Caring Practices May Save a Life.

Abstract

Sara Knippa, ms, rn, cns, ccrn, pccn, accns-ag, is the contributing editor of the column. Sara is clinical nurse specialist/educator in the cardiac intensive care unit at University of Colorado Hospital, Aurora, Colorado. She welcomes feedback from readers and practice questions from potential contributors at sara.knippa.cns@gmail.com. Sara wrote the introduction and CCRN review questions 3 through 5.KNIPPALeanna Leyes, bsn, rn, ccrn, is a clinical nurse in the intensive care unit at St. Charles Health System, Bend, Oregon. Leanna wrote CCRN review questions 1 and 2.LEYESAlyson Dare Kelleher, bsn, rn, ccrn-k, Naperville, Illinois, has more than 10 years’ experience working with cardiac surgery patients. Alyson wrote CSC review question 3 and cowrote questions 1, 4, and 5.KELLEHERJennifer Popies, ms, rn, ccrn-k, acns-bc, is a cardiovascular intensive care unit clinical nurse specialist at Froedtert Hospital, Milwaukee, Wisconsin. Jennifer wrote CSC review question 2 and cowrote questions 1, 4, and 5.POPIESOne year ago, at AACN’s National Teaching Institute, I attended a session that challenged me and gave me insight that may help me save a life someday. This impactful presentation was not about advanced life support techniques or interpretation of electrocardiograms. Instead, it was about recognizing and caring for patients with suicidal ideation. As the presenter spoke, I recognized my temptation to respond to these hurting patients by saying the right words but withholding the personal engagement necessary for true caring. This need to withhold personal engagement is one we all have at times: to maintain emotional distance between ourselves and our hurting patients. But, sometimes, the words of a fully engaged and caring nurse could be the difference between despair and the sight of a small ray of hope.In many situations, caring practices are just as important as clinical practice, and that is why caring practices is one of the Synergy competencies tested on the CCRN and PCCN examinations. The Synergy Model describes characteristics of a nurse expert in caring practices as “fully engaged with and sensing how to stand alongside” the patient and the patient’s family. I have invited an expert in caring practice for suicidal patients to share some tips. The Professional Caring and Ethical Practice questions (CCRN questions 1 and 2) were written by the primary presenter of that session at the National Teaching Institute in 2018.Perceptions of hopelessness and of being a burden to others are themes of suicidal thinking. Anytime a nurse suspects current suicidal ideation, the patient should be assessed by using a suicide screening tool. Of special importance, any patient with a risk for suspected suicide should be reassessed at discharge. Although family dynamics and resources (A) and understanding of a heart failure teaching and discharge plan (C) are important considerations for discharge, suicidal ideation would put the patient at increased risk for death after discharge if not addressed and is the most critical factor to reassess at this time. A cultural and spiritual needs assessment (B) may provide insight into the patient’s belief system but will not directly address the risk for suicide indicated by the patient’s subjective complaints of hopelessness.Letting a person know that they have been heard, that someone cares, and that they are not alone are therapeutic responses that help a suicidal person feel hope. Understanding and hope can be lifesaving tools in suicidal ideation. Keeping the person safe should be a collaborative effort that is patient centered. Deferring immediately to a social worker (A), with no therapeutic response from the nurse, may make a person feel the nurse does not have the time to help them or perhaps does not personally care. A nurse’s response of “Please don’t say . . . that” (C) may cause the person to feel unheard, not validated, or judged. Focusing on the patient’s family (D) may cause the patient to feel guilty, rather than heard and valued.The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is a validated delirium assessment tool for critical care patients who can follow simple commands. Even if a patient is receiving sedation (A) or cannot speak (B) because of mechanical ventilation, the CAM-ICU can be used. The tool requires patients to indicate yes and no in some way (eg, squeeze of the hand, nod of the head, blink of the eyes), so responding to or localizing pain (C) is not purposeful enough to allow completion of the assessment.Pulmonary fibrosis is a potential complication associated with administration of amiodarone that can lead to acute or chronic respiratory failure. Inflammation of the lung tissue causes the respiratory symptoms. Angiotensin-converting enzyme inhibitors such as lisinopril (A) can cause cough and angioedema but not changes in lung tissue. Nonselective β-blockers