Advanced Medical-surgical Nursing - Assignment Example

___________ ____________ ____November 2006 Advanced medical-surgical nursing Introduction Health care is a high risk environment issue. Several elements drawn from the health environs impinge upon the final design of a health care system. A lot many finer concepts at the level of nursing care have to be understood theoretically and applied to health care systems in order to ensure meeting of the final objective of such systems viz.complete patient care and discharge. Any health care system is characterized by the presence of elements which are highly technical & hazardous. These elements generally relate to having adequate and comprehensive procedures and equipment, coping with incomplete and rapidly changing medical knowledge, addressing workforce shortages and ensuring appropriate adherence to correct procedures with right nursing attitude. These finer concepts in nursing when applied lead to the identification and establishment of a patients' risk management process within the overall ultimate design of a health care process. Such processes are more required at the Intensive Care Unit (ICU)/facilities of any hospital as ICU is one of the most critical services of any hospital and the quality of such critical patients' response is important in determining the success of the entire hospital itself. In the following paragraphs we examine the application of the finer concepts of nursing care in three specific areas of nursing the critically ill patient. Areas discussed, with relative analysis are; airway management, sensory imbalance/overload and family communication within the intensive care unit. The discussions in these areas of nursing care become more pertinent if the patient is mechanically ventilated. Airway Management Both short and long duration airway management in critically ill patients require substantial caution and skills. Right approach which can be termed a model approach is still being evolved in research algorithms. Difficult ventilation has generally been reckoned as a state in which a trained anesthetist experience inability to maintain the oxygen saturation more than 90% using a face mask for ventilation and 100% inspired oxygen, given that the pre-ventilation oxygen saturation level was within the acceptable range.(American,1993) Difficult intubation ,on the other hand, has been reckoned as the need for more than three intubation attempts or attempts at intubations that last more than 10 minutes.(American,1993) Schwartz et al (1995) furnish data that 3% of critically ill patients hospitalized suffer death within 30 minutes of administering emergency intubation, and another 8% of intubation events end up in an esophageal placement. Li et al(1999) have demonstrated that adverse events happen in about 78% of critically ill patients put on emergency intubation. The occurrence of esophageal intubation was from 8 to 14% and that of aspiration from 4 to15%.(Reid et al,2004).Mechanical and administered ventilation was obstructed to the most by the changes in mental states and remarkable losses in airway tone.( Wilson & Benumof,1998). The crux of the problem lies in the fact, given the various types of critically ill conditions which warrant the use of intubation and the medications usually deployed in the related ICU procedures, such as sedatives, NMBAs, and opioids, go on to bring about enhanced upper airway resistance through the relaxation of the muscles of the soft palate. Several algorithmic approaches have been developed to address and care for these sequence of events-one among them, for instance, is a rapid-sequence intubation (RSI).This approach involves sequenced usage of neuromuscular blocking agents(NMBA), induction drugs, and adjunctive medications in a rather preset and measured routine carried in algorithm. Such approaches are known to have produced better clinical results for specific category patients' needing intubation. RSI, for instance, necessitates a complete comprehension of the entire physiology of intubation, and of the very many medications deployed for induction and paralysis, keeping in mind the critical condition of a particular patient's case. This approach requires that nursing care is oriented appropriately in such standardized approaches through rigorous training and experience. Once such a trained critical care nurse is manning the ICU then it becomes mandatory on such personnel to follow these procedures in entirety-both from the point of view of own activities and those taken up as follow-up to other ICU care providers. The RSI kind of standardization of intubation work running with in elaborate algorithms needs substantial discipline in following all steps meticulously. However other existing literature has a different point of view. It is in favour of surgical approaches. The existing research carries an important viewpoint that t translaryngeal intubation, long reckoned as a normal initial airway support (American, 1989), might in fact be leading to greater complications involving infections; which may make it long for a patient to be removed off the ventilator. In addition such normal practice has also been documented to result in damage to the trachea and laryngeal structures. Long term intubation is reckoned as any time period exceeding 7 days. In particular, translaryngeal intubation has been treated as unreliable and causing discomfort to patients when deployed on long term basis .This comparison becomes sharper when surgical options is reckoned by the side. (American, 1989; Burkey et al, 1991; Boyd et al, 1979; Sugarman et al, 1997; Rodriguez et al, 1990).In comparison, direct surgical access to the airway in the anterior neck makes for minimizing or even eliminating most of the complications associated with translaryngeal intubation. The most acceptable surgical approach has been the one commonly called anterior tracheotomy. It is usually approached through the second or third tracheal ring following seminal articles of Jackson's from 1909 and 1921 (Jackson, 1909; Jackson, 1921). Even the anterior tracheotomy has assumed a lot of standardization and simplification. A percutaneous procedure reduces this method to a rather routine procedure which can be even taken up by non-surgeons with little risks and mostly with effective outcomes. Despite the huge amount of simplification brought about in anterior tracheotomy still there were possibilities of technical errors as often the procedure was required to be executed in minutes. In order to safeguard against these eventualities and make the procedure more full proof there has been increasing trend to lead the procedure through the cricothyroid membrane; which is the least important section of the airway. It is located in the midsection of the anterior neck. This method has proven to be more effective, facile and time saving and it has now become the standard emergency airway in conditions when translaryngeal intubation appears arduous. Some research has voiced the opinion that cricothyroidotomies leaves damaged larynx and vocal cords and, therefore, it could be, at best, considered only as an emergency alternative. Such critics suggested that cricothyroidotomy should be continued with not beyond some hours, even if it was resorted to, and certainly not beyond a few days and a switch to normal tracheostomy should be carried out thereafter. However as if proving such critics wrong, in cases of some unstable and critically ill patients, where cricothyroidotomy was deployed and switch to normal tracheostomy was not possible, some researchers found that long-term cricothyroidotomy withstood without any significant negative outcomes (Hawkins et al; Wright et al, 1999) Essentially following such findings some institutions have shown a distinct preference for cricothyroidotomy as a surgical option in critical cases where normal tracheostomy was not possible. For instance, Trauma surgeons at Oregon Health & Science University usually deploy tricothyroidotomy in critical patients with challenging neck anatomy, in whose cases the normal tracheostomy would not work as a procedure for long-term airway management. Nursing care should be thorough in the concepts of the surgical procedure and they must provide as an ideal care provider in ICU settings armed with this knowledge. Only through thorough knowledge of the procedure will they be able to provide requisite critical care nursing step by step. Family Communications There is an immense need for proper communication with the families of the critically ill patients -particularly in the ICU settings. This communication has to be clear, consistent, relevant and delivered with adequate amount of courtesy. Even several research efforts have revealed that, for families of patients in the ICU, the most valid issue has always been one of communication. In fact any nursing establishment has got an important role to play in the overall communication strategy to provide information to family members. In fact families are looking forward to anyone who could convey useful information; in particular families desire more communication with ICU physicians, nurses, or other ICU team members whom they expect would provide most recent and relevant information without distortion. Often family members also want ready access to the patient. Any hospital, desirous of developing an image of being a responsible and responsive hospital would tend to assimilate these needs and put on anvil plans for developing and implementing enhanced communication. Ideally in all such plans, there must be a hospital wide communication coordinator (preferably a nursing major) who can serve as a bridge between hospital staff and family members. The chief task of this coordinator would be to spend time in the family waiting room each day, becoming familiar with families, their concerns, and their needs. This coordinator would also need to communicate with other nursing staff and listen to their observations regarding patients under their care. Coordinator would essentially educate the nurses on the structure of the message and the manner of its delivery to the patients' families as the coordinator already has the feel of the communication requirements of the family. Coordinator would also help fix nurses and staff interactions with the families. As and when communication problems arise, project coordinator(s) is able to respond expediently, alerting the physician, nurse, or other staff member about an issue that needs clarification. In case the issues concern the systems then coordinator would take it up with the top management and to evolve an appropriate response and an action plan. In most hospitals providing support for improved communication between ICU staff and patients' families remains a high priority area. Similarly, the intra team communication within the ICU i.e. among physicians, nurses, technicians, unit secretaries, and all staff caring for a patient also forms a priority communication. In fact gist of the intra ICU communication is the one most desired by patients' families. Communication is not limited to written or verbal or non verbal communication. In fact, it includes aspects like visitation hours and physical facilities available to visiting family members. Nursing care would not only be a part of verbal,non-verbal,and written communications with such families but they would be active communicators in regard to visitations hours and physical facilities available to visiting family members. Nurses should have the flexibility to mould visitation hours according to the need of the families keeping in mind the condition of the patient. An entirely rule based approach is likely to lead to insistence and unpleasantness. In fact communication policy should be such that it allows nurses to selectively raise effective visiting hours of family members. Depending on the patient's condition, family members would be able to spend more time in the patient's room than in the waiting room. This would foster more trust making future communication easy. Family members would view nursing staff taking care of their loved one; and they witness the concern and compassion with which that care is delivered. Some institutions even allow family members to raise pertinent queries and even participate in decisions being made about their ill family member. The overall effect of an open communication policy is positive for the family, the patient, and the ICU. For instance, the positive impact of flexible visitation hours have been found in some research studies (Dowling, 2004). Even Clark(2005) reiterated the same utility of flexible visitation hours who reported data that 38.9% of patients and families are dissatisfied, to some degree, with the adequacy of visiting hours in the ICU. Clark(2005) in fact established that there was a direct positive correlation between family satisfaction with the visiting hour policy; this was finding based on an earlier study by Berwick and Kotagal(2004). Overall communication is also fostered by the change in environment within the ICU. In some of the hospitals where such communication policy was consciously implemented surveys of family member respondents revealed that (Dowling, 2004) as such policy was able to address some of the basic family needs, family members were less anxious about their family member's condition. ICU staff also reported that families were more relaxed and were better able to understand the communication received from physicians, nurses, and other staff; they viewed all issues in better perspectives when invited to participate in decision making. Sensory Imbalance As has been stated above neuromuscular blocking agents (NMBs) play a vital role in the overall management of critical illness or injury through the outcome of relaxation of muscles. NMBAs were, to begin with, used extensively in the operating theatres to help bring about muscle relaxation and stop body movements during operating procedures.