learning outcomes Flashcards
Define transitions of care and where they occur
Transitions of care occur when all or part of a patient’s care is transferred between healthcare providers, locations, or different levels of care within the same location, as the patient’s conditions and care needs change*.
Transitions occur when:
>the patient moves between locations or healthcare providers
>different levels of care within the same facility
>patient’s care is discussed during multidisciplinary rounds
>patient transfers for a test or appointment
>admission or discharge
Describe why transitions of care are a time of risk for patient safety
> there is an increased risk of loss of critical information
> requires a high level of coordination between multiple healthcare providers especially when facilities use a mix of paperless and paper
> transitions need to focus on non-clinical issues too such as cognitive and functional status, housing, transport and carer support
Identify the data arising from poor transitions of care
> there are often gaps/failures in care planning involving multiple teams and collaboration between inpatient and community-based teams
> communication needs to be more clear during handover, throughout documentation, and when communicating with patients and their families/carers.
> patient complaints usually involve communication, treatment, and access.
Discuss methods to ensure a well-coordinated person-person centred transition of care
> coordination starts from preadmission unless they’re from emergency
> get an interdisciplinary team together to discuss the patient so you know you have the same goal
> work out how long the patient will be in the hospital
> setup referrals and liaisons early
> coordinate transfer out of hospital/early discharge planning
What patients are at higher risk during transitions of care?
>ATSI >older patient >disabled >change in cognitive status >rural and remote >homeless >CALD >low literacy >mental illness
What are our aims when planning for transitions of care?
> preventing unnecessary prolonged length of hospital care
> reduce unnecessary readmissions
> ensure safe and quality patient care for enhanced patient experience
> minimise the risk of preventable patient harm
How do we prevent medication errors during transitions of care?
- Collect all information to compile a list of the patient’s current medications
- Confirm accuracy
- Compare history with prescribed medications at every transfer of care
- Supply accurate medicines info to the patient and next healthcare provider at the transfer of care
Describe closed-loop communication and its benefits.
- Initiation - sender states information clearly and concisely (verbal or written)
- Repeat or reading back - receiver verifies the content of the message
- Verification - sender confirms that the information was received properly
Benefits:
>reduces the risk of errors arising from misunderstandings
>both sender and receiver confirm information
Briefly describe changes in patterns of living and
dying
> causes of death - used to be an acute condition. Now patients mostly pass away from a complication of chronic conditions
> duration of illness - used to be only a few weeks to months. Now months or even years
> life expectancy - we now expect the people to live longer
> location of death - patients used to die at home, now many de within an institution
Outline the philosophy of palliative care
An approach that improves the quality of life of individuals and their families facing the problem associated with a life-threatening illness, through prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems physical, psychosocial and spiritual.
Outline the principals of
palliative care
> Provides relief from pain and other distressing symptoms
Affirms life and regards dying as a normal process
Intends to neither hasten nor postpone death
Integrates the psychological and spiritual aspects of patient care
Provides support to help patients live as actively as possible
Provides support to the family during the illness and bereavement
Uses a multidisciplinary team approach
Enhances the quality of life and influences the course of the illness
Is applicable early in the course of illness alongside therapies that are intended to prolong life
Differentiate palliative care and end of life care
Palliative - person and family-centered care provided for a person with an active, progressive, advanced disease who has little or no prospect of cure and who is expected to die and for whom the primary goals are to optimise the quality of life.
End of life - the last few weeks of life in which a patient with a life-limiting illness is rapidly approaching death, the phase of palliative care is recognised as one where increased services and support essential to ensure quality coordinated care from the health care team is being delivered
Identify common symptoms experienced at end-of-life
> Peripheral shutdown and cyanosis
Changes in respiratory patterns (e.g. Cheyne-Stokes breathing)
Drowsiness and reduced cognition
Uncharacteristic or recent restlessness and agitation
Retained upper airways secretions
Cardiac signs (e.g. hypotension, tachycardia)
Decreased mobility (e.g. becoming bed bound)
Decreased ability to swallow safely
delirium
pain
dyspnoea
noisy respiration
urinary dysfunction - incontinence/frequency
bowel issues - constipation, incontinence
Outline common ethical dilemmas
> Withholding or withdrawing - futile or burdensome treatment.
> Voluntary Assisted Dying (VAD) (Euthanasia/Assisted suicide) - An act where a doctor/ person intentionally ends the life of a person by the administration of drugs, at that person’s voluntary and competent request, for reasons of compassion.
