaningful recognition

AACN strategies to promote a healthy work environment for nurses: Standard 2 >True Collaboration

*-Nurses must be relentless in pursuing and fostering true collaboration* >provide team members with support for and access to education programs that develop collaboration skills >create, use, and evaluate processes that define each team member's accountability for collaboration and how unwillingness to collaborate will be addressed >ensure the decision-making authority of nurses is acknowledged and incorporated as the norm >ensure unrestricted access to structured forums, such as ethics committees, and makes available the time needed to resolve disputes among all critical participants, including pts, families, and the healthcare team >embrace true collaboration as an ongoing process and invest in its development to ensure a sustained culture of collaboration >contribute to the achievement of common goals by giving power and respect to each person's voice, integrating individual differences, resolving competing interests, and safeguarding the essential contribution each must make in order to achieve optimal outcomes >act with a high level or personal integrity >master skilled communication, an essential element of true collaboration >demonstrate competence appropriate to their role and responsibilities >nurse managers and medical directors are equal partners in modeling and fostering true collaboration

AACN strategies to promote a healthy work environment for nurses: Standard 3 >Effective Decision Making

*-Nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations* >provide team members with support for and access to ongoing education and development programs focusing on strategies that ensure collaborative decision making; program content includes mutual goal setting, negotiation, facilitation, conflict management, systems thinking, and performance improvement >clearly articulate organizational values and incorporate these values when making decision >have operational structures in place that ensure the perspectives of pts and that their families are incorporated into every decision affecting patient care >share accountability for effective decision making by acquiring necessary skills, mastering relevant content, assessing situations accurately, sharing fact-based information, communication professional opinions clearly, and inquiring actively >establish systems, such as structured forums involving all departments and disciplines to facilitate data-driven decisions >establish deliberate decision-making processes that ensure respect for the rights of every individual, incorporate all key perspectives, and designate clear accountability >have fair and effective processes in place at all levels to objectively evaluate the results of decisions, including delayed decisions and indecision

AACN strategies to promote a healthy work environment for nurses: Standard 4 >Appropriate Staffing

*-Staffing must ensure the effective match between patient needs and nurse competencies* >have staffing policies in place that are solidly grounded in ethical principles and support the professional obligation of nurses to provide high-quality care >participate in all organizational phases of the staffing process from education and planning, including matching nurses' competencies with patients' assessed needs, through evaluation >have formal processes in place to evaluate the effect of staffing decisions on pt and system outcomes; include analysis of when pt needs and nurse competencies are mismatched and how often contingency plans are implemented >have a system in place that facilitates team members' use of staffing and outcomes data to develop more effective staffing models >provide support services at every level of activity to ensure nurses can optimally focus on the priorities and requirements of pt and family care >adopt technologies that increase the effectiveness of nursing care delivery; nurses are engaged in the selection, adaptation, and evaluation of these technologies

Acute Stress Response: >second phase

-*flow phase*, which is a hyperdynamic state that occurs as the body compensates for the oxygen deprivation and is also characterized by multiple hormonal influences >pain and discomfort are now prominent >movement is minimized to conserve metabolic costs >prolonged activation of the stress response can lead to immunosuppression, hypoperfusion, tissue hypoxia, and eventual death

Environmental Stressors in the ICU: >Noise

-Consequences of noisy environments include: >disrupted sleep >impaired wound healing >activation of the SNS >vasoconstriction >hyperarousal -sleep occurs best below 35 decibels (recommendation of 45 decibels during day and 35 at night)

Alternatives to Restraints: >modifications to therapy

-Frequently assess the need for treatments and discontinue lines and catheters at earliest opportunity -Toilet pts frequently -Disguise treatments, if possible (i.e. keep IV bags behind pts field of vision, apply loose stockinette or long-sleeved gown over IV sites) -Meet physical and comfort needs (i.e. skin care, pain management, positioning wedges, hypoxemia management) -When possible, guide the pts hand through exploration of the device or tube and explain the purpose, route, and alarms of the device or tube -Mobilize the pt as much as possible (i.e. consider physical therapy consult, need for cane or walker, reclining chairs, or bedside commode)

Alternatives to Restraints: >modifications to pt environment

-Keep the bed in the lowest position -Minimize the use of side rails to what is needed for positioning -Optimize room lighting -Activate bed and chair exit alarms where available -Remove unnecessary furniture or equipment -Ensure that the bed wheels are locked -Position the call light within easy reach

How does the nurse teach the patient and family in periods of prolonged illness and stress?

