(MEDICAL SURGICAL NURSING ii)

TOPIC:ACUTE & CRITICAL CARE NURSING

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D H RAVAL.Bsc(N), BA.EMT,pgdhhm.

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A. ACUTE CAREINTRODUCTION: If you talk to a nurse who has worked

in a hospital setting, you are likely to hear about how much hospital have been changed.

It is true, todays hospitalized clients are sicker than they were years ago, in part because of advances in health care technology that have enabled them to survive diseases and serious medical condition longer. 04/12/23 DHRAVAL 3

In the past some of the nurses case load included clients who were nearly well.

Today client who are not acutely ill are discharged from the hospital and are treated in out patient setting and by their families or significant others at home.

Therefore the case load for hospital nurses today consist of seriously ill clients.

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ACUTE CARE HOSPITAL The American Hospital Association

defines a hospital as an institution with the primary function of providing di agnostic and therapeutic client services for a variety of medical conditions, both surgical and nonsurgical.

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Acute care hospitals are distinguished from long-term care facilities such as nursing homes, rehabilitation centers, and psychiatric hospitals by the fact that the average client stay is less than 30 days.

Such hospitals are one of three types:

1. government, 2. voluntary/not-for-profit, and 3. For-profit.

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POST-ACUTE CAREPost-acute care is one of the fastest-

growing segments of health care. It is designed to fill the gap between

acute care and long-term or home care and is identified by a number of terms, including progressive, transitional, intermediate, telemetry, or step-down units.

In some hospitals, nursing units or beds on a given unit can serve a dual purpose.

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These swing beds can be used either for acute care or for post-acute care, depending on the circumstances.

Not all clients experience post-acute care.

If the client can provide his or her own care at home, discharge to home is appropriate.

Even if some nursing care is still required, home health care may be used to assist the client.

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Examples of post-acute clients include those recovering from myocardial infarction (heart attack) or open heart surgery; those who must be weaned from a ventilator; those who need wound management after burn injury or for multiple pressure ulcers; those who require more rehabilitation after stroke or orthopedic surgery; or those who have complex medical conditions such as diabetes or digestive or renal problems.

Care is delivered at a fraction of the cost or at about 30% of the cost of an acute care unit. 04/12/23 DHRAVAL 9

Post-acute units in a nursing home or rehabilitation facility include many clients who are Medicare benefici aries, whose younger counterparts with the same level of disability would receive home care.

Chronic post-acute units manage clients with little hope of ultimate recovery and functional independence.

The goal of care for all clients in post-acute care is to send them home or to a less expensive level of care, such as to long-term care or assisted-living centers.

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ENSURING QUALITY HEALTH CARE DELIVERY

Amid the fast-paced changes occurring in health care de livery, health care professionals remain responsible for ensuring quality client care.

Quality client care is the outcome of the integrated health care team approach, which involves the corporate, and hospital or agency ad ministration, medical staff, board of trustees, employees, community, and client.

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Contract services, community re sources, transfer agreements, and the expertise of social workers or case managers enable client transitions to al ternate levels of care to occur in a continuous, coordi nated, almost seamless fashion.

Through work-redesign and skill-mix reallocation, in stitutions are focusing goals on achieving efficient client outcomes.

Work redesign involves studying a job over a fixed period to discover if and how a certain job function might be made more efficient. 04/12/23 DHRAVAL 12

Skill mix is determined by studying the ratio of RNs to LPNs/LVNs and nurse as sistants on a unit.

The best skill mix delivers quality care while also controlling costs.

The "one-level-of-care" philosophy ensures that clients receive optimal care in all areas of an institution.

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For example, the same monitoring pertains when intra venous (IV) conscious sedation is administered in the en-doscopy unit as when general anesthesia is administered m the operating room or emergency department.

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Evidence-based practice is a concept used to improve: are to achieve client outcomes.

It uses research findings at are grounded in science along with client character istics to guide clinical practice, thereby preventing practice being directed by tradition or personal preference and setting the stage for quality client care.

