General Care of the Patient with Complex Health Needs

Question 1

Units that take care of patients at high risk for actual or potential life-threatening health problems
Intensive Care Units
Emergency department
Step-down units
Telemetry
Progressive care units
Interventional radiology/cardiology departments
Postoperative recovery units

Answer 1

Complex Care settings

Question 2

A team approach to care
Box 1.1: acute and critical care nursing

Answer 2

Complex care roles

Question 3

Direct care RN
APRN

Answer 3

A team approach to care

Question 4

AACN defines acute and critical care nursing as the specialty that manages human responses to actual or potential life-threatening problems. Nurses rely on a body of specialized knowledge, skills, and abilities to:
Restore, support, promote, and maintain the physiologic and psychosocial stability of patients of all ages across the lifespan
Assimilate and prioritize information in order to take immediate and decisive evidence-based, patient-focused action
Anticipate and respond with confidence and adapt to rapidly changing condition
Respond to the unique needs of patients and families coping with unanticipated treatments as well as quality of life and end of life decisions
Establish and maintain safe, respectful, healing, and caring environments
Recognize the fiscal responsibility of nurses working in a resources intensive-driven environment
Use health care interventions designed to restore, rehabilitate, cure, maintain, or palliate for patients of all ages across the lifespan

Answer 4

Box 1.1: acute and critical care nursing

Question 5

Identification of needs
Maslow’s Hierarchy of needs

Answer 5

Complex health needs

Question 6

Definition
A person’s perceived physical and psychological requirements for developing, maintaining, and enhancing him/herself.

Answer 6

Identification of needs

Question 7

Basic principles of needs theory
One’s need level progresses from basic to higher level needs, but may revert at any time.
One does not pursue higher level needs until the basic needs have been met.
The greatest human need is to perceive one’s self as an adequate or worthwhile person.
Major life changes may necessitate a refocusing of energies to meet a more basic need(s).

Answer 7

Maslow’s Hierarchy of needs

Question 8

Physical: the need for air, water, food, exercise, rest, freedom from diseases and disabilities
ABC’s
General physical condition (head-to-toe assessment)
Mobility (active, passive, PT/OT)
Skin integrity
Nursing intervention: Turn the patient, assess the skin
Nutrition
Uninterrupted sleep
Nursing intervention: Cluster care

Answer 8

Nursing assessment

Question 9

Effects of malnutrition on critically ill patient
Limited fat stores and muscle mass for healing & prevention of infection
Decreased visceral proteins (esp. albumin)
Decreased immunity (cellular & humoral)
Negative nitrogen balance (consumption of protein is greater than what is being provided)
Multiple organ failure (MOF)

Answer 9

Nutrition

Question 10

Nutrition screening within 24 hrs of admit
Clinical signs
Diet and pertinent health history
Box 7.1: patients who are at risk for malnutrition
Nutrition screening continued
Nutritional screening used to
Box 7.2: CM of nutrition alterations

Answer 10

Assessing nutrition status

Question 11

Anthropometric measurements
Height & weight
Laboratory data
Altered CBC
decreased transferrin (iron transport protein);
decreased total serum protein levels;
increased BUN/creatinine (indicative of negative nitrogen balance)
Serum proteins
Albumin, prealbumin

Answer 11

Nutrition screening within 24 hrs of admit

Question 12

Adults who exhibit any of the following
Infants and children who exhibit any of the following

Answer 12

Box 7.1: patients who are at risk for malnutrition

Question 13

Involuntary loss or gain of a significant amount of weight (>10% of usual body weight in 6 months, >5% in 1 month), even if the weight achieved by loss/gain is appropriate for height
Chronic disease
Chronic use of a modified diet
Increased metabolic requirements
Illness or surgery that may interfere with nutrition intake
Inadequate nutrient intake for > 7 days
Regular use of 3+ medications
Poverty

Answer 13

Adults who exhibit any of the following

Question 14

Low birth weight
Small for gestational age
Weight loss of 10% or more
Weight-for-length or weight-for-height <5th percentile or >95th percentile
Increased metabolic requirements
Impaired ability to ingest or tolerate oral feedings
Inadequate weight gain or signficant decrease in an individual’s usual growth percentile
poverty

Answer 14

Infants and children who exhibit any of the following

Question 15

Clinical signs
Diet and pertinent health history

Answer 15

Nutrition screening continued

Question 16

Identify patients who are malnourished or at risk
Determine nutritional needs
Selecting the most appropriate methods of nutritional support

Answer 16

Nutritional screening used to

Question 17

Manifestations that may indicate protein-calorie malnutrition
Manifestations often present in vitamin deficiencies
Manifestations often present in mineral deficiencies
Manifestations often observed with excessive vitamin intake

Answer 17

Box 7.2: CM of nutrition alterations

Question 18

Hair loss; dull, dry, brittle hair; loss of hair pigment
Loss of subQ tissue; muscle wasting
Poor wound healing; decubitus ulcer
Hepatomegaly
Edema