-Nurse must provide accurate information and share the plan of care with the family Including families in hands-on patient care, goal setting, daily rounds, and interdisciplinary meetings >helps enhance family support -Open-ended questions should be asked to allow the family members to express in their own words their understanding of the patient situation and current plan of care >reduces stress and improves communication with families by clarifying any misunderstandings -Patient conferences offer a therapeutic method of shared decision making between the health care team and the pts family

Components of teaching documentation:

-Participants (who was taught?) -Date and time (when was it taught?) -Patient status (what was the pts condition at the time?) -Content (what was taught) -Teaching methods and material (how was the pt taught?) -Evaluation of learning (how well was the information absorbed?) -Follow-up and learning evaluation (if teaching was incomplete, what was the reason and what additional education do they need?)

Synergy Model

-a model that describes nursing practice on the basis of patients' characteristics -also used to determine outcomes that are evaluated based on those derived from the pt, nurse, and health care system ~patient-derived outcomes include functional change, trust, satisfaction, comfort, and quality of life ~nurse-derived outcomes include physiological changes, absence of complication, and extent to which treatment objectives are attained ~healthcare system-derived outcomes include recidivism (negative outcome), costs (savings or overrun), and resource utilization (under- or overutilization or optimal utilization) >eight patient characteristics and eight nursing competencies that constitute nursing practice form the basis of the model >patient characteristics and nurse competencies exist on a continuum and range in intensity expressed as level 1, 3, or 5 (pt level 1 is most severe; nurse level 5 is what to strive for)

Environmental Stressors in the ICU: >Noise -strategies to reduce

-alarm fatigue is detrimental, which refers to nurses becoming desensitized to alarms because of the high percentage of alarms that are false -strategies to consider for cardiac alarms: >changing electrocardiogram electrodes every day >better skin preparation >education >making the alarm parameters individualized to decrease the number of false alarms

How can the nurse avoid "alarm fatigue"?

-alarms are now designed with varying levels of intensity to help distinguish those situations requiring an immediate response from those that do not -improvements are being made in clinical settings to mitigate nuisance alarms and alarm fatigue: >changing alarm delays >workflow changes >daily electrode changes >individualizing alarms based on a patient's status

Alternatives to Restraints: >involvement of the pt and family in care

-allow pt choices and control when possible -family members or volunteers can provide company and diversionary activities -consider solitary diversionary activities -ensure the pt has needed glasses and hearing aids

Anxiety

-an emotional state of apprehension in response to a real or perceived threat >typically the threat is associated with motor tension, increased sympathetic activity, and hypervigilance -can contribute to the morbidity and mortality of critically ill patients

Causes of Anxiety

-any stressor that threatens a person's sense of wholeness, containment, security, and control can cause anxiety >illness and injury >feelings of increased vulnerability and decreased security, which occurs when pts admitted to ICUs perceive a loss of control, a sense of isolation, and fear of death or loss of functionality -anxiety, pain, and fear can initiate or perpetuate the stress response and if left untreated or undertreated, anxiety can contribute to the morbidity and mortality of critically ill patients

Alarm fatigue may result in:

-apathy toward alarms -limits being changed -alarms being turned down -deactivation of alarms -individuals becoming insensitive to the alarms -failure to respond to alarms -ignoring the alarms -alarms not being heard >*it has been implicated in numerous patient deaths*; resulting in being identified as the top technology hazard for the past 4 years

Delirium

-can be an unintended consequence of a pts ICU experience that can lead to a prolonged stay and higher mortality -use CAM-ICU tool to assess -early mobility and limiting sedation are best practices for prevention and treatment -ABCDEF bundle to support pts: >Awakening and Breathing trial coordination; Careful sedation choice; Delirium assessment; Early progressive mobility and exercise; Family engagement and empowerment

Assessment of Anxiety

-challenging in the critical care population because of the severity of illness, barriers to communication, and altered cognitive state -top five physiologic and behavioral indications of anxiety are: >1. Agitated behavior >2. Increased BP >3. Increased HR >4. Verbalization of anxiety >5. Restlessness -assessment tools (i.e. visual analog scale) can be useful

