Acute and Critical Care Nursing at a Glance

Helen Dutton, Jacqui Finch, Helen Dutton, Jacqui Finch

• Publisher: Wiley-Blackwell
• Year: 2018
• ISBN:
  9781118815168
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

From the publishers of the market-leading at a Glance series comes a comprehensive yet accessible overview of all the fundamental elements of acute and critical care nursing.

Acute and Critical Care Nursing at a Glance provides an introduction to the key knowledge and skills for patient assessment and problem identification, as well as how to plan, implement and evaluate care management strategies. It also explores clinical decision-making processes and their impact on care delivery, as well as key psychosocial issues, pain management, and safe transfer. All information is presented in a clear, double-page spread with key information accompanied by tables, illustrations, photographs and diagrams.

Key features:

• Superbly illustrated, with full colour illustrations throughout
• An accessible, evidence-based, introduction to a complex topic
• Presents information structured according to the Resuscitation Council's systematic ABCDE framework for ease of understanding
• Accompanied by patient case studies to help apply theory to practice

Acute and Critical Care Nursing at a Glance is ideal for nursing students, healthcare assistants, and registered nurses working within the acute and critical care setting.

Part 1
Nursing in acute and critical care

Chapters

1. 1 Critical care without walls
2. 2 Recognising risk of deterioration: ABCDE assessment
3. 3 Early warning tools and care escalation
4. 4 Hospital-acquired infection: infection prevention and control
5. 5 Pain management
6. 6 Psychosocial issues
7. 7 Safe transfer of the acutely unwell patient

1
Critical care without walls

The last decade has seen a change in the environment in which care of the acutely unwell patient is delivered. Nurses working in acute care areas are increasingly exposed to patients who require more detailed assessment and monitoring. Nurses need to be competent in the skills required to care effectively for critically ill patients.

Changing patterns in acute care

The general population is ageing, with those requiring hospital admission older, sicker and generally more dependent. In 2010 the over-65 age group accounted for 10 million of the population in the UK, and by 2030 the number will be closer to 15.5 million. Emergency admissions for patients who have increasingly complex comorbidities requiring multidisciplinary and cross-speciality input are increasing. Meanwhile, greater emphasis has been placed on managing patients in their home environment for longer periods, meaning those who are admitted to hospital are sicker and require greater use of resources. Technological developments in healthcare means that treatments once thought too high a risk are now commonplace in hospitals.

With the increase in patient acuity it became evident that wards were not always able to cope effectively with the extra demands placed on them. Studies in the late 1990s identified that the deteriorating patient was not always recognised, and/or sufficient action was not taken prior to admission into the intensive care unit (ICU), adversely affecting patient outcome.

Reconfiguration of critical care services

In 2000 the Department of Health¹ published its report, Comprehensive Critical Care, recommending a systems approach was taken to deliver care for patients during acute and critical illness, and in the recovery period. Critical care emerged as a new speciality, addressing the severity of patient illness, regardless of their physical location within the hospital. The Department of Health introduced the concept of ‘critical care without walls’, to ensure acutely unwell patients nursed in a variety of environments, from ward-based care through to intensive care, come under the ‘critical care umbrella’ (Figure 1.1). A spectrum of dependency levels from levels 0 to 3, were outlined to encompass all those requiring critical care:¹

• Level 0: Patients whose needs can be met through normal care in an acute hospital.
• Level 1: Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care whose needs can be met on an acute ward with advice and support.
• Level 2: Patients requiring more detailed observation or interventions, including support for single organ failure, postoperative care, and those stepping down from a higher level of care.
• Level 3: Patients requiring advanced respiratory support or support of at least two organs, including all complex patients requiring support for multiorgan failure.

Workforce development, to ensure that staff caring for potentially critically ill patients receive education and training, is essential.² Key clinical competencies to be achieved have been identified.³ Registered nurses are accountable for all aspects of care, even those tasks often delegated to others, such as the taking and recording of observations.⁴

Safe staffing levels

The Intensive Care Society (2013) and others published core standards for organisation of intensive care units (levels 2 and 3) and recommended safe staffing levels.⁵ As acutely unwell patients are nursed across a range of environments, there are challenges for the provision of safe staffing levels on acute wards, which have been highlighted by the Francis Report (2013).⁶ NICE (2014) issued guidance for safe staffing for nurses in acute hospitals supporting ‘The Safer Nursing Care Tool’ (Table 1.1).² This tool is based on the Department of Health classification, but adds an additional level, 1b, acknowledging the differing demands on nursing care activities, such as supporting the patient at risk of self-harm. It is designed to inform nursing establishments to be planned, linked to patient acuity both in ward-based care and critical care units.

Resuscitation to medical emergency

Cardiac arrests are predictable and preventable. Survival to discharge post cardiac arrest is as low as 15%.⁷ Early recognition of deterioration is the first step in the chain of survival. Almost half of patients who die without a ‘do not attempt resuscitation’ (DNAR) order have serious, potentially reversible abnormalities in their vital signs in the 24 h preceding death. In fact, slow, progressive physiological deterioration with unrecognised and inadequately treated hypoxaemia and hypotension, can often be seen prior to admission to ICU and leads to poor survival. Delays in time to treatment have a profound effect on patient outcome. Specific intervention and timely instigation of organ support, via a medical emergency team or critical care outreach team (CCOT), is more important than getting the patient to the ICU.

Critical care outreach

Critical care outreach teams have evolved to provide expert input outside the environment of intensive and high dependency units. They aim to avert or ensure timely admissions to critical/intensive care and share critical care skills across the multidisciplinary team. Implementation of early therapies, for example, high flow oxygen, fluid resuscitation, or care bundles such as the ‘Sepsis Six’ (Box 1.1) can improve mortality and reduce rates of cardiac arrest. The CCOT’s role in sharing critical care skills, improving early recognition of deterioration, has empowered nurses to escalate care appropriately and is now a widely adopted approach to maintaining patient safety.

Monitoring the acutely unwell patient

Recommendations to improve the recording of six key physiological observations (Figure 1.2), include the use of multiparameter Early Warning Scores to help identify patients at risk and escalate care appropriately.⁸ The National Early Warning Score (NEWS)⁹ (see Chapter 3) is a well-validated tool in the recognition and prevention of deterioration, and is now used widely in acute care trusts throughout the UK. Acutely unwell patients require competent and confident nurses to interpret clinical signs, recognise risk of deterioration and escalate care to the appropriate healthcare professional, ensuring senior medical input occurs in a timely manner to optimise patient outcome.

2
Recognising risk of deterioration: ABCDE assessment

The acutely unwell patient

Most people in hospital are unlikely to become seriously unwell. If they should deteriorate, early detection through a detailed clinical assessment is essential so that nurses are able to identify the problem and ensure that appropriate care and treatments are given in a timely manner. When caring for an acutely unwell patient, the use of the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach helps keep the focus on those aspects of deterioration that are most likely to be life threatening, thereby improving patient outcome. This chapter gives an overview of each area, but these are also considered in more detail in later chapters.

...

Table of contents

• Cover
• E-book Logo
• Title Page
• Copyright
• Contributors
• Acknowledgements
• Preface
• Abbreviations
• About the companion website
• Part 1: Nursing in acute and critical care
• Part 2: Airway: maintaining airway patency
• Part 3: Breathing: patients with breathing problems
• Part 4: Circulation: patients with circulatory problems
• Part 5: Disability: patients with neurological impairment
• Part 6: Exposure
• Part 7: Decision making in acute and critical care
• Appendix
• References and Further Reading
• Glossary
• Index
• EULA