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Flashcards in High acuity nursing Deck (69)
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What is a key part of patient step down?

vigilance; vigilance decides when the care goes from continuous to intermittent.


What are the purpose of house wide bed flow meetings?

purpose is to improve allocation of resources and optimal patient bed assignments


What is the HR have to be for a rapid response team?

- greater than 140
- less than 40


What is the RR have to be for a rapid response team?

- greater than 28
- less than 8


What is the BP have to be for a rapid response team?

- BP greater than 180
- less than 90


What is the O2 sat have to be for a rapid response team?

- <90%


What is the urine output have to be for a rapid response team?

< 50 cc over 4 hours


What is another indicator of a rapid response team?

acute change in mental status


What is the number 1 indicator of acute stress?

respiratory rate above 20 is the number 1 indicator


What are the 6 indicators of a healthy work environment?

1. Skilled communication --> convey critical needs effectively
2. True collaboration --> interdisciplinary rounds. Include the family
3. Effective decisions making --> Patients and families being involved, nurses have a voice as well.
4. Appropriate ratios and/or staffing-->
5. meaningful recognition
6. Authentic leadership --> Trust between middle managers and higher managers and staff.


Describe level 1 trauma care:

a. Hospitals with ICUs that provide comprehensive care for patients with a wide range of disorders.
b. SPECIALIZED CARE is available
c. Sophisticated equipment
d. Units are staffed with specialized nurses and healthcare providers


Describe level 2 trauma care:

a. Hospitals with ICUs that have the capability of providing comprehensive care to most critically ill patients but not to specific patient populations (neurons, immunology)


Describe level 3 trauma care:

a. Hospitals with ICUs that have the ability to provide initial stabilization of critically ill patients but are limited in their ability to provide comprehensive care for the patients.
b. These hospitals are able to care for ICU patients requiring routine care and monitoring.


Who are most affected by environmental stressors?

1. Elderly
2. very young
3. post op pts.
4. unconscious pts


What are causes of stressors?

1. Nutrition
2. Anxiety
3. Pain: Invasive equipment and procedures that are done in ICU; Assume that there is pain
4. Impaired communication: Sedative drugs. Limited connection with reality
5. Sensory-Perceptual problems; Sensory overload  lights are on, alarms are on, telephones are on; Try to decrease sensory stimulation to allow time for rest.
6. Delirium; Preceded by anxiety and restlessness; Can cause long term morbidity and mortality; Optimal healing environment
7. Sleep problems


What is the RAAS?

i. 0 = calm
a. +1 - +5: agitation scale
b. -1 - -5: sedation scale: -1 = drowsy (most ideal). -5 = not responsive to anything


What does the CAM-ICU test for?

delirium; either positive or negative


What are non-pharmacologic interventions in the hospital?

1. headphones
2. Closing doors: Sometimes not allowed
3. Posting signs – quite time (min 2 hours). Most patients only get 2 hours – so risk of delirium is high
4. Day/Night Schedule
5. Use assistive devices: Connect to reality and environment


What are advantages of high tech environments?

1. Close monitoring
2. programmed approach
3. Programs available for diagnosis
4. readily available reference info!


What are disadvantages?

1. depersonalization
2. overload
3. heavy reliance


What is a huge stressor on families while pt.'s are in the ICU?



What is the first stage of Suchman’s Stages of Illness?

symptoms experience


What is the second stage of Suchman’s Stages of Illness?

seeking confirmation of illness from social network. Try to stay home
a. Assumption of the sick role


What is the third stage of Suchman’s Stages of Illness?

seeking care. Medical contact


What is the fourth stage of Suchman’s Stages of Illness?

entering into the health care environment. Patient is passive and accepting.
a. Dependent patient
b. They know people can get them better


What is the fifth stage of Suchman’s Stages of Illness?

Recovery or rehabilitation


How can family visitation be destructive?

physiologically; they can be distracting and make sleep very difficult.