Acute Stress Response: >first phase

-characterized by the body's efforts to survive and involves the stimulation of the SNS and activation of multiple neuroendocrine responses *-"ebb phase"*, which results in: >increased HR and contractility >vasoconstriction >increase in BP >blood flow is redirected to vital organs >pain sensations are temporarily attenuated (reduced) >body temp and nutrient consumption fall >sensation of thirst may be prominent >increase in minute ventilation and respiratory rate >hyperglycemia and insulin resistance >coagulopathies -this phase is deeply catabolic as protein stores are mobilized to respond to the threat and begin to repair the injury; if the phase is prolonged, it can result in impaired oxygen and nutrients delivery to tissues secondary to alterations in microcirculatory blood flow

Early and adequate patient education:

-decreases hospital lengths of stay -lessens risks for acute and chronic complications -reduces hospital readmission rates

When care is not based on evidence, it is:

-difficult to optimize outcomes -use resources efficiently -protect patient safety

Nursing Interventions: >fostering trust

-display a confident and caring attitude -demonstrate technical competence -develop effective communication techniques that will foster the development of a trusting relationship -for those that are mechanically ventilated and intubated, use nonverbal signals, writing pads, or commercial communication boards that can help make communication of basic needs easier >when pts mistrust their caregivers, they are more anxious and more vigilant of staff behaviors and lack the feeling of safety and security

"Teach-back" method

-effective way of assessing pt comprehension of orally presented material -it requires the HCP to ask a pt to repeat, in his or her own words, the information that was just presented -improves information retention and also exposes gaps in knowledge

The Joint Commission's Recommended Topics for Pt and Family Education:

-explanation of the plan of care -basic health practices and safety -safe and effective use of medications -nutrition interventions -pain management -safe and effective use of medical equipment -techniques that help the patient reach maximum independence -fall reduction strategies

AACN developed the HWE initiative that:

-focuses on barriers to employee and patient safety and identifies 6 essential standards, which encompass the aspects that are most important as nurses strive to provide optimal care

Considerations for the Older Patient: >Guidelines for Printed Education Materials (PEMs)

-font should be 12 points or larger -serif type is preferred over sans-serif type -avoid script or stylized types -use boldface headings -avoid using all uppercase letters for body type -use specific language and avoid generalizations -use "calls to action" to highlight important points -use four to five lines of text broken up with white space -avoid paper with a glossy finish bc the glare makes reading difficult; use matte-finish instead -enhance legibility by using black ink printed on white/off-white paper -avoid printing over a designed or customized background

Attributes of an authentic leader include:

-good communication skills -integrity -inspiring others -working as part of the team -asking for and giving 100% -establishing a vision

Unhealthy work environments play a role in:

-health care errors -results in ineffective health care delivery -waste scarce resources -leading to increased costs associated with healthcare -contributes to moral distress and adverse outcomes -dissatisfaction among HCP

Nursing Interventions: >cognitive techniques

-help the pt develop self-dialogue messages that increase the following: >confidence >sense of control >ability to cope >optimism >hope -any message that enhances the pts confidence, sense of control, and hope and puts him or her in a positive, active role, rather than the passive role of victim, increases the pts sense of coping and well-being

Nursing Interventions: >encouraging early mobilization

-helps prevent delirium and pTSD -demonstrates benefits of improved healing, positive mood, and shorter lengths of stay

Nursing Interventions: >creating a healing environment

-holism in nursing; caring for the whole person >manipulate the milieu by timing interventions to allow adequate sleep and rest >providing pain-relieving medication >playing music >teaching relaxation and mindfulness approaches such as breathing exercises >the physical environment can be altered to create a more healing and restful environment

Describe cultural competence: >what are the Four Cs of Culture that represents a method of questioning pts to ascertain information that's culturally sensitive?

-in health care, it is defined as having the knowledge, abilities, and skills to deliver care congruent with the patient's beliefs and practices >1. Call: ~attempt to identify the problem by asking the pt, "What do you call your problem?" >2. Cause: ~explore the pts belief surrounding the origin of the illness by asking, "What do you believe has caused your problem?" >3. Cope: ~figure out how the pt has been managing the problem by asking, "What have you or other HCP done to treat this problem?" >4. Concern: ~"What concerns do you have about your condition or the recommended treatment?"

