Flashcards in Exam 2 Deck (103):
What are Goals of Care?
Palliative care - goals that are most in line with the patient’s wishes.
What does the social worker in the palliative care team do?
Counseling. Referrals. Helps to organize and facilitate the patient’s wishes as well as facilitating the paperwork for the doctor’s order to carry out those orders.
What does a nurse practitioner do in palliative care?
Consults, symptom management, pain, goals of care, education.
What does the chaplain do in palliative care?
Spiritual care for patient, family and staff.
What is the nurse’s role in the quality of life model?
Assess how patients are doing in each domain (physical, psychological, social and spiritual), plan interventions with the team, coordinate care, evaluate outcomes.
What kind of illnesses warrant palliative care?
Life-limiting illnesses (as opposed to chronic pain)
How quickly is a patient who is in steady decline expected to die?
Weeks to months
What characteristics define progressive deterioration
Frailty and eventually death, but over an extended period time. Alzheimer’s disease is an example.
What are the distinct differences between palliative care and hospice?
-any time in a serious illness
-any clinical setting
-pts continue to receive disease-modifying treatment
-can continue through the end of life.
-reimbursement is poor - hospitals absorb many costs
-only in the last 6 months of life
-usually at home.
-can no longer receive disease-modifying treatment
-covered by Medicaid, medicare and private insurance
What is the CARES document?
Helps guide the practice/understanding of palliative care for nursing students
8 domains of palliative care
-structure and process
-psychological and psychiatric
-spiritual, religious and existential
-care of the patient at the end of life
-ethical and legal aspects of care
When does palliative care start?
At the time of diagnosis of a serious illness or event
What is the nurse’s role in palliative care?
Help establish goals of care.
Identify important tasks to be completed (at end of life).
Discuss barriers to care.
Communicate all this with the team.
Effective communication for the nurse in a palliative care setting means...
-Attentive listening (to patient and family)
-Assess knowledge/understanding of illness and its trajectory
-Be empathetic to fears
-Help pt/family identify what’s important to them.
-Advocate for family.
-provide pt-centered care with the team.
The foundation of excellent palliative care is ________
Communication (both verbal and non-verbal)
What are some reasons that providers are reluctant to share a poor prognosis with a patient?
-fear of death, not knowing the answers, fear of expressing emotion
-lack of experience with death and dying
-guilt or fear of being blamed
-desire to provide hope
-disagreement with the patient/family’s decisions
-lack of knowledge of cultures
Two questions for a cultural assessment?
-What has been important to you and your family?
-What gives your life meaning?
Why is it important to find out how much a patient or their family wants to know about an illness?
In some cultures, it’s forbidden to tell someone they have a terminal illness.
The right to determine what they want to know is a part of their personal autonomy.
How to encourage conversation with the family (palliative care)
Set right atmosphere
Express that you want to spend time with family
(Find out if family wants to talk or even if there is a need to - someone else might have already spoken with them)
Ask permission to engage in a lengthy conversation!
Sit at eye level
Uninterrupted eye contact (if culturally relevant)
Most powerful tool in conversation? Examples?
-Don’t change the subject
-Don’t give advice
(Don’t ever say ‘I understand’)
What are some attributes of mindful presence?
Knowing/being comfortable with oneself
Knowing other person
Affirming and valuing
Acknowledgment of vulnerability
Empathy, willingness to be vulnerable
Being in the moment
Serenity and silence
Initial Interview questions for patients in palliative care (6)
What has your healthcare team already told you?
What has been the most helpful to you?
Tell me more about...
How are you doing?
Is the treatment going the way you thought?
What do you understand about your illness?
What is “Ask-tell-ask”?
Technique for palliative care conversations:
Open with a question
(What do you know about how your disease is responding to treatment?)
Listen attentively, then respond with the truth. Then wait and listen.
At end of this part of the conversation, ask an open ended-question (what else have you heard from the team about how you are doing?) in order to continue the conversation.
What sorts of things can you give the patient and family hope about?
A good death
Chance to resolve issues with family
What are you likely to see in the event of a sudden or traumatic death? What sort of response can help?