such as propranolol (B) can cause bronchoconstriction, especially in patients with asthma or chronic obstructive pulmonary disease but not pulmonary infiltrates. Angiotensin II receptor blockers such as losartan (D) are less likely than angiotensin-converting enzyme inhibitors to cause a cough and are often used as an alternative medication.Generalized seizure activity and the sedative medications given in status epilepticus impair a patient’s ability to protect their own airway. Endotracheal intubation provides both a secure airway and oxygen delivery. As seizure activity is prolonged, large doses of sedatives are given, making the use of BiPAP (A) inadequate and unsafe in this situation. BiPAP (A) and oxygen administration (D) require adequate ventilatory effort, and the bedside monitor may interpret seizure movement as respiratory effort, making the displayed respiratory rate inaccurate. Nasal airways are appropriate initially, but oral airways (C) should not be inserted because they may stimulate vomiting or injure the patient’s teeth or mouth. Oxygen administration (D), while appropriate at the onset of seizure activity, will also be inadequate in status epilepticus because the intervention will not support ventilation.The patient most likely is having pulseless electrical activity (PEA) because of cardiac tamponade. The cardiac electrical activity continues without mechanical response. High-quality cardiopulmonary resuscitation should be started on patients in PEA until surgical decompression. Ensuring or increasing the output on the pacemaker (B) will not affect mechanical contractility. The arterial catheter most likely is accurate (C), because PEA will not have a corresponding blood pressure. Manipulation of chest tubes to maintain patency (D) is not the priority, and stripping of chest tubes may cause an increase in intrathoracic pressures in the pleural space that could lead to lung entrapment.The tip of the IABP should be positioned in the proximal descending thoracic aorta, just below the point where the left subclavian artery branches off. If the IABP is too high, a diminished pulse to the left hand may occur. Hourly assessment of the patient’s urine output (A) is important, but a decrease would potentially indicate the IABP catheter is placed too low, occluding the renal arteries, rather than too high. Similarly, hourly assessment of the patient’s lower extremity pulses (B) is important in detecting development of lower extremity ischemia, but the ischemia would not occur because placement of the IABP catheter was too high. Continuous monitoring of the skin color and temperature of the patient’s right hand (D) would not be indicated because catheter misplacement would not be expected to affect perfusion to the right upper extremity.Risk for thromboembolism remains in the early recovery period, particularly if a left atrial appendage was not ligated or the patient remains in atrial fibrillation. Early rhythm is not indicative of surgical success (A). Freedom from atrial fibrillation should be assessed at 6 and 12 months. If the patient remains in atrial fibrillation, medications need to be maintained (B). Risk for myocardial infarction is not specific to this procedure, and the patient most likely would not receive a prescription for nitroglycerin (C) at discharge.Inability to flex at the hip is a sign of increased spinal cord pressure resulting in paraplegia. Removal of cerebrospinal fluid will decrease the pressure in an attempt to restore lower-extremity movement. Whereas any of the other findings should prompt an alert to the provider for intervention, manipulating the lumbar drain would not affect perfusion to the arm (A) or kidneys (C), and the drain is not present for management of intracranial pressure (D).The patient has lost a moderate amount of volume through the chest tube since surgery and the hemodynamic profile is indicative of a hypovolemic state (slightly tachycardic and slightly low mean arterial pressure, diastolic pulmonary artery pressure, and cardiac index coupled with a slightly elevated systemic vascular resistance due to the compensatory efforts of the patient’s vascular system). Therefore, the nurse should anticipate volume replacement, such as albumin. Neither the patient’s chest tube output volume or description nor the hemodynamic profile matches an impending tamponade or other cardiac emergency that would require immediate chest reentry (B). Although the patient’s mean arterial pressure and cardiac index are slightly low, volume status should be optimized before inotropic or vasopressor supports such as milrinone (C) or norepinephrine (D) are started.AACN Certcorp publishes a study bibliography that identifies the sources from which items are validated. The document may be found in the AACN Certification exam handbook. The contributor of each question written for this column has listed the source used in developing each item.