Levels of Evidence: -lowest levels of evidence

-include the opinions of authorities or expert committees >this would result from clinical practice committees and professional organizations that may convene to discuss guidelines when higher levels of evidence are not available

Restraints in Critical Care:

-includes any drug or device that is used to restrict the pts mobility and normal access to his or her body >physical restraints may include limb restraints, mittens with ties, vests or waist restraints, geriatric chairs, and side rails ~side rails are considered a restraint if used to limit the ability of the pt to get out of bed rather than to help him or sit or stand up

Healthy Work Environments (HWEs)

-it can lead to positive patient outcomes -nurses gravitate to facilities that have optimal work conditions

Stress

-it exists when an organism is faced with any stimulus that causes disequilibrium between psychological and physiologic functioning -stimulation of the body's stress response involves activation of the hypothalamic-pituitary-adrenal axis >the resultant increase in catecholamine, glucocorticoid, and mineralocorticoid levels leads to a cascade of physiologic responses

What are the barriers to implementation of EBP in practice?

-it takes an average of 17 YEARS to translate research into clinical findings >lack of knowledge of the research process >limited access to literature >lack of skill to critique research >limited interest in scientific inquiry >limited power to change practice >time factors >lack of organizational support and commitment (including resources) >volume of research being published >availability of mentors >organization's culture, climate, and environment

Perceived Barriers to EBP: Resources and Mentoring -why? >strategies to overcome barrier?

-lack of evidence -isolated from knowledgeable colleagues -lack of computers, computer skills, library access, search skills -difficulty understanding research -lack of access to resources >administration must recognize and commit to EBP, putting systems in place to support the clinical nurses in their role with EBP >managers need to recognize the ability of clinical nurses, provide the necessary resources, and document the effectiveness of initiatives >implementation of an evidence-based champion >designated work groups

Low health literacy has been associated with:

-less use of preventive health services -lower rates of medication adherence -worse clinical outcomes -increased use of emergency services -greater racial and ethnic disparities in health care -higher medical costs for pts and the healthcare system -admission to the hospital; readmission within 30 days -higher rates of mortality >health literacy indicates the skills to navigate and act on instructions given in the healthcare setting

Environmental Stressors in the ICU: >Lights and Color

-light is a powerful zeitgeber, or environmental synchronizer, that assists in entraining sleep by promoting the normal circadian cycle of sleep and wakefulness -artificial light by fluorescent bulbs and tubes should be shielded because it leads to visual fatigue and headaches -constant lighting and high-intensity light can lead to a complete disruption of the normal melatonin concentration rhythm (i.e. therapy with melatonin is not a clear recommendation to increase sleep duration at this time) >patient view of natural scenery and outdoors vs. brick walls have shown less pain meds are used and hospital stays are shorter >impaired cognition occurs more often in windowless units than in those with windows

Nursing Interventions: >allowing control

-measures that reinforce a sense of control help increase the pts autonomy and reduce the overpowering sense of a loss of control -the nurse can help the pt exert more control over his or her environment in the following ways: >providing order and predictability in routines >using anticipatory guidance >allowing the pt to make choices whenever possible >involving the pt in decision making >providing information and explanation for procedures >allowing small choices (i.e. lie on left or right side; which arm to place IV; cough now or 20 min after pain med)

Environmental Stressors in the ICU: >Patients are more likely to experience a positive outcome in an environment that incorporates:

-natural light -elements of nature -soothing colors -meaningful and varied stimuli -peaceful sounds -pleasant views >less pain medication is needed and a faster recovery may occur when careful attention is given to provide a soothing environment

Perceived Barriers to EBP: Culture -why? >strategies to overcome barrier?