Answer 18

Manifestations that may indicate protein-calorie malnutrition

Question 19

Conjunctival and corneal dryness (vitamin A)
Dry, scaly skin; follicular hyperkeratosis, in which the skin appears to have gooseflsh continually (vitamin A)
Gingivitis; poor wound healing (vitamin C)
Petechiae; ecchymoses (vitamin C/K)
Inflamed tongue, cracking at the corners of the mouth (riboflavin [vitamin B2], niacin, folic acid, vitamin B12, other B vitamins)
Edema; heart failure (thiamine [vitamin B1])
Confusion, confabulation (thiamine [vitamin B1])

Answer 19

Manifestations often present in vitamin deficiencies

Question 20

Blue sclerae; pale mucous membranes; spoon-shaped nails (iron)
Hypogeusia, or poor sense of taste; dysgeusia, or bad taste; eczema; poor wound healing (zinc)

Answer 20

Manifestations often present in mineral deficiencies

Question 21

Hair loss; dry skin; hepatomegaly (vitamin A)

Answer 21

Manifestations often observed with excessive vitamin intake

Question 22

Goal of a nutritional assessment
Avoid overfeeding
Avoid underfeeding

Answer 22

Nutrition

Question 23

↑ fat stores → insulin resistance → hyperglycemia →
↑ risk of postop infection
Excessive production of CO2 → pulmonary compromise

Answer 23

Avoid overfeeding

Question 24

Oral supplementation
Enteral nutrition (aka tube feeding)
Total parenteral Nutrition (TPN)
Goals of nutritional support
safety/security needs
love/belonging needs
Self-esteem needs
Self-actualization needs

Answer 24

Nutritional support

Question 25

Patient population Can eat Normal digestion Unable to consume enough to meet caloric and protein needs Collaborate with dietitian Milkshake with instant breakfast preparations Commercial supplements Calorie count

Answer 25

Oral supplementation

Question 26

Patient population Have some digestive and absorptive capability Unable/unwilling to consume enough to meet caloric and protein needs by mouth Route Nasogastric Gastrostomy Jejunostomy Assessment and prevention of tube feeding complications Feeding tube occlusion Aspiration Prevention GI complications Tubing and catheter misconnections

Answer 26

Enteral nutrition (aka tube feeding)

Question 27

Skin integrity Dry mouth Infection Insertion site dressing

Answer 27

Assessment and prevention of tube feeding complications

Question 28

Regular irrigation Flush after meds

Answer 28

Feeding tube occlusion

Question 29

Risk factors ↓ LOC Supine position Swallowing disorders

Answer 29

Aspiration

Question 30

Confirm placement ↑ HOB 30o – 45o Stop feedings when supine Post pyloric feeding methods Measure residuals

Answer 30

Prevention

Question 31

Diarrhea Causes: Medications, malabsorption, formula contamination, low fiber formulas Constipation Causes: Dehydration, bed rest, opioids, ↓fiber Formula delivery Very clean or aseptic technique Hang enough formula for 8 hours

Answer 31

GI complications

Question 32

Connecting enteric feeding tube to an IV catheter Prevention Label all tubes and catheters Trace lines back to their origins when initiating any new devise or infusion Standardize a line reconciliation process with pt handoffs Never use a standard luer syringe for oral medications or enteric feedings

Answer 32

Tubing and catheter misconnections

Question 33

TPN Peripheral Parenteral Nutrition (PPN) Consideration Patient population Nursing Management of Potential Complications

Answer 33

Total parenteral Nutrition (TPN)

Question 34

The delivery of all nutrients (glucose, fat, protein, electrolytes, vitamins, trace elements) by the IV route High dextrose concentration (25% to 70%) Hyperosmolar formulation Central line

Answer 34

TPN

Question 35

Glucose concentration of 5% to 10% Peripheral line

Answer 35

Peripheral Parenteral Nutrition (PPN)

Question 36

Pharmacy prepared under laminar flow Change q24 hours In-line 0.22 micron filter

Answer 36

Consideration

Question 37

GI tract is not functional Nutritional needs cannot be met solely through the GI tract Have severely impaired absorption Intestinal obstruction Peritonitis Prolonged ileus Some: trauma, burn pts

Answer 37

Patient population

Question 38

Central Catheter Complications Metabolic Complications

Answer 38

Nursing Management of Potential Complications

Question 39

Bloodstream infection (BSI) Air embolism Pneumothorax Central venous thrombosis Catheter occlusion

Answer 39

Central Catheter Complications

Question 40

Hypoglycemia Hyperglycemia Hypertriglyceridemia

Answer 40

Metabolic Complications

Question 41

Replenish depleted protein stores Promote wound healing Restore patient to pre-illness state Restore patient's immunologic function Return patient to normal nitrogen balance If applicable, increase energy stores for weaning off of ventilator

Answer 41

Goals of nutritional support

Question 42

Security: the need for safety, shelter, stability Assess equipment (pumps, EKG monitor, ventilator, etc.) Provide basic safety measures Evaluation of Nursing Care Incorporated into assessment every shift Goal: Patient remains free of physical injury & fear of being harmed

Answer 42

safety/security needs

Question 43

Any repairs of equipment needed? How do pt & family perceive equipment? Do they feel safe? Any fear and/or anxiety identified? Any teaching needed?

Answer 43

Assess equipment (pumps, EKG monitor, ventilator, etc.)

Question 44

Side rails up Bed in lowest position possible Alarms on Routinely checking bed for needles, caps, etc. Reassuring pt & family of your availability

Answer 44

Provide basic safety measures

Question 45

Hourly rounding Room close to nursing station Bed & chair alarms Check for faulty equipment

Answer 45

Goal: Patient remains free of physical injury & fear of being harmed

Question 46

Social: the need for being loved, belonging, inclusion Assess pt's perception of self and situation Identify nursing diagnoses: altered role performance, personal identity Evaluation of Nursing Care

Answer 46

love/belonging needs

Question 47

How does pt perceive him/herself? Listen for comments indicating unworthiness as an individual. What are your observations of family dynamics?

Answer 47

Assess pt's perception of self and situation

Question 48

Alteration, ineffective coping, impaired communication Assess patient’s role(s) in life (family & societal). Will they be permanently disrupted? Is a specialist needed to help meet patient & family’s needs? (pastoral care, psychiatrist, etc.)

Answer 48

Identify nursing diagnoses: altered role performance, personal identity

Question 49

Patient refers to him/herself as being important & worthwhile & loved Patient begins to ask to see family & friends Moves from being “self” centered to “other” centered

Answer 49

Evaluation of Nursing Care

Question 50

Ego: the need for self-esteem, power, recognition, prestige; these needs are met through achievement, recognition, promotions, and bonuses Assessed under nursing diagnosis of "self-concept disturbance" (incorporates body image disturbance and self-esteem disturbance) Patients with poor self-esteem may view injury or illness as “punishment” for their wrong doings in life Evaluation of Nursing Care Patient identifies self as being worthwhile & having value Patient identifies reason(s) for living

Answer 50

Self-esteem needs

Question 51

Self-actualization: the need for development, creativity; these needs are met through autonomy and achievement Assessment Identify nursing diagnoses Evaluation of Nursing Care

Answer 51

Self-actualization needs

Question 52

Is patient future-oriented or past-oriented? Does patient express and demonstrate sense of control? Does patient express hope?

Answer 52

Assessment - Self-actualization needs

Question 53

Ineffective coping (individual and/or family) Powerlessness, self-care disturbance, hopelessness

Answer 53

Identify nursing diagnoses - Self-actualization needs

Question 54

Patient begins to look forward to the future Patient begins to seek more control & independence (in his personal care, medical decisions, etc.) Patient hopefully begins to accept & adapt to changes in health, body image, lifestyle (generally occurs during rehab phase of recovery; for some pts, they never reach this level)

Answer 54

Evaluation of Nursing Care - Self-actualization needs

Question 55

An unpleasant sensory and emotional experience associated with actual or potential tissue damage

Answer 55

Pain Definition

Question 56

Sensory – perception of pain Affective– negative emotions Cognitive – interpretation of pain Behavioral – strategies used to express, avoid, or control pain Physiologic – neural processes of pain response

Answer 56

Components of pain

Question 57

Intensity Location quality

Answer 57

Sensory – perception of pain

Question 58

Unpleasantness Distress Anticipation Anxiety & fear

Answer 58

Affective– negative emotions

Question 59

Acute Chronic pain Nociceptive Neuropathic

Answer 59

Types of pain

Question 60

Short duration (<6months) Usually corresponds to a healing process

Answer 60

Acute

Question 61

> 6 months after healing process May or may not be associated with an illness

Answer 61

Chronic pain

Question 62

Activation of nociceptors Somatic – superficial tissue (skin, muscles, joints, bone) Visceral – organs (heart, stomach, liver)

Answer 62

Nociceptive

Question 63

Lesion or disease affecting the somatosensory system

Answer 63

Neuropathic

Question 64

Patient report Simple yes/no, thumbs up/down Use of the pain scale PQRSTU Provocative and palliative or aggravating factors Quality – dull, aching, sharp, burning, stabbing Region or location, radiation Severity and other symptoms – pain scale Timing – onset, duration, frequency Understanding – pts perception

Answer 64

Subjective - Pain assessment

Question 65

Observed behaviors Facial expression Muscle rigidity Less compliance with ventilator Physiologic Indicators Vital signs – not supported in the literature Pupil dilation reflex

Answer 65

Objective - Pain assessment

Question 66

Opioids Nonopioids Adjuvants Ketamine Lidocaine

Answer 66

Pharmacologic - Pain management

Question 67

Anticonvulsant (gabapentin, carbamazepine) – neurogenic pain Antidepressants (Pamelor, Amitriptyline)

Answer 67

Adjuvants

Question 68

Physical Techniques Cognitive-Behavioral Techniques

Answer 68

Nonpharmacologic - Pain management

Question 69

Ice therapy Massage Reposition

Answer 69

Physical Techniques

Question 70

Relaxation Guided imagery Music therapy

Answer 70

Cognitive-Behavioral Techniques