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PROVIDING QUALITY CLIENT CAREAny plan for providing client care

involves the following aspects:Strategic planning to serve as a

guideline for the continued or expanded services provided by the health care agency

Budgeting process to assist the institution in study ing, spending, and using the information to reduce costs or maintain them at the present rate

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Performance improvement plan to show the steps taken to improve performance based on monitoring and evaluation of staff performance

Risk management input to identify and eliminate potential injuries to staff and clients

Utilization review data to explore items such as acuity levels (a degree of severity of illness that aff ects the amount and complexity of care the client requires), outcomes, and costs and to discover what is and is not effective care

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Client satisfaction survey results, which gather data from clients at various stages of their stay in the agency (e.g., Preprocedure, admission procedure, discharge)

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Physician input to incorporate professional input into client care planning

Census data to plot current and future trends of health care in the organization

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Changes in client population, diagnoses, programs, or staffing that would necessitate changes in the type, level, or amount of care are reviewed on an ongoing basis. Other factors contributing to quality care include

(1) The adherence to, monitoring of, and

evaluation of care given according To professional standards;

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(2) Joint Commission on the Accreditatio of Health care Organizations (JCAHO) and Department of Health criteria; and(3) Input from other regulatory

agencies. In addition, clinical pathways, Clinical

prac tice guidelines, standards of practice and care, & competence Standards serve as models for

professional delivery of client care.

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ETHICAL ISSUESEthical issues in acute care

commonly occur when the nurse is caught in the middle between clients, physicians, administrators, and other nurses and feels powerless to change the situation.

Ethical distress can lead to negative consequences for everyone involved.

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Nurses are often called on to assist families in making informed decisions about client care, and they must be familiar with ethical, legal, economic, and emotional factors that affect the family's decision.

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LEGAL ISSUESNurses have more responsibility today

than in the past. Expanded roles open the doors to

greater legal risk. The nurse's employer is obligated to

carry malpractice insur ance for its employees.

You should know what is cov ered in the policy.

In addition, you should consider car rying individual malpractice insurance.

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Proper documentation is crucial to serve as evidence of the quality of nursing care provided.

The court still assumes that if something was not noted in a chart, it was not done.

Be specific, and document nursing actions taken and the client's response (e.g., pain reduction).

If unusual events occur, complete an incident report.

The benefit of incident reports is that they allow analysis of adverse client events.

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They should not be treated as a punitive activity but rather as a method of promoting quality care and risk management.

Errors are examined to determine whether or not the error was due to a sys tem problem (e.g., a faulty electrical outlet that leads to a fire or an improperly mounted side rail that allows a client to fall).

If a lawsuit is filed, incident reports usually are not revealed; instead, the court system relies on the information in the medical record.

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CULTURAL ISSUESNurses who practice in the 21st

century will be interact ing with an increasingly multicultural American society.

Areas of the United States that had few immigrants now see people from all over the world.

This diverse popula tion requires that nurses be able to recognize differences

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And to be sensitive to those differences in perceptions of health and illness, in communication styles, and in non-traditional approaches to health care.

Culturally compe tent care in its broadest sense is knowing, explaining, in terpreting, and predicting nursing care within the knowledge of the client's cultural and ethnic beliefs and practices, whether the client is well or sick.

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PERFORMANCE IMPROVEMENT AND GOALS

Institutions generally seek to enhance their measurement activities as they relate to institutional quality indicators.

These indicators generally include the following:

Results of basic clinical indicatorsContinuous quality improvementAccess to care issues

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Clinical Indicators with a Focus on High-Volume, High-Risk, and Problem-Prone Issues

The community/clinic focus includes the following:

Communicable diseases (e.g., TB, HIV)Low birth weight as a percentage of live

birthsBirths to mothers 10 to 17 years of age as a

percentage of all live birthsPercentage of women receiving prenatal

care during the first trimester

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Breast cancer rates & mammography statistics

Immunization ratesReturn visits to the same level of care or

visit within 72 hours to a higher level of care

Accessibility, availability,& acceptability of care

Appropriateness and relevance of care (e.g., based on diagnostic laboratory work, symptomatology)

Appropriateness of treatment frequencyIntake system

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Provision for information on an emergency or after-hours basis

Client educationConsultationDocumentation including, for

example, transfers and advance directives

Availability of emergency carts/equipment

Use of leasing for expensive/alternative resources

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Client recordClient rights, including advance

directives, informed consent, and special concern for abuse victims and for those with cultural diversity.

