Essentials of Progressive Care Nursing

“We were never tired of visiting and examining and ausculting, and of examining and ausculting again and again,”
‐‐Peter Mere Latham (1789‐8175) Wendy Sue Killham RN, BSN, MSN, FNP‐s
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Recognize system‐based alterations in patient status through an integrative assessment and demonstrate accurate interpretation of medical information and assessment data in delivery of care.
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Discuss the importance discharge planning and list essential components of the process. Last week I was on Pediatrics as an instructor when I had the nurse LaWanna from Hematology and Oncology ask me if my student from yesterday Hillary would come back today. During Hillary’s clinical yesterday she meet a 7 year old boy and his family who have just found out he has cancer. Today was the day were they were to going to do multiple tests, that were very invasive on a child who had no medical history. I called Hillary and told her that her patient’s from yesterday was asking for her. We did not tell the patient that she was coming in. When she showed up, we went into the room and the patient looks at his mother and blushes and states "mom you did not have to tell everyone.”
I explained to my nursing student this day that she had made the greatest sacrifice for her patient. This child is going to remember her as a happy point during a time of despair, this is what a nurse is.
Progressive is defined by the Merriam‐Webster dictionary as
"moving forward or onward.” Progressive Care Nursing was adopted in the early 1970’s when it became apparent that having only Heart and Lung units was not enough to house the ever growing population of patient’s entering our hospitals. Not only were the patient acuity’s higher, the care of the patient was requiring more intensive specialized nursing care. Progressive Care Nursing is the “term the American Association of Critical‐Care Nurses (AACN) uses to collectively describe areas that are also referred to as Intermediate Care Units, Direct Observation Units, Step‐
down Units, Telemetry Units, or Transitional Care Units as well as to define a specific level of patient care.”
Long gone was your regular heart and lung, but many other’s that did not just need cardiac monitoring but a transition or step‐down to a critical unit was needed. So Progressive Nursing was born. The nurses no longer had just your myocardial patient, they had the myocardial patient who had a traumatic event such as a MVC or stroke that gave them a MI.
Scenario
• Patient is to be transferred from ICU to the current telemetry/ progressive care unit today.
• The patient has been up and out of bed in ICU, is off of his cardiogenic drips, continues to have his chest tubes in place, as well as his external pacemaker.
The Paitent
Arrival to the Unit
• The patient arrives to the unit in a wheelchair, with his chest tubes, connected to the pleural vac, his external pacemaker is connected to the patient and hanging on the IV pole. The patient is on 3L of oxygen by a nasal canula.
• What is the first assessment that you are going to do?
Assessment of the Cardiac Patient
• Head‐to‐toe initial Assessment
• What can be assessed on arrival of the patient?
• Patient’s Orientation • Skin
• Color, temperature, moisture
• Breathing
• Rate, depth, symmetrical
• Position of the patient
Assessment Triangle
Continued Assessment of the Cardiac Patient
• Head and Neck
• JVD, Tracheal Deviation, listening to the patient’s carotid’s?
• What are you looking for?
• How could this be a potential problem for this patient?
Continued Assessment of the Cardiac Patient
• Inspecting and Palpating the patient’s chest wall
• Precordium
• The front of the chest wall over the heart
• Important area
• Apex/mitral area (5th intercostal space, mid‐clavicular line)
Continued Assessment of the Cardiac Patient
• Auscultation of the Heart and Lung fields
Heart
• Know your anatomy!!
• Listen for S1 and S2
• S1 is when the AV valves close and indicates the start of systole
• S2 is when the closing of the semilunar valves and the end of systole • S3 and S4 are extra heart sounds that can indicate excessive fluid overload, as in CHF
• S1 is louder than S2 at the apex of the heart, S2 is louder than S1 at the base of the heart
• On Auscultation of the heart note the rate, rhythm, listen for murmurs, or extra heart sounds Continued Assessment of the Cardiac Patient
Lungs
• Know your anatomy
• Auscultate and listen for:
• Crackles or rales
• Wheeze or Rhonchi
• Diminished or distant lung sounds
• And listen anteriorly and posteriorly to compare sounds
• Note the rate of respirations, depth, level of consciousness of the patient, and skin color and condition
Anterior Lung Fields
Posterior Lung Fields
Continued Assessment of the Cardiac Patient
Neurovascular Status
• Assessing the patient’s pulses, on the affected extremity, and the opposite extremity
• Look for skin color
• Pallor, redness, cyanosis…
• What are the five “P’s”
• Pallor, Pain, Paresthia, paralysis, pressure
Medical Management of a Complex Cardiac / Trauma Patient
• Treatment Goals
• Wound healing
• Control of pain
• Control edema
• Assessment of depression and anxiety
• Discharge Planning
• Physical Therapy
• Occupational Therapy
• Cardiac Rehab
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Continued Assessment of the Cardiac Patient
When your are observing the patient’s skin color and condition, look at the face, hands, lower extremities
• Is there any edema? Is it pitting edema?
• Palpate pulses Central and peripheral. Compare the two. Where they normal, thready, bounding….. And of course not to be overlooked the patient’s vital signs including pain!!
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Albert, N.M. (2014). Improving Medication Adherence in Chronic Cardiovascular Disease. Critical Care Nurse, 28(5).
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Emergency Nursing Pediatric Course. (2012). Emergency Nurses Association, Fourth Edition.
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Jevon, P., & Cunnington, A. (2007). Cardiovascular Examination‐
Part Two: Inspection and palpation of the precordium. NursingTimes.net, 103 (26).
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Kurtz, K. (1990). Bruits and Hums of the Head and Neck. Clinical Methods: The History, Physical, and Laboratory Examination. 3 rd
Edition.
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Mace, S.E., & Mayer, T.A. Triage. Section IV –The Practice Environment. Retrieved from https://www.us.elsevierhealth.com/media/us/samplechapters/97814160
00877/Chapter%20155.pdf on January 12, 2014. •
Roguin, A. (2006). Rene Theophile Hycinthe Laennec (1778 – 1826): The Man Behind the Stehoscope. Clinical Medicine & Research, 4 (3).
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Physical Assessment (Adult). (2014). Retrieved from http://www.atitesting.com/ati_next_gen/skillsmodules/content/physical
‐assessment‐adult/equipment/cardiac.html on January 10, 2014.