Complicated grief. Shock. Anger, guilt, blame, hostility.
Information as to the cause of death, time of death, who was present, and what care was provided.
Normalize the grief.
Be present. Give them a supportive environment to grieve their loss.
What is the nurse’s role in the health care team during palliative care or after a sudden death?
To advocate for the patient and family wishes
To communicate assessments
To coordinate care
What does SBAR stand for?
Keys ideas for handling conflict (ELNEC)
-take a step back
-identify your emotions
-try to describe them (not display them)
-make sure that the conflict is not about you getting your way.
-agree on the area of difference
What are Elizabeth Kubler Ross’s stages of death and dying? (Also apply to diagnosis of a life-threatening illness).
Why is a spiritual assessment a required part of a nursing assessment?
Because healthcare decisions are often based on personal beliefs.
Especially in end-of-life situations.
What three topics does a spiritual assessment cover?
General spiritual status
What spiritual care interventions are within the nurse’s scope?
Creating time and space for religious rituals
Helping make connections to the patient’s spiritual community/clergy/chaplain
(Don’t offer spiritual advice).
What four spiritual issues are likely to arise when facing a life-threatening illness?
Need for forgiveness/reconciliation
Need for prayer and religious services
Spiritual assistance at death
A sense of peace
Is ‘presence’ a nursing intervention? What is its goal? What does it entail?
Yes! Its goal is patient well-being.
Focused on pt
Silence is the norm
What is the goal of palliative care?
Symptom control and promotion of comfort.
What does CMO stand for? What about AND?
CMO: comfort measures only
AND: allow natural death
What are some common physical symptoms during grieving?
Loss of appetite
Shortness of Breath
Tightness in the neck or chest
Lack of energy
What are Bowlby’s four stages of grieving/mourning?
1. Numbness (and possibly denial)
3. Disorganization and despair (hopeless, apathetic, depressed)
4. Reorganization (new relationships, remake life)
What are some appropriate nursing interventions for grieving families?
Listening to feelings/memories
Identifying support systems
Helping them verbalize how loss has changed their world and expectations
Celebrating positive lessons and stories that are part of shared history.
What are Worden’s four tasks of mourning?
Accept the reality of the loss
Work through the pain of grief
Adjust to the environment in which the deceased is missing
Relocate the deceased emotionally and move on with life.
What are the three physical stages of illness?
What are the psychosocial stages of illness? What are the stages of assimilating physical changes?
Damage to self-esteem/feelings of worthlessness
Transition to illness
How long does grief last?
Normal to have difficulty doing things you usually do.
Grief depresses immune system.
People/events/memories bring on feelings of sadness.
How many hours do you spend crying for the loss of a pet? What about a spouse/friend/child?
20 hours for a pet
200-300 hours for the loss of a spouse/friend child.
What is dysfunctional grieving
When the person is repeatedly unsuccessful working through the process of loss.
What is anticipatory grieving?
We all have this - you have an emotional response to a potential loss.
What are Koenig’s guidelines?
-Take a spiritual history
(If a pt is not religious, don’t continue with this)
Support patients beliefs
Say a short prayer if requested by the patient (if you are comfortable)
Refer to chaplains
Alter environment to accommodate religious rituals/practices.
Having or showing a confident or forceful personality.
What are some strategies for passive placaters?
Be wary of unrealistic commitments
Spell out what you need to know
What are some scenarios in which there might be oppressive communication?
What is the XYZ formula?
Helps with assertiveness.
I would like______.
What is the DESC script? When do you use it?
Describe the situation (and provide concrete evidence)
Express how it made you feel (or what your concerns are)
Suggest other alternatives and seek agreement.
Consequences of the situation (team goals or patient safety)
Use when other strategies are unsuccessful, when hostile or harassing behaviors recur, when patient situations worsen.
What format is this an example of?
You’re talking to me in a really loud tone and that makes me feel uneasy. I’d like to sit down and talk about this in the break room where patients can’t hear us or patients are going to feel uncomfortable.
What is STEPPS Check-Back criteria
System of communication for clinical practice before writing anything down. Helpful because of fast pace and distractions.