Consumer satisfaction and judgment input

JCAHO indicatorsHuman resource managementOrganization performance

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THE FUTURE OF ACUTE CARE HOSPITAL NURSING

The following are a few of the trends that will influence the delivery of care in hospitals:

As technology makes care in other settings more affordable, the acuity of clients in hospitals will increase, which will prompt the use of master's prepared, acute care nurse practitioners and clinical nurse specialists in the acute care setting.

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The 79 million baby boomers as well as their aging parents will present an unparalleled need for health care.

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Health care will be directed at populations rather than individuals. Examples include hospitals providing flu shots, community education programs, and screenings.

Bioterrorism concerns will result in acute care hospitals taking the lead for disaster preparation. The skills of nurses working in acute care will be utilized in a variety of settings.

A growing number of health care workers and clients will be immigrants and speak English as a second language. 04/12/23 DHRAVAL 36

There will be continued emphasis on cost containment with projected cuts in entitlement programs.

The hospital work force may be a virtual work force with a core of flexible workers and, based on acuity and census, other workers who contract for periods of time. Examples include employee health, accounting, computer personnel, and nursing staff.

The length of a shift for nurses and rate of error will be examined.

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CONCLUSIONS Acute care hospital-based nursing

has changed. Years ago, clients could stay in the

hospital until they felt well enough to go home.

Cost-containment issues have demanded that clients today spend as little time as possible in acute care and quickly move to less expensive areas for care.

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Professional nurses are the cornerstone of high-quality care during these shortened stays.

All health care providers are trying to maintain excellence in health care during these changing times, and it is essential that nursing do so as well because excellence in health care is the primary reason the client is hospitalized.

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B. CRITICAL CAREINTRODUCTION:The first step inside an intensive care unit, or

ICU, can be overwhelming.The machinery is complex, medications are

potent, stress and worry are visible on the faces of the families, and alarms seem to sound endlessly.

The ICU can be intimidating and confusing. The reality is that the ICU is a place where

skilled nurses, doctors, technologists, pharmacists, respiratory therapists, & others competently care for the sickest clients in the hospital. 04/12/23 DHRAVAL 40

Their efforts are rewarding: More than 96% of clients admitted to the ICU are discharged alive.

20 Although formally this specialty is less than 40 years old, clients with life-threatening illnesses have been organized into specific geographical areas for many years before designated critical care units were developed.

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Florence Nightingale in the 1880s detailed the benefits of grouping postoperative clients together to optimize their care and recovery.

John Hopkins Hospital in Baltimore developed a three-bed postoperative neurosurgical unit in the early 1890s.

In 1927 a unit specifically for premature infants was established in Chicago.

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DEFINITION OF CRITICAL CARE:

Critical care is a term used to describe "the care of patients who are extremely ill and whose clinical condition is unstable or potentially unstable.“

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HISTORY OF CRITICAL CARENursing and technology continued to

evolve in the 20th century to meet the ever-changing needs of society and its population.

During World War II, "shock Wards" were developed to meet the needs of injured solders.

After the war, a nursing shortage spurred the development of post-anesthesia care units (PACUs) to ensure prompt attentive care for clients emerging from anesthesia.

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By 1960 almost every hospital in the United States could boast of such recovery rooms.

During the late 1940s, the polio epidemic required the use of iron lungs as well as tracheotomy procedures and manual ventilation to support clients with respiratory paralysis.

The physical needs were so great that intensive nursing care was required by these clients.

