D



D



5250


Decision-Making Support


Definition: Providing information and support for a patient who is making a decision regarding health care


Activities:



• Determine whether there are differences between the patient’s view of own condition and the view of health care providers


• Assist patient to clarify values and expectations that may assist in making critical life choices


• Inform patient of alternative views or solutions in a clear and supportive manner


• Help patient identify the advantages and disadvantages of each alternative


• Establish communication with patient early in admission


• Facilitate patient’s articulation of goals for care


• Obtain informed consent, when appropriate


• Facilitate collaborative decision making


• Be familiar with institution’s policies and procedures


• Respect patient’s right to receive or not to receive information


• Provide information requested by patient


• Help patient explain decision to others, as needed


• Serve as a liaison between patient and family


• Serve as a liaison between patient and other health care providers


• Use interactive computer software or web-based decision aides as an adjunct to professional support


• Refer to legal aid, as appropriate


• Refer to support groups, as appropriate


1st edition 1992; revised 2008



4095


Defibrillator Management: External


Definition: Care of the patient receiving defibrillation for termination of life-threatening cardiac rhythm disturbances


Activities:



• Initiate cardiopulmonary resuscitation, as indicated


• Prepare for immediate defibrillation of pulseless, unresponsive patient in conjunction with cardiopulmonary resuscitation


• Maintain cardiopulmonary resuscitation when not administering external defibrillation


• Determine type and operation techniques for available defibrillator


• Apply pads or paddles according to machine recommendations (e.g., paddles need conduction agent; pads are ready-made with conduction agent)


• Place appropriate monitoring devices on patients (automated external defibrillator pads or monitor leads)


• Place paddles or pads to avoid clothing or bed linens, as appropriate


• Determine need for shock per defibrillator instructions or interpretation of arrhythmia


• Charge machine to appropriate joules


• Use safety precautions before discharging (e.g., call “clear” three times, ensure no one is touching the patient including self)


• Monitor results and repeat as indicated


• Minimize interruptions to chest compressions in unresponsive patients


• Record events appropriately


• Assist in patient recovery as indicated (e.g., activate emergency medical systems when out of hospital for transport of patient to emergency care institution; arrange for transport within hospital to appropriate nursing unit for intensive cardiac care as indicated)


• Instruct new nursing staff on type and operation techniques for available defibrillator


• Assist in education of public related to proper use and indications of external defibrillation in cardiopulmonary arrest


5th edition 2008




4096


Defibrillator Management: Internal


Definition: Care of the patient receiving permanent detection and termination of life-threatening cardiac rhythm disturbances through the insertion and use of an internal cardiac defibrillator


Activities:



• Provide information to patient and family related to defibrillator implantation (e.g., indications, functions, cardioversion experience, required lifestyle changes, potential complications)


• Provide concrete, objective information related to the effects of defibrillator therapy to reduce patient uncertainty, fear, and anxiety about treatment-related symptoms


• Document pertinent data in patient’s permanent record regarding initial insertion of defibrillator (e.g., manufacturer, model number, serial number, implant date, mode of operation, capability for pacing and/or shock delivery, delivery system for shocks, upper and lower rate limits for rate-responsive devices)


• Confirm defibrillator placement post-implantation with baseline chest x-ray


• Monitor for potential complications associated with defibrillator insertion (e.g., pneumothorax, hemothorax, myocardial perforation, cardiac tamponade, hematoma, PVCs, infections, hiccups, muscle twitches)


• Observe for changes in cardiac or hemodynamic status, which indicate a need for modifications of defibrillator parameters


• Monitor for conditions that potentially influence sensing (e.g., fluid status changes, pericardial effusion, electrolyte or metabolic abnormalities, certain medications, tissue inflammation, tissue fibrosis, tissue necrosis)


• Monitor for arm swelling or increased warmth on side ipsilateral to implanted device and leads


• Monitor for redness or swelling at the device site


• Instruct patient to avoid tight or restrictive clothing that might cause friction at insertion site


• Instruct patient on activity restrictions (e.g., initial arm movement restrictions for pectoral implantations, avoidance of heavy lifting, avoid contact sports, adhere to driving restrictions)


• Monitor for symptoms of arrhythmias, ischemia, or heart failure (e.g., dizziness, syncope, palpitations, chest pain, shortness of breath) particularly with each outpatient contact


• Instruct patient and family member(s) regarding symptoms to report (e.g., dizziness, fainting, prolonged weakness, nausea, palpitations, chest pain, difficulty breathing, discomfort at insertion or external electrode site, electrical shocks)


• Instruct patient about emergent symptoms and what to do if symptoms occur (e.g., call emergency responders if dizzy)


• Monitor drug and electrolyte levels for patients receiving concurrent antiarrhythmic medications


• