lOMoARcPSD|26582732
Lomoarcpsd|26582732
NR 341 Week 1 Edapt notes 2025
Complex Adult Health (Chamberlain University)
NR 341 Week 1 Edapt notes:
Unit 1: Nursing Care: Complex Health Situations
Aspects of the Critical Care Environment
Environment coupled with loss of privacy & separation from loved ones can stress & anxiety for both cleints &
their loved ones.
How to lessen negative impact:
Issue: Physical environment – overwhelming. Constant presence of artificial lighting interferes with natural
circadian rhythms, disorientation and agitation.
Solution: Orient client & family to the equipment used for care to stress & sense of bewilderment. Keep wires
& tubing untangled & out of the wat to prevent disruption of care (clear environment), natural lighting in the
room, & allow client to see out of window to promote awareness of day-night cycle (circadian rhythm). Turn
off artificial lights when not needed & close the room door to block light form hallways.
Issue: Noise – environment is super loud & chaotic. Sheer # of loud noises within the room puts clients, visitors
& caregivers hearing at risk & can stress related health alterations.
Solution: Tailor device alarms to each clients needs to # of false alarms. Close door to noise from outside the
room. Establish quiet time by blocking calls into client rooms, prohibiting the use of overhead paging systems,
& reinforcing quiet verbal communication during nighttime hours.
Issue: Sensory Deprivation - stress & anxiety b/c of: separation from loved ones, use of pain medications and
sedation may prevent client from interacting with loved ones when they have the opportunity, being away
from home, loss of a normal routine, loss of sense of time w/o calendar or clock.
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
Solution: Allow visitors when possible & encourage family/lov ed ones to speak and touch client when
present. Ask family to bring meaningful objects from home & place them where they are visible to client.
Reorient an alert client to time & place, ask family to share current events in the lives of the clients’ loved
ones. Assure a clock & calendar are visible to the client & set to reflect the current time & date (include the
white board in the pt. Room & UPDATE daily).
Family Dynamics and Access to Loved
One
Evidence based approach to in volving family in the care of critically ill clients = EPICS Family Bundle. ’s
coping
of family members & provides nurses steps for including family in their loved ones care.
EPICS = Evaluate, Plan, Involve, Communicate & Support.
Evaluate: Family background, relationship to client, current family stressors, current coping skills, needs of the
family, level of involvement desired.
Plan: how to meet needs, extent of family participation, communication touch points, encouraging touch.
Involve: Include family members, invite suggestions, meet w/ family as needed, allow the family to provide
simple care, personalize the environment.
Communicate: Be honest, provide information as needed, encourage conversation, ask how the family
members are doing, facilitate communication w/ the health care team.
Support: Advocate for the family, offer assistance, provide resources, show concern, mediate concerns/issues
w/ the healthcare team, provide references.
Responding to Alarms:
1. Assess the client’s level of consciousness and activity.
2. Check the endotracheal tube.
3. Observe the rise and fall of the chest during ventilation.
4. Feel for carotid pulse.
5. Check the ventilator alarm and address any issues as needed.
6. Check the telemetry alarm and address any issues as needed.
7. Assess the intravenous (IV) site.
8. Check the infusion pump alarm and address any issues as needed.
The client should always be assessed first, starting with the level of consciousness and activity,
followed by the airway, breathing, and circulation ( abcs ):
• Airway (endotracheal tube – Does it appear to be in place and connected to the ventilator
tubing?)
• Breathing (Does the client’s chest rise and fall with ventilation?)
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
• Circulation (Does the client have a carotid pulse?)
Next, check the ventilator alarm (it can be silenced at that time) and address any issues, as
needed. The telemetry alarm is the next highest priority, followed by checking the IV site and
addressing the infusion pump alarm.
Communication With the Health Care Team
Teamstepps: Team Strategies & Tools to Enhance Performance & Patient Safety. aimed at optimizing
performance among teams of hcps, enabling them to respond quickly & effectively to whatever situations
arise.
Teamstepps Process: ISBAR
Lack of appropriate communication plays a critical role in adverse events.
Remember ISBAR
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
ISBAR: use in any communication in which the client’s information is shared:
Giving report, between shifts, transfers between units/floors/specialties, transfers between facilities,
time-critical situations (medical emergencies & evacuations), communication w/ members of the
healthcare team, communication with the client & family.
Teamstepps Process: Call-Out and Check-Back
Call-Out: used to communicate critical information during an emergency. Helps team to prepare & anticipate
the next steps for care. Benefits the recorder when present during a code or emergent event to accurately
document the clients staus and the care provided.
Important: direct the information to a specific individual.
Ex:
"What are the vital signs?"
"Blood pressure 78/40, heart rate 167 supraventricular tachycardia, respirations
28 , O2 sat 88% on 50% non-rebreather."
"Thank you. Add a liter of normal saline to infuse over 60 minutes."
Call-Back: Closed loop communication strategy used to verify & validate info exchanged. Involves: (1) sender
initiating a message, (2) receiver accepting the message & confirming what was communicated, (3) sender
verifying that the message was received.
Ex:
"Add a liter of normal saline to infuse over 60 minutes."
"1 liter of normal saline to infuse over an hour." "Correct."
Advantage to Call-Out & Call-Back: entire team hears info at the same time & has a chance to respond.