What is burnout?

feelings of personal and professional frustration, job dissatisfaction, job insecurity, and emotional and physical exertion


What are symptoms of burnout

- withdrawal
- risk taking and impulsiveness
- ambivalence
- decreased productivity
- contemplating career change
increased use of caffeine, alcohol, and nicotine.
- chronic fatigue
- frequent minor ailments
- appetite change
- sexual difficulty
- attempts to blame others
-stereotyping patients
- nightmares
- depression
- hostility and negativism
- loss of tolerance
- decried ability to make decisions
- poor judgment
- lack of initiative
- forgetfulness


What is compassion fatigue

when the compassion energy that has been expended by the nurse exceeds the ability to personally re-energize


What is the difference between burnout and compassion fatigue?

compassion fatigue results from the stress nurses experience from the daily relationships with patients and families


What is the importance of critical incident stress debriefings?

1. address staff symptoms of stress
2. provide staff with a sense of closure
3. assess the need for follow-up


What is race?

race is inheritable


What is ethnicity?

all the things that are learned. Religious, Tribal, Linguistic, Cultural


We want to provide CRASH. What is CRASH?

a. consider Culture
b. show Respect
c. Assess and Affirm differences
d. show Sensitivity and Self awareness
--> Knowing that some people may want to be called something specific
e. provide care with Humility


What is DNR?

Do Not Resuscitate


What is AND?

Allow natural death; this is more acceptable to families.


What is DNI?

Do Not Intubate


What is the goal of a DNR, AND, or DNI?

1. allows nature to take its course
2. prevents unnecessary suffering


What does a nurse do if a family decides to take the pt. off life support?

a. Change environment
--> Silencing alarms/darken screen, music, family gathering or providing privacy
b. Pain management – admin analgesics/anxiolytics as ordered
c. Offer chaplain/spiritual support
d. Cessation of treatments and assess for air hunger
e. Contact DNA to approach family regarding organ donation
f. Make sure charge nurse aware to provide care for other patient.


What is palliative care?

a. Inter or multidisciplinary approach to relieve suffering and improve quality of life


What is the proper procedure to ensure client safety when the nurse is prepping a med that will be administered to the client by another person?

1. Labels should be verbally verified by the two healthcare providers
2. labels should be visually verified by the two healthcare providers


What factors contribute to medical errors?

1. staffing ratios
2. overtime
3. excessive documentation


What must be done to ensure client safety before a percutaneous tracheostomy's is placed?

the correct client, site, and procedure should be identified during a time-out


The nurse manager has made a commitment to improve the health of the ICU work environment. Which activities will help meet that goal? (Select all that apply.)
1. Make every effort to assign patients so that their needs match the nurse’s strengths.
2. Set up a program in which a “nurse of the day” is chosen and honored each day.
3. Engage the hospital nurse executive in efforts to improve the health of the entire environment.
4. Role-model successful collaboration with health care providers.
5. Communicate in a clear and effective manner.

1, 3, 4, 5


The hospital is planning to implement a CPOE system. One of the nurses says, “I don’t see how that is going to help.” Which statement by another nurse is a good response to this concern?
1. “You are right; these systems often contribute to medication errors.”
2. “I heard that these systems can cause drug–drug interactions.”
3. “Actually, hospitals that have used these systems generally see error reduction.”
4. “The systems may help prevent errors, but they are way too expensive for use in most hospitals.”



The high-acuity unit’s Operations Council is seeking suggestions concerning the use of technology to prevent errors on the unit. What statements by nurses are good responses to this request? (Select all that apply.)
1. “Barcode medication administration has been shown to reduce medication errors.”
2. “We could completely eliminate errors if we had new tablet computers.”
3. “We need more of the newest infusion pumps. They are always accurate.”
4. “Don’t purchase anything that isn’t fail-safe.”
5. “If we had smartphones, we could look up so much information.”

