lOMoAR cPSD| 47061011
Complex Adult Health Nursing
● Caring for clients with acute and unstable conditions
● Perform frequent assessments with the ability to recognize trends
● Set goals, intervene, and evaluate
● Provide psychological support to client and family
● Communicate and collaborate with all team members
Critically ill patient: one who is at high risk for actual or potential life threatening health problems and
who requires intense and vigilant nursing care
A patient can be admitted to ICU for 3 reasons:
1) Physiologically unstable; required advanced clinical judgements
2) Pt may be at risk for serious complications and need frequent assessments and invasive
interventions
3) Pt may need intensive and complicated nursing support related to use of IV polypharmacy and
advanced technology
Polypharmacy: sedation, thrombolytics, drugs requiring titration (vasopressors)
Advanced technology: mechanical ventilation, intracranial pressure monitoring, continuous renal
replacement therapy, hemodynamic monitoring Respondin t alarm :
➢ When you enter a room after hearing the alarms for the infusion pump, telemetry monitor, and
pulse oximetry sound; perform these actions…
1) Assess clients LOC
2) Assess respiratory status
3) Palpate for a carotid pulse
4) Check pulse oximetry alarm and address issues noted
5) Check telemetry alarm and address any issues noted
6) Assess clients IV site
7) Check infusion pump alarm and address any issues noted
Pharmacologica Managemen of Pai an Anxiet
For anxiety:
★ Benzodiazepines (Midazolam, Lorazepam)
○ Side Effects: Paradoxical agitation, hypotension, tachycardia, respiratory depression
○ Desired effects: treat delirium, maintain anesthesia/amnesia, decrease anxiety and pain ○
Reversal agents: Flumazenil (Romazicon)
For pain:
★ Opioids (Fentanyl, morphine sulfate, hydromorphone)
○ Side effects: respiratory depression, constipation, vomiting, bradycardia, high pruritus
, lOMoAR cPSD| 47061011
(urticaria), hypotension, urinary retention
○ Desired effects: decrease pain (most effective way to assess pain is to as the patient) ○
Reversal agent: Naloxone (Narcan)
ABCDEF Bundl
➔ Assess, prevent, and manage pain (start with lowest dose)
◆ Pain is treated by using pharmacologic and non pharmacologic interventions ➔ Both
spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT) (Assess daily) ◆ If a
client is on a ventilator, use tools to assess the client's readiness for extubation.
◆ SAT and SBT must be done while the client is not sedated.
◆ Trials should be done while level of pain and agitation is closely monitored
➔ Choice of analgesia and sedation (start with lowest dose, we can always increase)
◆ Treat pain first to control pain and anxiety, decreasing onset of delirium
◆ Identify expected outcomes for both analgesia and sedation ➔
Delirium assessment and management (preventable and reversible
◆ Identify and treat causes of delirium (infection, sepsis, dehydration, hypoglycemia, sleep
deprivation, or meds)
◆ Prevent delirium by improving nighttime sleep, promoting early mobility, assuring clients
have eye glasses and hearing aids in, and encouraging engagement with family and
friends
➔ Early mobility and exercise
◆ Promote mobility, passive ROM, Active ROM, standing and walking as clients condition
allows
➔ Family engagement and empowerment
Deliriu
(CAM assessment) and risk for developing delirium
❖ Risk Factors:
➢ Age
➢ Infection/Sepsis
➢ Hypoglycemia
➢ Alcohol withdrawal
➢ Dehydration
➢ Benzos
➢ Restraints
➢ Bed rest/ Immobilized
➢ Not weaning a patient off a ventilator
➢ Pre existing dementia
❖ How to prevent/ improve delirium
➢ Adjust alarms
, lOMoAR cPSD| 47061011
➢ Promote sleep
➢ Using hearing aids/glasses
➢ Engage family members in patients care
➢ Mobilize patients/ get them out of bed
➢ Make sure patients know date/time - use calendars, clocks, white boards
Lega /Ethica
Autonomy: self-determination (making your own decisions)
- Advanced directives or POA paperwork: someone else can make decisions, DNR, what
to do when heart stops, patients wishes; paperwork goes into effect when patient is no
longer able to make decisions; patient could change POA anytime they want
Beneficence: intended to benefit, to do good
Non-maleficence: to do no harm
Justice: distribute fairly, to be fair
Veracity: tell the truth
Fidelity: faithfulness
Confidentiality: protect information
Moral distress: ethical dilemma
Informed consent: given voluntarily (physicians take it, nurses witness)
Advocacy: represent the patient, what does pt want
Rapi Respons Tea
- We call the RRT when patient shows subtle signs of deterioration (mild confusion,
tachypnea, vital sign changes)
- This brings rapid care to unstable patients in non critical care settings
Advance Directive an D No Resuscitat
- If not in the computer system, we need to call a code
- If you don’t have POA paperwork, an adult child, then parents would make medical
decisions if you don’t have any POA paperwork
, lOMoAR cPSD| 47061011
Client/Family responsibilities
● Understand the consequences of refusing resuscitation measures
● Provide an original, unaltered DNR form for health care team
● Accept that if DNR form is not available and client can’t confirm wishes, resuscitative
care will be provided
● SHould an active DNR be discovered during resuscitation efforts, consult with the health
care team to determine how to proceed
● Participate in care to the extent able
Healthcare provider responsibilities
● Accept that if DNR form is not available and the client can’t confirm their wishes,
resuscitation must be provided
● Should an active DNR be discovered during resuscitation measures, stop interventions
and assess how to proceed
● Determine if the client has a terminal condition and the capacity to provide consent
● Withhold or withdraw resuscitative care upon finding a valid DNR form
Nurse responsibilities
● Accept that if the DNR form is not available and client can’t confirm their wishes,
resuscitative measures must be provided
● Should an active DNR be discovered during resuscitation efforts, notify HCP and nursing
supervisor
● Confirm the validity of DNR form and identify client
● Withhold or withdraw resuscitative measures upon finding a valid DNR form
● Provide palliative and supportive treatment for client and family
Orga Donatio
Living Donors: Healthy individuals offer organs to a client with end-organ disease. Examples of
organs donated by living donors are kidneys, lung lobes, part of a pancreas.
Brain Death: one who is pronounced dead by neurologic criteria; cessation of brain function.
Circulatory Death: one who does not meet brain death criteria but has an illness from which no
recovery is expected.
● The healthcare team notifies an Organ Procurement Organization (OPO) of the
impending death. The OPO will approach the potential donor’s family for consent
○ Due to conflict-of-interest OPO will take consent for organ donation, and they are
trained for that.
Potential complications for organ transplant:
● Rejection- reason for use of immunosuppressive medications (huge risk of infection)
● These patients need to be up to date with all immunizations and all cancer screenings ●
Medications are lifelong
Palliative care: Parkinson’s, COPD, Heart failure
Complex Adult Health Nursing
● Caring for clients with acute and unstable conditions
● Perform frequent assessments with the ability to recognize trends
● Set goals, intervene, and evaluate
● Provide psychological support to client and family
● Communicate and collaborate with all team members
Critically ill patient: one who is at high risk for actual or potential life threatening health problems and
who requires intense and vigilant nursing care
A patient can be admitted to ICU for 3 reasons:
1) Physiologically unstable; required advanced clinical judgements
2) Pt may be at risk for serious complications and need frequent assessments and invasive
interventions
3) Pt may need intensive and complicated nursing support related to use of IV polypharmacy and
advanced technology
Polypharmacy: sedation, thrombolytics, drugs requiring titration (vasopressors)
Advanced technology: mechanical ventilation, intracranial pressure monitoring, continuous renal
replacement therapy, hemodynamic monitoring Respondin t alarm :
➢ When you enter a room after hearing the alarms for the infusion pump, telemetry monitor, and
pulse oximetry sound; perform these actions…
1) Assess clients LOC
2) Assess respiratory status
3) Palpate for a carotid pulse
4) Check pulse oximetry alarm and address issues noted
5) Check telemetry alarm and address any issues noted
6) Assess clients IV site
7) Check infusion pump alarm and address any issues noted
Pharmacologica Managemen of Pai an Anxiet
For anxiety:
★ Benzodiazepines (Midazolam, Lorazepam)
○ Side Effects: Paradoxical agitation, hypotension, tachycardia, respiratory depression
○ Desired effects: treat delirium, maintain anesthesia/amnesia, decrease anxiety and pain ○
Reversal agents: Flumazenil (Romazicon)
For pain:
★ Opioids (Fentanyl, morphine sulfate, hydromorphone)
○ Side effects: respiratory depression, constipation, vomiting, bradycardia, high pruritus
, lOMoAR cPSD| 47061011
(urticaria), hypotension, urinary retention
○ Desired effects: decrease pain (most effective way to assess pain is to as the patient) ○
Reversal agent: Naloxone (Narcan)
ABCDEF Bundl
➔ Assess, prevent, and manage pain (start with lowest dose)
◆ Pain is treated by using pharmacologic and non pharmacologic interventions ➔ Both
spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT) (Assess daily) ◆ If a
client is on a ventilator, use tools to assess the client's readiness for extubation.