Downloaded by NELSON KIIRU ()
Lomoarcpsd|26582732
NR 341 Week 1 Edapt notes 2025
Complex Adult Health (Chamberlain University)
NR 341 Week 1 Edapt notes:
Unit 1: Nursing Care: Complex Health Situations
Aspects of the Critical Care Environment
Environment coupled with loss of privacy & separation from loved ones can stress & anxiety for both cleints &
their loved ones.
How to lessen negative impact:
Issue: Physical environment – overwhelming. Constant presence of artificial lighting interferes with natural
circadian rhythms, disorientation and agitation.
Solution: Orient client & family to the equipment used for care to stress & sense of bewilderment. Keep wires
& tubing untangled & out of the wat to prevent disruption of care (clear environment), natural lighting in the
room, & allow client to see out of window to promote awareness of day-night cycle (circadian rhythm). Turn
off artificial lights when not needed & close the room door to block light form hallways.
Issue: Noise – environment is super loud & chaotic. Sheer # of loud noises within the room puts clients, visitors
& caregivers hearing at risk & can stress related health alterations.
Solution: Tailor device alarms to each clients needs to # of false alarms. Close door to noise from outside the
room. Establish quiet time by blocking calls into client rooms, prohibiting the use of overhead paging systems,
& reinforcing quiet verbal communication during nighttime hours.
Issue: Sensory Deprivation - stress & anxiety b/c of: separation from loved ones, use of pain medications and
sedation may prevent client from interacting with loved ones when they have the opportunity, being away
from home, loss of a normal routine, loss of sense of time w/o calendar or clock.
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
Solution: Allow visitors when possible & encourage family/lov ed ones to speak and touch client when
present. Ask family to bring meaningful objects from home & place them where they are visible to client.
Reorient an alert client to time & place, ask family to share current events in the lives of the clients’ loved
ones. Assure a clock & calendar are visible to the client & set to reflect the current time & date (include the
white board in the pt. Room & UPDATE daily).
Family Dynamics and Access to Loved
One
Evidence based approach to in volving family in the care of critically ill clients = EPICS Family Bundle. ’s
coping
of family members & provides nurses steps for including family in their loved ones care.
EPICS = Evaluate, Plan, Involve, Communicate & Support.
Evaluate: Family background, relationship to client, current family stressors, current coping skills, needs of the
family, level of involvement desired.
Plan: how to meet needs, extent of family participation, communication touch points, encouraging touch.
Involve: Include family members, invite suggestions, meet w/ family as needed, allow the family to provide
simple care, personalize the environment.
Communicate: Be honest, provide information as needed, encourage conversation, ask how the family
members are doing, facilitate communication w/ the health care team.
Support: Advocate for the family, offer assistance, provide resources, show concern, mediate concerns/issues
w/ the healthcare team, provide references.
Responding to Alarms:
1. Assess the client’s level of consciousness and activity.
2. Check the endotracheal tube.
3. Observe the rise and fall of the chest during ventilation.
4. Feel for carotid pulse.
5. Check the ventilator alarm and address any issues as needed.
6. Check the telemetry alarm and address any issues as needed.
7. Assess the intravenous (IV) site.
8. Check the infusion pump alarm and address any issues as needed.
The client should always be assessed first, starting with the level of consciousness and activity,
followed by the airway, breathing, and circulation ( abcs ):
• Airway (endotracheal tube – Does it appear to be in place and connected to the ventilator
tubing?)
• Breathing (Does the client’s chest rise and fall with ventilation?)
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
• Circulation (Does the client have a carotid pulse?)
Next, check the ventilator alarm (it can be silenced at that time) and address any issues, as
needed. The telemetry alarm is the next highest priority, followed by checking the IV site and
addressing the infusion pump alarm.
Communication With the Health Care Team
Teamstepps: Team Strategies & Tools to Enhance Performance & Patient Safety. aimed at optimizing
performance among teams of hcps, enabling them to respond quickly & effectively to whatever situations
arise.
Teamstepps Process: ISBAR
Lack of appropriate communication plays a critical role in adverse events.
Remember ISBAR
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
ISBAR: use in any communication in which the client’s information is shared:
Giving report, between shifts, transfers between units/floors/specialties, transfers between facilities,
time-critical situations (medical emergencies & evacuations), communication w/ members of the
healthcare team, communication with the client & family.
Teamstepps Process: Call-Out and Check-Back
Call-Out: used to communicate critical information during an emergency. Helps team to prepare & anticipate
the next steps for care. Benefits the recorder when present during a code or emergent event to accurately
document the clients staus and the care provided.
Important: direct the information to a specific individual.
Ex:
"What are the vital signs?"
"Blood pressure 78/40, heart rate 167 supraventricular tachycardia, respirations
28 , O2 sat 88% on 50% non-rebreather."
"Thank you. Add a liter of normal saline to infuse over 60 minutes."
Call-Back: Closed loop communication strategy used to verify & validate info exchanged. Involves: (1) sender
initiating a message, (2) receiver accepting the message & confirming what was communicated, (3) sender
verifying that the message was received.
Ex:
"Add a liter of normal saline to infuse over 60 minutes."
"1 liter of normal saline to infuse over an hour." "Correct."
Advantage to Call-Out & Call-Back: entire team hears info at the same time & has a chance to respond.
Downloaded by NELSON KIIRU ()