Sender initiates a message
Receiver provides feedback and confirmation.
What is Call-Out?
In an emergent situation, you call out information so that EVERYONE in the team knows what’s happening right at that moment.
Only for critical situations where everything has to be perfect.
What is the two-challenge rule?
When the nurse expresses concern about something twice - first in the form of a question, second with supporting evidence for the concern.
Use it during:
-departs from standards of practice
-exhibits unprofessional behaviors
-disregards his or her initial assertion.
State what you need to happen and why (not in front of the patient).
What is this an example of:
“I need you to get another catheter because this patient can get an infection”
The two-challenge rule
What is the CUS strategy? When would you use it?
Helps develop assertiveness when interacting with team members. Helps the nurse stop an activity or draw attention to a safety issue.
S: safety issue.
What is this an example of:
I’m concerned because you’re reinserting this catheter. I’m uncomfortable because the patient could get an infection.
What should you do if you feel like you’re going to cry (in a conflict situation)?
Exit the situation. Tell them you need a few minutes.
Ie, “I know this is an important conversation for you - give me five minutes and we can talk about it?”
How to respond to aggression, hostility and sarcasm?
Ask them to sit down (tell them you’ll sit down with them).
Use a calm, quiet voice.
Be concerned about what they’re upset about.
Pause after the outburst while you count to 10.
What should you do if the hostile person refuses to sit?
Remain standing with them.
What should you do if you are sitting while approached by an angry person?
Stand up slowly and calmly.
Quietly ask the person to sit down.
What should you do if the situation is escalating, or there is threat of physical harm?
Seek assistance. Call security while staying calm and in control.
If some has a weapon, try to get patients safely behind a door.
What should you do if the angry person seems inebriated?
Call security. You won’t be able to reason with them.
What listening/communication techniques can you use with a hostile person?
Let them set the pace
Use empathy, reflection, clarifying, restating
Keep your tone low and controlled
Ask questions to get to the root of the problem.
Acknowledge the emotional part of the problem.
Use clear I responses about actions to resolve the problem.
How to respond to sarcasm?
Be direct, but be calm.
“Was there something in that remark you just made?”
“I don’t know what you meant by that comment... could you please explain it to me?”
What are the functions of a group (8)?
Socialization (teaching social norms)
Support (sense of security, membership, processing difficult emotions)
Normative (groups reinforce the established norms - Joint Commission, Oregon State Board: enforce rules)
Empowerment (for bringing about change)
What types of groups are there?
Task groups (focus on a specific task)
Teaching groups (convey knowledge, usually with a set number of meetings)
Support/therapy groups (prevent future problems, learning effective ways of dealing with stress)
Self-Help Groups (AA, Weight watchers, etc).
What are the stages of group process? (Tuckman & Jensen)
Forming (relationship building, boundary setting, establishing expectations)
Storming (interaction/reaction, dealing with conflict and confrontation)
Norming (Effectively cooperating and collaborating. Forming solidified goals, group cohesiveness)
Performing (issues resolved, roles become more flexible and functional)
Adjourning (meet goals. Evaluate/review outcomes, closure).
What are the three phases/stages of groups?
Phase I - initial/orientation phase
Phase II - Middle/working phase
Phase III - Final/Termination Phase
What is process?
The way in which group members interact with each other.
Constructive group member roles
What are some non-constructive group member roles?
Intellectualizer (facts without feelings)
Town Crier/Recognition Seeker
Play Girl/Play Boy (jokes around)
Self Confessor/Seducer (talks about personal problems)
Blocker (impedes group process)
Aggressor (expresses hostility/negativism towards other members)
Monopolizar (dominates the conversation)
What are some examples of care transitions?
Within a setting (shift change)
During hand-off’s (going to lunch)
Teaching patients and families.
What does a transitions coach do?
What four pillars is the job of a transitions coach based on?
Helps transition high-risk, chronically ill older adults through post-hospital care. Multidisciplinary. Goal is to prevent complications and improve outcomes.