◆ SAT and SBT must be done while the client is not sedated.
◆ Trials should be done while level of pain and agitation is closely monitored
➔ Choice of analgesia and sedation (start with lowest dose, we can always increase)
◆ Treat pain first to control pain and anxiety, decreasing onset of delirium
◆ Identify expected outcomes for both analgesia and sedation ➔
Delirium assessment and management (preventable and reversible
◆ Identify and treat causes of delirium (infection, sepsis, dehydration, hypoglycemia, sleep
deprivation, or meds)
◆ Prevent delirium by improving nighttime sleep, promoting early mobility, assuring clients
have eye glasses and hearing aids in, and encouraging engagement with family and
friends
➔ Early mobility and exercise
◆ Promote mobility, passive ROM, Active ROM, standing and walking as clients condition
allows
➔ Family engagement and empowerment
Deliriu
(CAM assessment) and risk for developing delirium
❖ Risk Factors:
➢ Age
➢ Infection/Sepsis
➢ Hypoglycemia
➢ Alcohol withdrawal
➢ Dehydration
➢ Benzos
➢ Restraints
➢ Bed rest/ Immobilized
➢ Not weaning a patient off a ventilator
➢ Pre existing dementia
❖ How to prevent/ improve delirium
➢ Adjust alarms
, lOMoAR cPSD| 47061011
➢ Promote sleep
➢ Using hearing aids/glasses
➢ Engage family members in patients care
➢ Mobilize patients/ get them out of bed
➢ Make sure patients know date/time - use calendars, clocks, white boards
Lega /Ethica
Autonomy: self-determination (making your own decisions)
- Advanced directives or POA paperwork: someone else can make decisions, DNR, what
to do when heart stops, patients wishes; paperwork goes into effect when patient is no
longer able to make decisions; patient could change POA anytime they want
Beneficence: intended to benefit, to do good
Non-maleficence: to do no harm
Justice: distribute fairly, to be fair
Veracity: tell the truth
Fidelity: faithfulness
Confidentiality: protect information
Moral distress: ethical dilemma
Informed consent: given voluntarily (physicians take it, nurses witness)
Advocacy: represent the patient, what does pt want
Rapi Respons Tea
- We call the RRT when patient shows subtle signs of deterioration (mild confusion,
tachypnea, vital sign changes)
- This brings rapid care to unstable patients in non critical care settings
Advance Directive an D No Resuscitat
- If not in the computer system, we need to call a code
- If you don’t have POA paperwork, an adult child, then parents would make medical
decisions if you don’t have any POA paperwork
, lOMoAR cPSD| 47061011
Client/Family responsibilities
● Understand the consequences of refusing resuscitation measures
● Provide an original, unaltered DNR form for health care team
● Accept that if DNR form is not available and client can’t confirm wishes, resuscitative
care will be provided
● SHould an active DNR be discovered during resuscitation efforts, consult with the health
care team to determine how to proceed
● Participate in care to the extent able
Healthcare provider responsibilities
● Accept that if DNR form is not available and the client can’t confirm their wishes,
resuscitation must be provided
● Should an active DNR be discovered during resuscitation measures, stop interventions
and assess how to proceed
● Determine if the client has a terminal condition and the capacity to provide consent
● Withhold or withdraw resuscitative care upon finding a valid DNR form
Nurse responsibilities
● Accept that if the DNR form is not available and client can’t confirm their wishes,
resuscitative measures must be provided
● Should an active DNR be discovered during resuscitation efforts, notify HCP and nursing
supervisor
● Confirm the validity of DNR form and identify client
● Withhold or withdraw resuscitative measures upon finding a valid DNR form
● Provide palliative and supportive treatment for client and family
Orga Donatio
Living Donors: Healthy individuals offer organs to a client with end-organ disease. Examples of
organs donated by living donors are kidneys, lung lobes, part of a pancreas.
Brain Death: one who is pronounced dead by neurologic criteria; cessation of brain function.
Circulatory Death: one who does not meet brain death criteria but has an illness from which no
recovery is expected.
● The healthcare team notifies an Organ Procurement Organization (OPO) of the
impending death. The OPO will approach the potential donor’s family for consent
○ Due to conflict-of-interest OPO will take consent for organ donation, and they are
trained for that.
Potential complications for organ transplant:
● Rejection- reason for use of immunosuppressive medications (huge risk of infection)
● These patients need to be up to date with all immunizations and all cancer screenings ●
Medications are lifelong
Palliative care: Parkinson’s, COPD, Heart failure