(Booij,1997).It is only of late that the NMBs have found usage in ICU settings and the intended impact remains the same i.e. to bring about muscle relaxation by pharmacologic blockade at the neuromuscular junction.(Topulos,1993).However there is a remarkable change in usage from operation theatres to ICUs-in operations theaters NMBs were usually deployed till the hours the operation lasted but in ICU the NMBs can be administered for days together often stretching to weeks. (Meistleman & Plaud 1997). Neuromuscular blocking agents can be classed either as being depolarizing or non-depolarizing, depending on the way they act to bring about muscle relxation. Succinylcholine, the most significant of the depolarizing NMB in use, produces impact akin to that of acetylcholine at the postsynaptic receptors. It frees the ion channels, and leads sodium and calcium to move into the cell; this makes the muscle cell membrane to depolarize and ,as a result, the muscles contract. Nondepolarizing NMBs, on the other hand, block postsynaptic acetylcholine receptors themselves. This works to restrain and stop impulse transmission and results in muscle relaxation causing a somewhat flaccid paralysis. (Coursin & Prielipp,1995;Walker,1997;Wheeler,1993) Such neuromuscular blockade can be used both as short term procedure and on a longer time horizon. Typically short term deployment comprise in emergencies in which patient agitation may cause risk to life or the patients demonstrates combative behaviour .It can also be used to quieten a patient in procedures like angiography or insertion of invasive lines ;it also has specific usage in administration of endotracheal intubation. (Topulos, 1993).Administration of NMBs often results in Post-traumatic stress disorder (PTSD) ,which is triggered by an event which has caused trauma and threatened bodily integrity of a patient. This threat is often overpowered and laced with overwhelming and intense fear, horror, and helplessness. (Schelling,1998) .Patients administered NMBs suffer PTSD as they often relive the intense pain which they experienced during ICU procedure as they had fleeting consciousness within a state of paralysis caused by NMBs. Sometimes consciousness may not allow such patients to relive the pain which they had experienced as yet, they do have an intense feeling of emotional deprivation which was not present before the illness. (Clark, 1997).It is important for the nursing staff in critical care to appreciate differences in various medications and their possible impacts.Symptomatology can be an important training point for nursing profession all through the study of imbalances in patient emotions and sensory perceptions after the prolonged treatment through NMBs in painful ICU situations. This can improve nursing responses by a substantial margin. A further analysis would reveal that the NMBs treated patients (rather not properly treated and dealt) may frequently recall the painful experience and have flashbacks of the agonizing and distressing images involved in the NMB run ICU event. These may work to distort thoughts or perceptions for long and the patients may develop evasive behaviour, more akin to intense phobia, manifested in demonstrative avoidance of any stimuli associated with the event; patients may also reveal specific symptoms of heightened and explosive arousal, such as intense and prolonged anxiety or an exaggerated startling response. Accompanying these, and as a consequence of above symptoms, the patient may manifest new areas of aggravating distress and severe impairment in their social, occupational, or other areas of daily lives. (Schelling, 1998; Spencer, 1995). Another debilitating complication occurs in the form of critical illness polyneuropathy, which is featured by weakened sensory and motor movements which might have been caused by nerve fiber damage from microvascular ischemia during critical illness. (Prielipp et al,1995; Hoyt,1994). However, it is important to realize that acute myopathy and polyneuropathy also happen even if NMB therapy is not resorted to. In such cases it may be caused by intensity or criticality of condition and due to treatment with other drug courses e.g. corticosteroids.( Lowson & Sawh,1999). Nursing care may have to reckon with progressive injury or severe seizure activity, as in the absence of adequate neurologic assessment of a medicine induced paralysis in patients, sufficient forewarning may not be coming forth. Nurses can, however, carry out the assessment of abdominal pathology through the physical examination of abdominal condition. However, skeletal muscle relaxation from MNB induced relaxation can hide abdominal pathology substantially.(Miller,1995).In short patients receiving NMBs' assisted treatment become substantially dependent on nursing care and the critical care nurse is ,perhaps, best placed to assist them. As has been stated above, nursing inputs would be comprised in the assessment and monitoring of all body systems related to the patient's critical illness and then a fair assessment of the impact of NMBs ,in conjunction with any other medications courses being run. . Nursing care must reckon that patient positioning and eye care become critical for patients on NMBs due to the fact that the patient on chemical induced paralysis does not blink, artificial tears and eye lubricants are needed to prevent corneal drying, abrasions .Nurses would be helped by certain essential monitoring parameters, such as the electrocardiogram, blood pressure, oxygenation/ ventilation, and hemodynamic status. These monitoring tools become important as some symptoms may result in reduced blood pressure from histamine release or from reduced catecholamine levels from attenuation of the stress response related to anxiety or pain. Work Cited American Society of Anesthesiologists.(1993). 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Neurologic function and neuromuscular blocking agents in critical care. Critical Care Nursing Quarterly .18(2).74-84. Read More