NR 341 Week 1 Nursing Care: Complex Health Situations

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Chamberlain University

NR-341 Complex Adult Health

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Date

NR 341 Week 1 Edapt Notes: Nursing Care in Complex Health Situations

1. Critical Care Environment and Stress Reduction

In critical care settings, the environment’s overwhelming nature, combined with constant artificial lighting and noise, significantly elevates stress and anxiety levels in clients and their loved ones. To mitigate these stressors, nursing interventions can focus on enhancing client orientation and providing a serene, orderly environment. Ensuring the room has adequate natural lighting helps clients maintain their circadian rhythms, potentially reducing disorientation. Additionally, nursing staff should implement strategies such as orienting clients and their families to the equipment used, which can lessen their bewilderment. Ensuring the untangling and proper arrangement of tubes and wires is essential for a clear environment that supports seamless care provision. By reducing artificial lighting during rest periods, clients can benefit from an environment more aligned with natural day-night cycles (Patel et al., 2019).

2. Family Dynamics and Communication in Critical Care

An evidence-based approach, known as the EPICS Family Bundle, can enhance family involvement in the care of critically ill clients. This model helps families cope with the stress of a loved one’s critical illness and provides a structured process for engagement. The EPICS framework—Evaluate, Plan, Involve, Communicate, and Support—encourages family members’ inclusion in care planning. For instance, evaluating family needs and coping abilities, alongside providing honest and consistent communication, fosters a supportive environment. Allowing families to participate in simple caregiving tasks or bringing familiar items to the client’s room may help reduce feelings of isolation. Proper communication among healthcare professionals, utilizing strategies like the ISBAR technique, can improve information transfer and reduce adverse outcomes due to communication breakdowns (Rodgers & Peterson, 2020).

3. Pain and Stress Management Protocols in ICU Settings

The stress associated with ICU care and complex health conditions often triggers physiological responses such as stress ulcers, impacting overall recovery. Pain and delirium management using the ABCDEF Bundle is a comprehensive approach that covers assessing, preventing, and managing pain, encouraging mobility, and engaging family in the client’s recovery process. Non-pharmacologic methods, including positioning, family interaction, and sensory items from home, should be encouraged for pain relief. For clients unable to verbally communicate, validated tools like the Critical-Care Pain Observation Tool (CPOT) and the Behavioral Pain Scale (BPS) can assist in accurately assessing pain levels. Pharmacologic interventions should be conservative, prioritizing lower dosages with upward titration based on client response, ensuring pain relief is provided before sedation to reduce delirium onset (Smith & Lin, 2022).

Stress-related mucosal disease (SRMD) in critically ill patients primarily results from gastric hypoperfusion, caused by activation of the sympathetic nervous system’s “fight or flight” response. This activation triggers an increased release of catecholamines, vasoconstriction, and inflammation mediated by cytokines. Although gastric acids may play a minor role, they are not the main contributor. SRMD encompasses a range of gastrointestinal (GI) mucosal changes, from superficial mucosal disruptions to deep erosions in gastric muscles, potentially leading to significant bleeding. Initially, these changes can be beneficial by redirecting blood flow away from the gastrointestinal tract to more critical organs like the brain, heart, lungs, and kidneys. However, sustained stress may cause diminished blood flow to the gastric mucosa, increasing the risk of ulcerations and damage to the GI lining.

Risk Factors and Treatments

Patients experiencing certain conditions are at higher risk for stress-related complications, especially those requiring respiratory support via mechanical ventilation, those with altered blood clotting, acute renal or hepatic failure, sepsis, hypotension, or severe head or spinal cord injuries (SCI). To prevent SRMD, prophylactic treatments may include the administration of proton-pump inhibitors (PPIs), such as pantoprazole or rabeprazole, to mitigate gastric acid production. Additionally, managing blood pressure and maintaining adequate fluid volume are crucial steps in preventing visceral hypotension.

