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Critical Care > General Care of the Patient with Complex Health Needs > Flashcards

General Care of the Patient with Complex Health Needs Flashcards

1
Q

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

A

Complex Care settings

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2
Q

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

A

Complex care roles

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3
Q

Direct care RN
APRN

A

A team approach to care

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4
Q

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

A

Box 1.1: acute and critical care nursing

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5
Q

Identification of needs
Maslow’s Hierarchy of needs

A

Complex health needs

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6
Q

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

A

Identification of needs

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7
Q

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).

A

Maslow’s Hierarchy of needs

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8
Q

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

A

Nursing assessment

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9
Q

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)

A

Nutrition

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10
Q

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

A

Assessing nutrition status

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11
Q

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

A

Nutrition screening within 24 hrs of admit

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12
Q

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

A

Box 7.1: patients who are at risk for malnutrition

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13
Q

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

A

Adults who exhibit any of the following

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14
Q

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

A

Infants and children who exhibit any of the following

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15
Q

Clinical signs
Diet and pertinent health history

A

Nutrition screening continued

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16
Q

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

A

Nutritional screening used to

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17
Q

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

A

Box 7.2: CM of nutrition alterations

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18
Q

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

A

Manifestations that may indicate protein-calorie malnutrition

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19
Q

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])

A

Manifestations often present in vitamin deficiencies

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20
Q

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

A

Manifestations often present in mineral deficiencies

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21
Q

Hair loss; dry skin; hepatomegaly (vitamin A)

A

Manifestations often observed with excessive vitamin intake

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22
Q

Goal of a nutritional assessment
Avoid overfeeding
Avoid underfeeding

A

Nutrition

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23
Q

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

A

Avoid overfeeding

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24
Q

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

A

Nutritional support

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25
Q

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

A

Oral supplementation

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26
Q

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

A

Enteral nutrition (aka tube feeding)

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27
Q

Skin integrity
Dry mouth
Infection
Insertion site dressing

A

Assessment and prevention of tube feeding complications

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28
Q

Regular irrigation
Flush after meds

A

Feeding tube occlusion

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29
Q

Risk factors
↓ LOC
Supine position
Swallowing disorders

A

Aspiration

30
Q

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

A

Prevention

31
Q

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

A

GI complications

32
Q

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

A

Tubing and catheter misconnections

33
Q

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

A

Total parenteral Nutrition (TPN)

34
Q

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

A

TPN

35
Q

Glucose concentration of 5% to 10%
Peripheral line

A

Peripheral Parenteral Nutrition (PPN)

36
Q

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

A

Consideration

37
Q

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

A

Patient population

38
Q

Central Catheter Complications
Metabolic Complications

A

Nursing Management of Potential Complications

39
Q

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

A

Central Catheter Complications

40
Q

Hypoglycemia
Hyperglycemia
Hypertriglyceridemia

A

Metabolic Complications

41
Q

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

A

Goals of nutritional support

42
Q

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

A

safety/security needs

43
Q

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

A

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

44
Q

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

A

Provide basic safety measures

45
Q

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

A

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

46
Q

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

A

love/belonging needs

47
Q

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

A

Assess pt’s perception of self and situation

48
Q

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.)

A

Identify nursing diagnoses: altered role performance, personal identity

49
Q

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

A

Evaluation of Nursing Care

50
Q

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

A

Self-esteem needs

51
Q

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

A

Self-actualization needs

52
Q

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

A

Assessment - Self-actualization needs

53
Q

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

A

Identify nursing diagnoses - Self-actualization needs

54
Q

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)

A

Evaluation of Nursing Care - Self-actualization needs

55
Q

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

A

Pain Definition

56
Q

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

A

Components of pain

57
Q

Intensity
Location
quality

A

Sensory – perception of pain

58
Q

Unpleasantness
Distress
Anticipation
Anxiety & fear

A

Affective– negative emotions

59
Q

Acute
Chronic pain
Nociceptive
Neuropathic

A

Types of pain

60
Q

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

A

Acute

61
Q

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

A

Chronic pain

62
Q

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

A

Nociceptive

63
Q

Lesion or disease affecting the somatosensory system

A

Neuropathic

64
Q

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

A

Subjective - Pain assessment

65
Q

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

A

Objective - Pain assessment

66
Q

Opioids
Nonopioids
Adjuvants
Ketamine
Lidocaine

A

Pharmacologic - Pain management

67
Q

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

A

Adjuvants

68
Q

Physical Techniques
Cognitive-Behavioral Techniques

A

Nonpharmacologic - Pain management

69
Q

Ice therapy
Massage
Reposition

A

Physical Techniques

70
Q

Relaxation
Guided imagery
Music therapy

A

Cognitive-Behavioral Techniques

Critical Care (41 decks)

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