In the 1950s, mechanical ventilation was developed. 04/12/23 DHRAVAL 45

The physical needs were so great that intensive nursing care was required by these clients.

In the 1950s, mechanical ventilation was developed.

Again it was found that care of clients requiring ventilatory support was more efficient when clients were grouped together in a single unit.

Soon general ICUs were developed for other very ill clients.

By 1958, 25% of community hospitals in the United States with more than 300 beds reported having at least one ICU.

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By the end of the 1960s, almost every hospital in the United States had at least one ICU.

Today more than 5000 ICUs exist in the United States; many of them very specialized, caring for highly specific groups of clients.

Examples include cardiovascular, trauma, neurologic, surgical, cardiovascular surgical, pediatric, respiratory, transplantation, burn, neonatal, spinal cord injury, and medical ICUs to name a few.

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Examples include cardiovascular, trauma, neurologic, surgical, cardiovascular surgical, pediatric, respiratory, transplantation, burn, neonatal, spinal cord injury, and medical ICUs to name a few.

20 day stays in critical care units are common, and 80% of Americans will experience the critical care unit as a client or a family member.

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REASONS FOR ADMISSION TO THE INTENSIVE CARE UNIT

The most common reasons for admission to ICU are for intensive monitoring and life-supportive care or for intensive nursing care that cannot be provided on a general medical surgical floor.

Clients may be admitted following surgery, from the emergency room, or from the other floors within the hospital.

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Common conditions necessitating admission to ICU include the following:

• Respiratory difficulties impairing the client's ability to ventilate or oxygenate:

These problems often include disorders such as pneumonia, pulmonary embolism, drug overdose, and respiratory distress.

Ventilators, also called respirators, may be required to assist with breathing.

The use of these devices requires intense monitoring and skilled care providers to assess both the equipment and the client's response.

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Circulatory problems such as hypotension (low blood pressure) or cardiac rhythm disorders: Clients may have had a myocardial infarction (heart attack), may be bleeding from internal or external wounds, or may have irregular heart rhythms that have become life threatening.

The term hemodynamically unstable is used to describe these clients.

Clients are routinely placed on cardiac rhythm monitors.

They also may require sophisticated monitoring of cardiac output and pressures within the heart. 04/12/23 DHRAVAL 51

Neurologic changes, such as loss of consciousness or changes in mental status: Intensive monitoring of the client's neurologic status provides needed data on the progress or deterioration of the brain's perfusion.

Clients with head injuries, brain surgery, stroke, or spinal cord injury are admitted to the ICU for frequent reassessment.

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Life-threatening infection or the risk of infection, such as burn wounds or sepsis, requires intensive care to control the blood pressure and maintain perfusion of the heart, brain, lungs, and kidneys.

Clients with sepsis or large open wounds require very intensive care for medication administration and fluid management.

Metabolic problems, such as abnormal electrolytes from diabetes, renal failure, or acid-base imbalances require intensive monitoring and medication titration to control and treat complications.

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Clients who have had open heart surgery, thoracic surgery, brain surgery, extensive abdominal surgery, or orthopedic surgery are admitted postoperatively to the ICU for monitoring.

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Clients who have less invasive procedures, but have a personal history of cardiac or pulmonary disease, may also be admitted for observation and frequent assessment

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NEEDS OF THE CRITICALLY ILL CLIENT AND FAMILY

1.Clients in the ICU are at a most vulnerable stage.

2.Not only do these clients have great physical needs, but their emotional, psychological, social, and environmental needs must be identified.

3.Critically ill clients often experience pain, immobility, disorientation, and sleep deprivation.

4.They can feel isolated, anxious, and depressed.

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5. Fears about their treatments, the unknown, and even death are not unusual.

6. Everything in their environment is stress producing unusual machines, loud noises, equipment alarms, constant light, and constant attention, staff conversations, physical restraints, lack of privacy, inadequate control of pain and anxiety, and separation from significant others.