-no authority to change practice -other staff and disciplines not supportive -research not generalizable to setting -lack of value of research in practice -lack of administrative support -difficulty changing behavior -organizational culture rewarding routine, task-based practice -lack of nursing autonomy >a research-based needs assessment to provide an evidence-based foundation for organizational strategic planning >performance appraisals and clinical ladder reviews require examples of EBP >educational activities that help clinicians critically review the literature >clinical resources available 24hr/day >streamlined processes for practice >incorporating the doctor of nursing practice role as leader of this process >progress reported to a central source and shared among clinical areas and facilities >mentors and champions at the bedside >utilize clinical nurse specialists who may have a better understanding of research and EBP

Perceived Barriers to EBP: Time -why? >strategies to overcome barrier?

-no time to read and evaluate research or implement EBP -heavy workload/lack of time >schedule time for review and discussion of evidence in the form of EBP committes >nurses need time away from clinical bedside responsibilities for EBP activities

The Synergy Model has been used in a variety of clinical settings as a basis for:

-nursing clinical advancement -determining staffing ratios -preceptorship -safe critical care patient transport -building a nursing productivity measure -guiding practice of rapid response teams -foundation for advanced practice nursing

The following are effective communication and relationship strategies that have been found to ease family members' stress and increase confidence in their role as surrogate decision makers (SDMs):

-perceived transparency of information conveyed between HCP and the SDM -inclusivity -availability of providers to answer questions -clarity of information -patience -responsiveness and empathy toward SDM concerns -extended social support network of friends and family -communication with nurses -knowledge of pts wishes r/t treatment preferences or advanced directives -faith and spirituality

Nursing Interventions: >"presencing" and reassurance

-presencing is the therapeutic use of self, adopting a caring attitude, and paying attention to a person's needs; giving one's full attention to the person, focusing on the person, and practicing active listening; energy/attention is directed at the pt and their needs/feelings -reassurance can be provided by the form of presencing and caring touch, as well as verbal >verbal reassurance is effective if it provides realistic encouragement or clarifies misconceptions; it is intended to reduce fear and anxiety and evoke a calmer, more passive response and best directed at pts who are expressing unrealistic or exaggerated fears

List the strategies that are most often recommended to promote sleep:

-provide large clocks and calendars -block sleep times -provide a quiet time during the day shift -have the pt use earplugs and eye masks -assess sleep time and quality of sleep by asking the pt when possible -provide opportunity for music therapy -provide a 5-minute backrub before sleep -consider using white noise or ocean sounds -eliminate pain -position pt for comfort with pillows -stop the practice of bathing pts in the middle of the night for the convenience of the nursing staff -titrate environmental stimuli (i.e. turn down lights, turn down alarms, and decrease noise from television and talking) -evaluate the need for nursing care interruptions -at bedtime, provide information to lower anxiety; do a review of the day and remind pt of progress made toward recovery, then add what to expect for the next day -institute "PM Care" back to basics, brushing teeth, and washing face before "bedtime" -allow family to be with the pt and provide open visiting -use relaxation techniques, mindfulness meditation, and guided imagery -ensure pt privacy (i.e. close door or pull curtains) -post sign at designated times (i.e. pt sleeping)

Nursing Interventions: >providing information

-pts need to know what will happen to them, how they are doing, and what they can expect -reorient them, sort out sequences of events, and help them distinguish real events from dreams or hallucinations -anxiety can be greatly relieved with simple explanations -families have the need for information also, but nurses should have the pts permission before giving confidential medical information to family members; if not possible, a family spokesperson should be identified as the person who may receive confidential information and should be documented

Restraints in Critical Care: >chemical restraint

-refer to pharmacologic agents that are given to pts as discipline or to limit disruptive behavior >meds that are used include: psychotropic drugs (i.e. haloperidol), sedative agents (benzodiazepines), and the anticholinergic antihistamine diphenhydramine; does NOT apply to meds given to treat a medical condition -use the least amount of medication that is feasible to achieve the goals of pt care because meds have potential side effects and adverse reactions -continually assess for comfort, use caution when admin PRN meds for over- or under-medication

Restraints in Critical Care: >initiating restraints

-requires the order of a licensed independent practitioner who must personally see and evaluate the pt within specified time periods -used only as an emergency measure or after treatment alternatives have failed -instituted by staff members who are trained and competent to use restraints safely -orders must be time limited (should not be longer than 24 h) -pts and families are informed about the reason/rationale for the use of the restraints

Discuss the difference between conducting research and EBP

-research is conducted to generate new knowledge >through translation of new knowledge, EBP takes what is known and uses it to guide patient care to achieve the best possible outcomes

When are restraints to be used?