1, 5


What is the best advice that an experienced ICU nurse can offer to new nurses on how to remain focused on the patient?
1. “Learn about the equipment before caring for the patient.”
2. “Don’t come to work in ICU until you are proficient in all the equipment we use.”
3. “Try to arrange equipment so that you have ample opportunity to use the power of your touch with the patient.”
4. “Until you are comfortable with equipment, ask to be assigned with another nurse.”



New, fairly complex monitoring devices have been purchased to replace current monitors in the ICU. How should the nurse manager plan to introduce this equipment to the unit?
1. Have one device placed in one room and rotate nurses through caring for patients on the monitor.
2. Require that all nurses caring for patients on this monitor have extensive training on its use.
3. Have all the old monitors replaced with the new devices so that nurses can learn by using the equipment.
4. Tell the nurses to focus on how to use the monitor when caring for patients for the first few days.



In the middle of a shift a nurse comes to the manager to discuss the acuity level and number of patients he has been assigned. Which statement would the manager interpret as indicating the nurse needs further education about nurse–patient ratios?
1. “I cannot provide the amount of care that all these patients need.”
2. “Our professional organizations would not approve of exceeding their recommended ratios.”
3. “Is there someone who can be called in to help me with this patient load?”
4. “I am worried I’m going to miss something with one of these patients.”



A nurse is interviewing for a position in a community hospital. Hospital brochures describe a Level III ICU. Which statement describes the resources that the nurse would expect in this hospital?
1. Those working in the ICU have specialty training and use specialized equipment to care for a wide variety of patient illnesses and injuries.
2. Staff and equipment in the unit are capable of providing comprehensive care for patients with a variety of illnesses and injuries.
3. Staff in the unit can provide initial stabilization of patients for transfer to more advanced care.
4. The hospital is a teaching facility with sophisticated equipment and provider expertise.



The ICU nurse receives a call from the medical–surgical unit requesting transfer of a patient to the ICU. The patient is in acute respiratory failure and requires mechanical ventilation. He will require vasoactive drugs to help manage his profound hypotension. Based on the SCCM prioritization model, what is this patient’s priority for ICU placement?
1. Priority 1
2. Priority 2
3. Priority 3
4. Priority 4



What are Kubler-Ross's stages of grief?

1. denial
2. anger
3. bargaining
4. depression
5. acceptance


What is denial?

diagnosis does not have an emotional meaning


What is anger?

Patient rejects diagnosis


What is bargaining?

Patient attempts to regain control


What is depression?

Diagnosis is accepted


What is acceptance?

patient's identity is changed


When teaching high-acuity clients, what are the initial goals?

1. to reduce stress
2. promote comfort


What is the effect of unrestricted visiting hours on some clients?

fewer hallucinations


Family presence during CPR contributes to which result?

Ability to say goodbye


What is delirium?

An acute onset of fluctuating awareness, impaired ability to attend to environmental stimuli, and disorganized thinking


What is often preceded by delirium?

anxiety and restlessness that escalate to confusion and agitation


What are common characteristics of delirium?

1. inability to attend to environment stimuli
2. acute onset
3. disorganized thinking
4. agitation


A client is crying about a below-knee amputation sustained as a pedestrian in a pedestrian–vehicle crash. She expresses fears about ambulating in physical therapy. The nurse interprets this situation as a sign that the client is in which stage of illness?



The nurse is conducting an admission assessment on a client who is an immigrant to the United States. How would the nurse demonstrate cultural competence when caring for this client?

Be aware of the impact of cultural differences on the nurse.


A client has been an active participant in all aspects of hospitalization. This morning the client seems confused and has difficulty completing a form documenting consent to a procedure to be done tomorrow. What nursing action is indicated?

Review the client’s most recent laboratory results.


The hospital supports open visitation throughout the facility. Family members visiting in the coronary care unit have been noisy and disruptive even after being asked to keep down the level of their voices. What nursing action is indicated?

Ask the visitors to leave the unit.


A client has developed confusion while in the ICU. Medical reasons for the confusion have been ruled out and a diagnosis of sensory perceptual alterations made. What should the nurse tell visitors about this client?

Talk about familiar and calming things while in the room.