Personal health record/concerns (Do they have correct info)
Red flags (make sure drug allergies are current)
Why do 80% of heart failure patients come back in three months? What can we do about it?
Patient doesn’t understand risks/complications, diet, what they’re supposed to do and why. This is a failure in transition care.
Improving transitional care for these patients will prevent such a high rate of return.
What is the Ask me 3 campaign?
Campaign to provide patients with the information they need to know.
1. What is my main problem? (Ie, why am I at the facility THIS time).
2. What do I need to know? (Signs/symptoms, self-management, how to stay out of the hospital next time).
3. Why is it important for me to do this?
What kinds of alarms do we have but people get desensitized to?
What is Accident Causation Theory?
Framework to guide critical thinking (nursing) about system influences that lead to human error, comminication error or harmful events.
Use Unusual Occurrence Reports (UORs)
Determine and Resolve the underlying cause for errors (In the SYSTEM).
What are the three most common mistakes in hand-offs of care?
#1: medications (dosage, timing, kind) not correct
#2: forgetting drug allergies
#3: leaving out information (comorbidities, injuries, diabetes, etc).
What is medication reconciliation?
Look at everything the patient is going home with (medication-wise) and make sure that no one forgot anything or made mistakes.
OR, could be transition between departments (or any transition).
Nearly half of all medication errors occur at transition.
What are tall letters for?
Labeling: To clearly differentiate between look-alike and sound-alike drug names.
LamiCTAL and LamiSIL
What is Read-back/Hear-back?
Sender states information.
Receiver writes it down first, then reads back what was written.
Sender provides hear-back acknowledgment.
Continues until the message is mutually verified.
(Mechanism so we don’t mis-hear orders)
What to do before SBAR?
Assess pt (complete vitals)
Review medical record (to know appropriate physician)
Know admitting diagnosis/date
Read most recent physician/nursing notes
Have medical record available
Focus on problem (concise)
Review with charge nurse prior to calling.
What is SBARR?
Situation (identify problem)
Background (pertinent to problem)
Assessment (clinical data)
(Initiated/recommended by the Joint Commission)
What does “Situation” entail?
Name and Department
I am calling about (pt name, room number, code status)
The reason I am calling is (change in condition, critical lab values, lack of response to intervention/treatment)
What does “Background” consist of?
Admission Diagnosis and admitting date
Brief summary of treatment to date
Name of primary physician (if speaking to an on-call physician)
Relevant medical history
What does “Assessment” consist of?
Most recent Vitals, SpO2, pain level
Physical Assessment pertinent to problem (changes from prior assessment, mental status, complaint given)
What does “Recommendation” consist of?
“Would you consider...”
“I need you to...”
(Clarify how often to monitor the patient and under what circumstances to call again).
In what situations is an I-statement likely to diminish resentment and defensiveness?
When there is a basis of mutual trust and respect
What is the ultimate point of practicing I statements?
To develop a sense of ownership and respect for others.
What is the trickiest place to practice I statements (as a nurse) and why?
Within the provider-patient relationship.
-patients are in a dependent position
-must be able to discern what is appropriate (I statements often entail vulnerability)
What is socially distributed cognition? (Hutchins)
Needed for team intelligence.
Cognitive labor distributed among people who share the task - both the task and the coordination of the task.
Means that we not only do our own work, but appreciate the value/meaning/purpose of everyone else’s work in their team.
What is Crew Resource Management?
Focuses on safety (team) in high-risk industries.
(Started with aviation)
What is Team STEPPS?
Training curriculum and teamwork principles.
Encourages huddles and debriefs
Why are care transitions so complicated?
-patients with multiple chronic conditions
-complicated treatment plans with several professionals
What does a minority decision mean in group decision-making process?
One+ strong members make the decision, even though the majority doesn’t agree.
What does a default decision mean in group decision-making?
Members can’t agree, so they all agree not to make a decision.
What is autocratic leadership?
“My way is the best way” attitude.
Focus is on the leader.
Productivity is high, but morale is low.
What does democratic leadership look like?
Lower productivity, but higher morale.
What does a laissez-faire leadership style look like?
No direction from any leader, no decisions made, no problems solved.