-restraints are to be used as the LAST resort >only after other measures have failed or when the pt is a danger to self or others ~other interventions may include modifying the pts environment, providing diversionary activities, allowing the pt more control or choices, and promoting adequate sleep and rest

Levels of Evidence: -next [stronger] level of evidence (higher than systematic review of correlational or observational studies)

-single RCT and nonrandomized control trial (quasi-experimental)

Levels of Evidence: -next level of evidence (higher than systematic review of descriptive, qualitative, or physiologic studies)

-single correlational or observational study >it is a quantitative study that lend themselves to precise measurement allowing for examination of relationships

Levels of Evidence: -next level of evidence (second to last)

-single descriptive, qualitative, or physiologic study

Nursing Interventions: >promoting rest and sleep

-sleep deprivation can have cumulative effects and lead to altered cognition, confusion, impaired wound healing, and the inability to wean from the ventilator because of muscle fatigue and carbon monoxide retention -pts own report of sleep quality is the best measure of sleep adequacy >implement a sleep protocol that institutionalizes the importance of sleep, blocks sleep times, and truly controls the environment

Levels of Evidence: -next level of evidence (HIGHEST level)

-systematic review of RCTs ~aka *META-ANALYSIS*!!! >a meta-analysis is a statistical approach to combine the data derived from a systematic review; therefore, every meta-analysis should be based on an underlying systematic review, but NOT every systematic review leads to a meta-analysis

Levels of Evidence: -next level of evidence (higher than single correlational or observational study)

-systematic review of correlational or observational studies, examining relationships and evaluating cause and effect

Levels of Evidence: -next level of evidence (higher than single descriptive, qualitative, or physiologic study)

-systematic review of descriptive, qualitative, or physiologic studies >a systematic review refers to rigorous and systematic synthesis of findings from several studies in a focused area of inquiry

Examples of The Joint Commission standards related to patient and family education are as follows:

-the hospital provides, coordinates, and evaluates pt education and training based on each pts needs and abilities -education provided is appropriate to the pts condition and clearly addresses the pts identified learning needs -communication between pts and providers requires written documentation of all health teaching with pts and families; it is not acceptable for practitioners to text orders for pts to the hospital because the senders cannot be verified -the hospital performs a learning needs assessment, which includes cultural and religious beliefs, emotional barriers, health literacy level, desire and motivation to learn, physical or cognitive limitations, and barriers to communication >the goal of these standards is to guide hospitals to create an environment in which both the pt and family and the health care team members are responsible for teaching and learning

Restraints in Critical Care: >monitoring pts in restraints

-the pts rights, dignity, and well-being are to be protected -the pt will be assessed every 15 minutes by trained and competent staff -the assessment and documentation must include evaluation of adequate nutrition, hydration, hygiene, elimination, vital signs, circulation, ROM, injury d/t the restraint, physical and psychological comfort, and readiness for discontinuance of the restraint

Alarm Fatigue

-the purpose of alarms on medical devices is to notify care providers of either a change in a patient's physiologic status or that a predetermined threshold for a variable has been exceeded -"alarm fatigue" occurs when the nurse is surrounded by harsh noise from too many alarms, including false alarms (i.e. nuisance alarms, meaning there was not a valid triggering event) >nuisance alarms distract the HCP from patient care

Anxiety occurs when people experience the following:

-threat of helplessness -loss of control -sense of loss of function and self-esteem -failure of former defense -sense of isolation -fear of dying

Health Literacy Universal Precautions Toolkit encourages HCP to:

-treat all pts as though they have low health literacy by applying "universal precautions" to deliver clear and plain language to ensure effective health care communication to everyone

Treatment for the acute stress response

-treatment is directed at: >eliminating the stressors >providing supportive care in the form of nutrition >oxygenation >pain management >anxiety control >specific measures related to the cause of illness or injury

Perceived Barriers to EBP: Knowledge -why? >strategies to overcome barrier?