> Palliative Sedation – the administration of medication to relief extreme uncontrolled symptoms
> ‘Desire to die’ statements – often associated with existential distress
Describe care of the body after death
The body is washed and a shroud is placed on the body and wrapped before a transfer to the morgue/funeral parlour (community setting).
Respect any religious and cultural beliefs.
Discuss legal requirements at the time of death
Death needs to be verified - doctor, nurse, paramedic/ambo:
>no palpable carotid pulse
>no heart sounds heard for 2 minutes
>no breath sounds heard for 2 minutes
>fixed dilated pupils
>no responses to centralised stimulus (trap squeeze or eternal rub)
>no motor response or facial grimace in response to painful stimuli (pinch the inner elbow)
Certification of death - must be performed by a medical practitioner
>legislative requirement in the births, deaths and marriages registration act
>medical practitioner who was responsible for the patient’s care immediately before death must examine the body 48 hours after death and give the registrar notice of the cause of death.
Discuss loss, grief and bereavement
Loss - refers to the state that exists when something to which one has an attachment is gone
Grief - the multifactoral assortment of reactions to the experience of loss. Grief reactions are complex, and experienced with interrelated physical, emotional, behavioural and cognitive aspects.
Bereavement - is a term referring to the objective state of having lost attachment to something of value and is situational and tangible.
Discuss loss, grief and bereavement
Loss - refers to the state that exists when something to which one has an attachment is gone
Grief - the multifactoral assortment of reactions to the experience of loss. Grief reactions are complex and experienced with interrelated physical, emotional, behavioural, and cognitive aspects.
Bereavement - is a term referring to the objective state of having lost attachment to something of value and is situational and tangible.
Define pain
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
Pain is whatever the experiencing person says it is, existing whenever they say it does.
Pain is subjective and the patient’s self-report is the most important indication of pain
Pain is known as the 5th vital sign
How do we assess pain?
P: >provides >what caused the pain >what increases the pain >very important question if you are yet to have a diagnosis
Q:
>quality
>what does it feel like?
>stabbing, pressure, thudding, dull, aching, throbbing, burning, tingling, numbness,
R:
>region, radiation, relief
>does the pain go anywhere?
>what makes it better or worse?
S: >severity >on a scale of 0-10 >Wong-baker faces >abbey pain scale
T: >time of onset and duration >when did the pain start? >is it constant or intermittent? >have you already received analgesia? If so, when and what?
Describe the different types of pain
> acute (nocireceptive - tissue damage)
> chronic (nocireceptive - tissue damage)
> neuropathic - nerve damage
When do we assess pain?
> On admission - gives us a baseline for future assessment
> Whenever obs are done - pain is the 5th vital sign
> Regularly when performing painful procedures
> Whenever analgesia is required - assess pain before and after
> Assess and document the outcome of the analgesia
Why do we assess pain?
> The first step of pain management.
> Early identification and recognition of people experiencing pain leads to improved health outcomes and greater patient satisfaction.
> Well managed acute pain can reduce the likelihood of developing chronic pain
> Moral and legal to assess and treat pain. It is the patient’s right and our responsibility
> Provides a baseline for ongoing assessment
List of the medications often used to manage acute pain
> aggressive treatment often involving a multimodal analgesic management including opioids
> Simple analgesics - paracetamol
> Non-steroidal anti-inflam - ibuprofen, diclofenac
> Opioids - morphine, fentanyl
> S4 - Tramadol
> adjuvants - ketamine
> Antidepressants - amitriptyline
> Anticonvulsants - gabapentinoids
Briefly discuss the pathophysiology of pain
> When tissue damage occurs a range of chemical mediators, pro-inflammatory cytokinases are released
> These stimulate the nociceptors which then transmit pain signals to the CNS via afferent nerves
> The signal ascends the spinal cord along the ascending pathways
> It is then projected into the medulla, thalamus and cerebral cortex of the brain for higher interpretation
> It is at this point that the signal is greatly influenced by emotion, cognition and behaviour
Outline the nurses’ role in providing optimal pain
management
> Monitor and treat any adverse effects to analgesia
> Advocate for the patient if analgesia is inadequate
> Provide reassurance and education
> Role in providing adequate analgesia/patient education on discharge
Outline the physiological effects of acute pain
Physiological effects of pain mediated by metabolic and neuro-hormonal mechanisms (stress response) caused by:
>lipolysis
>hyperglycaemia
>protein catabolism
>increased antidiuretic and catecholamine leaves
>immunosuppression
>hypocoaulable state
Effects of acute pain on the respiratory system: >atelectasis >decreased cough >sputum retention >infection >hypoxaemia
Effects of acute pain on the cardiovascular system: >tachycardia >hypertension >increased myocardial O2 consumption >myocardial ischaemia >DVT
Effects of acute pain on:
>GIT - decreased gastric and bowel motility
>genitourinary system - urinalysis retention
>neuroendocrine system - increased catecholamines, cortisol, glucagon, growth hormone, vasopressin, aldosterone and insulin
Discuss any barriers to reporting and assessing pain
Barriers to assessing pain: >age >culture >gender >previous experienced >severity of disease >internal or external locus of control>threat value of pain >communication skills CALD/NESB
Barriers to reporting pain:
>fear of addiction to opioids
>patients may view pain as a part of he healing process
>fear of adverse effects such as nausea, purity’s or constipation
>patients may fear judgement for seeing opioids
What are some barriers healthcare workers might face when addressing pain?
