Cognition Flashcards
Hypoactive delirium
Flat affect, withdrawal, apathy, lethargy, and/or decreased responsiveness
Delirium risk factors
Pre-existing dementia, Hx of baseline hypertension, Alcoholism, Admission severity of illness, Age (questionable), Sedative use (specifically benzodiazepines)
Delirium management
Antipsychotics,
THINK mnemonic,
ABCDE bundle,
Delirium assessment
Validated tool for delirium assessment used at least once per shift,
Perform, document, and communicate assessment,
Evaluate for potential risk factors,
Consider strategies for decreasing benzodiazepine usage or use alternative,
Early progressive mobility and exercise,
Evaluate pts for causes of delirium using THINK
THINK
Evaluation for pts with delirium
Toxic situations? Hypoxemia? Infection/sepsis? Immobilization? Nonpharmacologic interventions? K+ or electrolyte problems?
ABCDE bundle
Awakening and Breathing trial coordination, Choice of sedative, Delirium detection, Early progressive mobility and exercise
Unrestricted visitation in ICU
Can improve the safety of care and enhance pt and family satisfaction,
Improves communication, facilitates a better understanding of the pt, advance patient- and family-centered care, helps calm the pt, and enhances staff satisfaction
Family presence during resuscitation and invasive procedures
Pt is comforted by family members presence,
Helps family to understand the severity of their loved ones condition,
Decreases family anxiety and fear,
Allows closure and facilitates the grieving process in the event of death,
Improves medical decision making, pt care, and communication with pt family
Promote sleep and prevent alarm fatigue
Provide proper skin prep for ECG electrodes,
Change ECG electrodes daily,
Customize alarm parameters on ECG and pulse ox monitors,
Monitor only those pts with clinical indications for monitoring
Assessing pain in the critically ill pt
Attempt to obtain the pts self report of pain,
Perform a pain assessment using a validated behavioral pain scale for those unable to self report,
Avoid referring to vital signs for pain assessment,
Consider a proxy to identify behavior that may indicate pain
Moral distress
Occurs when you know the ethically appropriate action to take, but are unable to act upon it;
Occurs when you act in a manner contrary to your personal and professional values, which undermines your integrity and authenticity
Unaddressed Moral distress
Restricts nurses’ ability to provide optimal pt care and find job satisfaction;
Causes suffering, poor communication, lack of trust, defensiveness, and lack of collaboration
The 4 A’s
Ask: you may be unaware of the exact nature of the problem but are feeling distress,
Affirm: affirm your distress and your commitment to take care of yourself. Validate feelings and perceptions with others,
Assess: identify source(s) of distress, determine severity of distress, and contemplate your readiness to act,
Act: prepare to act, take action, and maintain desired change
“Five Rights of Clinical Reasoning”
Right cues: clinical data collected and clustered by the nurse to recognize the relevance and relationship to the pt,
Right patient: identify if pt is high risk for complication of condition,
Right time: recognizing early signs of complications and initiating nursing interventions,
Right action: once a clinical judgement is made, the right action must be taken,
Right reason: understanding the rationale
Tips for data collection in ICU
What happened? (Brief history, critical numbers and when),
What is going on? (Assess vitals, O2 therapy, physical exam, drips, fluids, screens, foley, ask nurse, ask RT),
What is missing?
Reasons for transfer to ICU
Respiratory failure requiring ventilation,
Severe acid-base disturbance with critical numbers,
Loss of consciousness, failure to protect airway,
State of shock, hypotension not responding to fluids