-unaware of research -literature not compiled in one place -not capable of evaluating quality of research -misconceptions about EBP -lack of ability to understand research -poor understanding of statistics -inadequate understanding of jargon used in research articles >invest, as a student, in the process of searching and evaluating the evidence >be a change agent in the facility, mentoring nurses who are less familiar with the process >commit to lifelong learning

Alternatives to Restraints: >therapeutic use of self

-use calm, reassuring tones -introduce yourself and let the pt know they are safe -find acceptable means of communicating with intubated or nonverbal pts -reorient pts frequently by explaining treatments, devices, care plans, activities, and unfamiliar sounds, noises, or alarms

Restraints in Critical Care: >physical restraint

-used to prevent potentially serious disruptions in pt care through accidental dislodgement of endotracheal tubes or lifesaving IV lines and other invasive therapies -other reasons include: fall prevention, behavior management, and avoidance of liability lawsuits resulting from pt injury >restrained pts have been shown to have more serious injuries secondary to falls as they fight the device that limits their freedom -it can prolong a pts hospitalization by skin alterations, loss of muscle tone, impaired circulation, nerve damage, and pneumonia, agitation

Strategies to improve written and oral communication for pts with low health literacy skills:

-verbal sharing of information -limiting the amount of information presented at one time can improve learning recall -provide only the "need to know" information -repeat information that is essential -avoid medical jargon -speak in short sentences -use open-ended questions -use different modalities when educating (i.e. oral, written, video, pictures) -teach-back method

The ideal ICU environment has:

-windows with natural views -soothing artwork (depicting many diff cultures and peacefulness of nau -calm colors (muted beige, blue, & green) -work and computer stations with glass soundproof partitions that permit proximity to the patient for easy observation while shielding the patient from noise -equipment selected for its low noise level

The underlying premises of the Synergy Model are that:

1) patients' characteristics are of concern to nurses 2) nurses' competencies are important to patients 3) patients' characteristics drive nurses' competencies 4) when patients' characteristics and nurses' competencies match and synergize --> outcomes for the patient are optimal

Provide six strategies to facilitate communication with ventilator-dependent patients:

1. Establish a trusting and friendly environment for communication: >ensure you are visible to the pt, maintain eye contact when speaking, use adequate lighting, limit excess noise, ensure the call bell is within reach, and allow adequate time for pt responses 2. Assess functional skills that affect communication: >identify visual and auditory acuity, dominant handedness, and muscle strength 3. Anticipate needs: >ask questions about basic care needs, be consistent with communication methods, and ensure other staff are aware of pt-specific techniques 4. Facilitate lip reading: >position the bedside light to illuminate lips; avoid interruptions when communicating via this mode; speak normally, avoiding overly exaggerated speech 5. Use alternative communication methods and devices: >use gestures, head nods, writing, picture boards, or computer assistive devices to communicate with the health care team and family members; consider consultations with a SLP 6. Educate the pt and family >to encourage consistent use of communication methods, share with the family (in oral and written form) the communication strategies established specifically for the pt

There are six core principles related to the science of teaching an adult learner:

1. The need to know >adults need to understand why they need to learn something before they are willing to commit the energy and time to learn it; to raise the learner's level of awareness of their needs, the facilitator should use real or simulated experiences to help the learner discover gaps in their knowledge 2. The learner's self-concept >adults are self-directed and responsible for their own decision making; educators need to create learning situations that give adults options and independence 3. The learner's life experience >life experiences define and shape adult beliefs, values, and attitudes; adult education methods emphasize experiential techniques such as case method, simulation, and problem-solving exercises; they learn well from their peers, making group learning effective 4. Readiness to learn >adults are ready to learn the things they need to know; the info should be relevant and applicable to real-life situations 5. Orientation to learning >adults are motivated to learn if the information will help them to perform useful tasks or to deal with problems in their lives 6. Motivation to learn >adults are more motivated by internal forces such as improved quality of life, increased job satisfaction, and heightened self-esteem; external factors such as job promotion or increased salary are less likely to sustain learning

The Synergy Model: -nurse competencies

1. clinical judgment 2. advocacy/moral agency 3. caring practices 4. collaboration 5. systems thinking 6. response to diversity 7. clinical inquiry 8. facilitator of learning

The Synergy Model: -patient characteristics

1. participation in decision making 2. stability 3. resiliency 4. complexity 5. participation in care 6. resource availability 7. predictability 8. vulnerability