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7 Alteration of sleep quality and quantity in the critically ill client can have important adverse consequences, including impaired immunity and healing, an increase in oxygen consumption and carbon dioxide production, negative nitrogen balance, and stimulation of the "fight or flight" response of the sympathetic nervous system.

An over whelming sense of powerlessness is the overall recurrent theme verbalized by critically ill clients. 04/12/23 DHRAVAL 58

8. Characteristics' of hopelessness can actually impede recovery and lead to specific behavioral and physiologic changes.

9. Because of airway devices, medications, or physical pathology, many critically ill clients cannot communi cate their needs well, making their situation even more stressful.

10. Even with the best of circumstances and nurs ing care, critically ill clients can experience delirium, of ten called ICU psychosis.

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11.The critical care nurse has a great responsibility in controlling the environment to avoid or diminish the stressors that are specific to the critically ill client.

12.Allowing open visitation as able, providing appropriate day and night cycles of activity and sleep, and controlling noise and conversation can allow the client a more restful and therapeutic recovery.

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13. Providing privacy and explaining all equipment, noise, and activities can be comforting measures for the critically ill client as well as his or her family.

14. Designing some type of simple com munication system to allow the client at least to answer "yes" or "no" questions is important.

15.The nurse must adequately assess the client's analgesia and sedation needs.

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16.Often few overt clues are evident that the client requires such medications.

17.Looking at subtle changes in vital signs or behavior and routinely providing sedation and analgesia are frequently required.

18.lastly, the nurse may need to control open visitation to balance clients' needs for rest with families' needs to be close to their loved one.

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CRITICAL CARE NURSING"Critical care nurses concentrate

specifically on the care of clients with life-threatening problems."

Interventions for these clients must be adjusted continually based on constant monitoring of their response to treatment.

Because of the multidisciplinary nature of critical care, co ordination of care is essential.

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The critical care nurse is primarily responsible for such coordination.

Continuous nursing vigilance is the key to this nursing specialty and can make a significant difference in client outcomes.

The critical care nurse does not just use the latest ma chines and technologies to provide highly technical nursing, although maintaining technological devices is crucial.

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Creating an environment that promotes healing or an optimal health level in a nurturing, caring manner is especially essential for a critically ill client to ensure positive optimal outcomes."

Often complementary and alternative therapies, such as massage, prayer, music ther apy, and therapeutic energy provision, assist the critical care nurse in providing such a healing environment.

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Providing such care must include not only the client but also his or her family members and significant oth ers.

Many times the critically ill client does not remem ber his or her ICU stay; however, the time in the critical care unit is often a significant emotional event and is traumatic for his or her loved ones.

Often the only cop ing mechanism families have is hope.

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It is extremely es sential that the critical care nurse foster this coping mechanism because hope can fortify a family's inner strength and helps the family members look beyond the present situation of pain and suffering.

Nurses have a fiduciary relationship with their clients and families; in other words, nurses have an ethical and legal obligation to act in their best interest.

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The American Association of Critical-Care Nurses (AACN) defines this advocacy as "respecting and supporting the basic values, rights and beliefs of the critically ill client."

Further delin eates the advocacy role of the critical care nurse.

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Family Needs in the Intensive Care Unit

The top nine priorities of critical care families were as follows

1. Assurance that the best care was being given

to their family member by caring Personnel2. To feel that there was hope3. To know the prognosis4. To understand how the client was being

treated medically5. To be reassured that it is all right to leave

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6. To feel accepted by hospital staff7. To feel someone is concerned for

the family's health8. To feel the hospital personnel care

about the client9. To have explanations given in

terms that can be understood.

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ImplicationsAs shown by this list of priorities,

nursing can do much to alleviate many of the stressors that face our critical care patients and family members.

Much can be accomplished by listening to clients and their families and by taking time to meet their needs.

Nurses have the knowledge base and the opportunities to address and meet almost all of the priorities listed here.