> personal views and experiences with pain
> busy environment may mean pain assessment is missed or rushed
> compassion fatigue
Describe a post-op assessment.
Airway:
>patent/compromised
Breathing: >rate >depth >SpO2 >blood gas analysis >chest auscultation
Circulation: >HR >BP >cap refill >bleeding >pallor >urination
Disability:
>neurological
>GCS
>AVPU
Exposure:
>check patient head to toe
Fluids:
>fluid regimes/balance
Glucose
What are some post-op complications we need to look out for?
Complications may include: >respiratory function >cardiovascular function >neurological function >pain and discomfort >thermoregulation >Nausea and vomiting
On transfer from recovery, what do we need to do?
> receive ISBAR handover
> undertake ABCDEFG assessment.
> Check medical records to ensure that you understand the procedure undertaken ad any special instructions
Make sure the patient is comfortable by considering: >nausea and vomiting >thermoregulation >pain >orientation to the ward
What are 2 common post-op respiratory complications?
Atelectasis and pneumonia can occur following any surgery especially abdo
> Absence of deep breathing due to pain or sedentary reclined position and lack of coughing leads to the development of mucus that plugs in the lungs
How do we identify and avoid atelectasis and pneumonia?
Identify atelectasis and pneumonia during a respiratory assessment.
To avoid atelectasis and pneumonia: >encourage deep breathing >encourage regular coughing >teach patient how to diaphragmatically breath >incentive spirometer >regular analgesia >splinting to reduce pain of coughing/breathing >regular repositioning >teach these things pre-op >mobilisation >engages assistance of physio
What are some common post-op cardiovascular complications?
> arrhythmias - dependant on surgery and other risk factors, the patient may require cardiac monitoring
Reduction in CO caused by:
>hypovolaemia (hemorrhage) or vasodilation (eg. sepsis or anesthetic agents) resulting in reduced preload.
>poor cardiac conduction or ventricular failure leading to reduced contractility
>hypertension (either pre-existing or a result of the sympathetic NS) affecting afterload.
What are some S&S of post-op cardiac complications?
Signs: >reduced BP >increased RR >dysrhythmia >bleeding >diaphoretic >altered LOC
Symptoms: >pain >SOB >anxiety >palpitations >fear >feeling unwell
What are the risk factors for venous thromboembolism and how do we prevent it?
Risk factors: >smoking >surgery (cause hypercoagulation) >contraceptive pill >previous VTE
Prevention: >early mobilisation >lower leg exercises >anti-embolism stockings >anti-coagulants (enoxaparin, warfarin) >regular repositioning of patients who are not conscious or cannot move themselves >physio >regular monitoring of swelling, redness, tenderness in the legs (especially calf area)
What is considered hypothermia and what might cause it post-op?
Temperature below 36.
Caused by:
>cold operating theatre
>heat loss due to exposure of body organs
> anesthesia and lead to vasodilation
What are the complications of hypothermia and how do we manage it?
Complications of hypothermia: >immune system >bleeding >delayed drug metabolism >malignant hypothermia
Management:
>monitor temperature
>warming blankets
What are some GIT alterations we might see post-op and what nursing care might we provide for them?
> nausea and vomiting
imbalanced nutrition (NBM pre-op) leads to increased nutritional requirements post-op
Nursing care:
>patient may have NG tube to decompress the stomach
>IV fluid may be prescribed to maintain hydration
>specific instructions from the surgical team may include clear fluids only, light diet or NBM
>early ambulation May help stimulate the bowel
>encourage the expulsion of flatus