The three main goals of "teach-back" are as follows:

1. to confirm that a pt or family member has understood what is being said 2. to correct misconceptions 3. to open dialogue between the pt and family and the HCP

The best time to begin to present discharge information is:

24 to 48 hours prior to discharge from the ICU

The mnemonic ASSURE can be applied by ICU nurses to help organize and carry out the education process:

>A: analyze the learner >S: state the objectives >S: select the instructional methods and materials >U: use the instructional methods/materials >R: require learner performance >E: evaluate the teaching plan and revise as necessary

Patient characteristics drive nursing competencies. When patient characteristics and nursing competencies match, synergy (a positive energy) results and patient outcomes improve. >How can the charge nurse practice the synergy model when making patient care assignments?

By ensuring that the patient and family needs align with the competency of the nurse >i.e. having more experienced and seasoned nurses paired with higher acuity patients (level 1 pts with level 5 nurses)

Patient characteristics that are of concern to nurses: >Predictability

a characteristic that allows one to expect a certain course of events or course of illness

EBP

applying the best available research results (evidence) when making decisions about health care; use research evidence along with clinical expertise and patient preferences ~crucial step in improving health care quality

Nursing competencies that nurses should strive to attain and that are concern to patients: >Systems Thinking

body of knowledge and tools that allow the nurse to manage whatever environmental and system resources exist or the patient/family and staff, within or across health care and non-health care systems

Nursing competencies that nurses should strive to attain and that are concern to patients: >Clinical Judgment

clinical reasoning, which includes clinical decision making, critical thinking, and a global grasp of the situation, coupled with nursing skills acquired through a process of integrating formal and informal experiential knowledge and evidence-based guidelines

Patient characteristics that are of concern to nurses: >Resource Availability

extent of resources (i.e. technical, fiscal, personal, psychological, and social) the patient/family/community bring to the situation

Patient characteristics that are of concern to nurses: >Participation in Care

extent to which patient/family engages in aspects of care

Patient characteristics that are of concern to nurses: >Participation in Decision Making

extent to which patient/family engages in decision making

Nursing competencies that nurses should strive to attain and that are concern to patients: >Caring Practices

nursing activities that create a compassionate, supportive, and therapeutic environment for patients and staff, with the aim of promoting comfort and healing and preventing unnecessary suffering -includes, but is not limited to, vigilance, engagement, and responsiveness of caregivers, including family and health care personnel

Patient characteristics that are of concern to nurses: >Vulnerability

susceptibility to actual or potential stressors that may adversely affect patient outcomes

Nursing competencies that nurses should strive to attain and that are concern to patients: >Facilitation of Learning

the ability to facilitate learning for patients/families, nursing staff, other members of the health care team, and community -includes both formal and informal facilitation of learning

Patient characteristics that are of concern to nurses: >Stability

the ability to maintain a steady-state equilibrium

Patient characteristics that are of concern to nurses: >Resiliency

the capacity to return to a restorative level of functioning using compensatory/coping mechanisms; the ability to bounce back quickly after an insult

Patient characteristics that are of concern to nurses: >Complexity

the intricate entanglement of two or more systems (i.e. body, family, therapies)

Nursing competencies that nurses should strive to attain and that are concern to patients: >Clinical Inquiry (Innovator/Evaluator)

the ongoing process of questioning and evaluating practice and providing informed practice -creating practice changes through research utilization and experiential learning

Nursing competencies that nurses should strive to attain and that are concern to patients: >Response to Diversity

the sensitivity to recognize, appreciate, and incorporate differences into the provision of care -differences may include, but are not limited to, cultural differences, spiritual beliefs, gender, race, ethnicity, lifestyle, socioeconomic status, age, and values

Nursing competencies that nurses should strive to attain and that are concern to patients: >Advocacy and Moral Agency

working on another's behalf and representing the concerns of the patient/family and nursing staff; serving as a moral agent in identifying and helping to resolve ethical and clinical concerns within and outside the clinical setting

Nursing competencies that nurses should strive to attain and that are concern to patients: >Collaboration

working with others (i.e. patients, families, health care providers) in a way that promotes/encourages each person's contribution toward achieving optimal/realistic patient/family goals -involves intradisciplinary and interdisciplinary work with colleagues and community