Clinical Case Study and Analysis

A 79-year-old client with COVID-19-associated acute respiratory distress syndrome (ARDS) is admitted to the intensive care unit (ICU) and is undergoing mechanical ventilation. Nursing assessments revealed critical findings such as low blood pressure, delayed capillary refill, and signs of pain, indicated by facial grimacing, all of which require immediate intervention to maintain adequate perfusion and minimize discomfort. Laboratory values indicate elevated blood urea nitrogen (BUN) and creatinine, suggesting renal impairment.

The client is at risk of developing stress-induced ulcers and acute renal failure due to prolonged ICU stay and continuous stress. The nursing team’s priority is to address blood pressure, heart rate, and urine output. Essential treatments include maintaining a blood pressure above 100 mm Hg using dobutamine infusion, frequent blood pressure monitoring, and proton-pump inhibitors to prevent stress ulcers.

Ethical and Legal Aspects

In complex health situations, discussions around advanced care planning, including durable power of attorney (DPOA) and living will, are essential. Critically ill clients and their families should be informed about these options to ensure that care aligns with their values and wishes.

Table 1. Key Findings and Interventions in ICU Management for Critically Ill Patients

Category	Findings	Intervention
Risk Factors for SRMD	Mechanical ventilation, altered clotting, renal failure, sepsis, hypotension, head or spinal cord injuries.	Administer PPIs, manage blood pressure, maintain fluid volume.
Clinical Indicators	Low BP, delayed capillary refill, facial grimacing, renal impairment (elevated BUN, creatinine).	Address BP, pain management, monitor urine output, assess renal function.
Ethical Considerations	Need for advanced care planning (DPOA, living will) for patient’s expressed wishes.	Educate on DPOA, living will, and personalized care options.

Health Disparities and Barriers to Health Care Access

Health disparities represent preventable differences in the burden of disease, injury, violence, or opportunities for optimal health among socially disadvantaged groups (CDC, 2017). Over one-third of the U.S. population belongs to a racial or ethnic minority group (U.S. Census Bureau, 2011). These disparities have resulted in disproportionate rates of disease, disability, and death within these communities. The COVID-19 pandemic underscored these inequalities, revealing a heightened disease impact on socially and economically disadvantaged populations.

Barriers to accessing quality health care are multifaceted and often associated with social determinants of health, such as income, education, gender, race, and geography. Lower-income individuals have limited access to health insurance, and lower educational levels are linked to reduced access to jobs offering health benefits. Gender disparities also exist, with males more likely to be treated for cardiac conditions than females, regardless of risk factors. Minority children, such as Black and Latino children, face higher hospitalization rates due to asthma complications than their white counterparts (Institute for Healthcare Improvement, n.d.). Geographic location adds further complexity, as rural residents often face barriers in obtaining timely medical care.

Health Equity, Social Justice, and Ethical Considerations in Complex Health Needs

Health equity, a cornerstone of social justice, strives to provide equal access to quality health care across all socioeconomic classes. Socioeconomic status often determines access to health care providers and facilities, leaving disadvantaged populations vulnerable to preventable health complications. For individuals with complex conditions, such as diabetes or cardiovascular disease, lack of preventive care results in frequent emergencies and critical care needs. Nurses often witness these health disparities and must advocate for equitable health care by delivering respectful, individualized care for each client, especially those with complex health conditions.

For clients with complex needs, ethical considerations around autonomy and self-determination are vital. Advance directives and do-not-resuscitate (DNR) orders safeguard clients’ rights, even when they cannot communicate their preferences. Health care providers play a central role in discussing these directives with clients and families, ensuring that treatment aligns with the clients’ values. If a client requests non-resuscitation, the health care provider documents DNR or allow-natural-death (AND) orders, specifying the level of care to be provided.