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AACN'S Advocacy (American association of critical nurses)

The critical care nurse will do the following:1. Respect and support the right of the

patient or the pa tient's designated Surrogate to

autonomous informed decision-making.2. Intervene when the best interest of the patient is in question.3. Help the patient obtain necessary care.4. Respect the values, beliefs, and rights of the patient.

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5. Provide education and support to help

the patient or the patient's designated

Surrogates make decisions.6. Represent the patient in accordance

with the patient's choices.7. Support the decisions of the patient

or the patient's des ignated surrogate, or

Transfer care to an equally qualified critical care nurse.

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8. Intercede for patients who cannot speak

for themselves in situations that Require

immediate action.9. Monitor and safeguard the quality of

care the patient receives.10. Act as liaison between the patient,

the patient's family, and health care Professionals.

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Critical Care Practice Settings and Roles

Critical care nursing is not limited to designated critical care units.

In 2000 the Department of Health and Hu man Services identified that about 31% of all hospital nurses work with critically ill clients in ICU, PACU, emergency room (ER) and in step-down units.

It is not the location of care that is important, however Critical Care nursing is not nursing in a specific place; rather, it is nursing with a specific mind-set that utilizes a specialized body of knowledge and skills. 04/12/23 DHRAVAL 75

Critical thinking and clin ical decision-making become more consistent the longer the critical care nurse practices in the critical care envi ronment.

The critical care nurse must constantly keep up with the latest information and become proficient with more complex new technologies and treatments.

The need for such nursing skills and knowledge will only increase as the population grows older and sicker.

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Today's changes in technology and health care will keep more of Our population out of the hospital, but those who are admitted to critical care units will be more severely ill than ever before.

Critical care nurses are found in a variety of formal roles:

bedside nurse, critical care educator,

case management, department manager, clinical nurse specialist, and

nurse practitioner. 04/12/23 DHRAVAL 77

Only they are with the client on a 24 hours a day, 7 days a week.

The critical care educa tor can educate clients; the case manager can promote appropriate and timely care; the manager can direct them; the clinical nurse specialist can help to plan client care; and the nurse practitioner can order treatments and medications.

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Although all these roles are important, the bedside nurses are the backbone of critical care nursing.

Ultimately, however, it is the bedside criti cal care nurse who coordinates the entire team's efforts to implement the plan of care and modify it as needed by the client's response.

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Advance practice nurses in critical care

Advance practice nurses in critical care are registered nurses with a master's degree who have a specialty in crit ical care.

The critical care clinical nurse specialist (CNS) uses an advanced level of knowledge of critical care, pharmacology, and pathophysiology in completing the role of educator, consultant, manager, researcher, and practitioner.

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The acute care nurse practitioner (ACNP) provides advanced nursing care to acutely and critically ill clients in a wide variety of settings, including the emer gency department, ICUs, and step-down units.

Making rounds, developing a plan of care, and performing specific advanced procedures are all tasks the ACNP may do.

Some ACNPs serve as intensivists and may insert central lines or chest tubes, assist with surgery or intubation, or complete various functions once reserved for physicians.

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CRITICAL CARE PROFESSIONAL ORGANIZATIONS

Critical care practitioners are specifically supported by two national organizations, AACN & the Society of Critical CareMedicine.

These organizations provide practice guidelines, opportunities for networking, educational programs, professional publications, scholarship and grant money, research opportunities, Internet re sources, and practitioner support. 04/12/23 DHRAVAL 82

In addition, both are considered as the "official" professional organizations that speak on behalf of critical care.

Representatives from these organizations are often asked to testify or provide information for various national and state leg islative organizations.

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CONCLUSIONSCritical care nursing occurs in a variety

of settings. Health care will be pressed to provide

efficient and cost-effective services.Government subsidies of health care

may not be able to keep up with the demand.

An impending shortage of nurses in the next 10 years will challenge our health care institutions.

Aging nurses are retiring or leaving critical care.

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Young or new nurses must step up to meet the exciting challenges of critical care nursing.

Despite all the challenges of the future, the center of all health care will still be the client, and the critical care nurse will be there at the client's side.

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