Role and Responsibilities of the Rapid Response Team

The rapid response team (RRT) plays an essential role in identifying and intervening when a client’s condition worsens in non-critical settings, aiming to reduce incidents of in-hospital cardiac arrest (IHCA) (Dukes et al., 2019). Bedside nurses are responsible for identifying early signs of deterioration and activating the RRT to address the client’s needs promptly. Symptoms such as altered vital signs, oxygen levels, and mental status may signal a need for urgent intervention. The RRT follows established protocols, including diagnostic tests, airway management, and medication administration, ensuring the client receives the necessary level of care. Ongoing evaluation and quality improvement are critical to the team’s success, with debriefing sessions designed to enhance learning and support for staff (Jackson, 2017).

Category	Contributing Factors	Implications
Health Disparities	Income, education, race, gender, disability, geography	Disproportionate disease burden, higher rates of disability, and mortality within disadvantaged groups
Ethical Considerations	Advance directives, DNR orders, and autonomy in care	Ensures client-centered care, respecting client preferences even in cases where they cannot communicate
Rapid Response Team	Early detection of health decline, swift intervention	Reduced rates of in-hospital cardiac arrest, better outcomes for clients in non-critical settings

Palliative Care in Intensive Care Units

In palliative care, addressing the practical and emotional needs of patients, such as bereavement counseling, is essential. The objective is to support patients in living as actively as possible until their end of life (World Health Organization, 2020). In Intensive Care Units (ICUs), which are designed for critical and life-saving interventions, the focus of care shifts from cure to comfort when a patient is nearing the end of life. This transition encompasses five essential dimensions of care that prioritize symptom management, holistic support, and dignity for both the patient and their loved ones.

Symptom Alleviation and Palliative Care Goals

Palliative care in critical settings aims to manage disease symptoms, supporting the patient and their family through the dying process with comfort and dignity. The primary goals include acknowledging dying as a normal process, alleviating symptoms (e.g., pain), affirming life without hastening or delaying death, enhancing quality of life, and supporting both the patient and family during the illness and in bereavement (World Health Organization, 2020). Open and honest communication among the healthcare team, patient, and family is prioritized in end-of-life care discussions, which may involve setting care goals and discussing palliative care versus aggressive treatment.

Decision-Making in Treatment Withdrawal and Nursing Care for Organ Donation

Withdrawing or withholding life-sustaining treatment should be a collaborative decision involving the patient, family, and healthcare team, guided by ethical considerations. Nursing support for withdrawing treatment includes keeping the family informed, addressing symptoms such as anxiety, and allowing family presence. In cases where the patient has chosen organ donation, the focus shifts to preserving the organs for transplantation. Nursing care ensures that organ function is maintained through evidence-based practices, including managing hemodynamics and providing comfort until the organ recovery process can begin.

Table of Key Aspects in ICU Palliative Care and Organ Donation

Aspect	Palliative Care Focus	Organ Donation Process
Symptom Management	Alleviates symptoms such as pain to support patient comfort and dignity during the dying process	Ensures comfort-focused interventions while maintaining stability for organ viability
Communication and Goals	Direct and open communication with patient and family about end-of-life care options; includes setting goals and discussing care plans	Involves discussing patient’s wishes if organ donation is brought up; preserves patient dignity throughout the process
Ethical Decision-Making	Involves decisions about withdrawing life-sustaining treatments collaboratively with healthcare team and family	Follows ethical protocols for preserving organs post-death, working with organ procurement organizations (National Law, 2018)

References

World Health Organization. (2020). Palliative care. WHO.

National Conference of Commissioners on Uniform State Laws. (2018). Model Uniform Determination of Death Act.

Centers for Disease Control and Prevention. (2017). Health Disparities. https://www.cdc.gov/healthdisparities/

Dukes, T., Tyson, M., & Cannon, R. (2019). The role of rapid response teams in reducing in-hospital cardiac arrests. Journal of Critical Care Nursing, 34(2), 112-119.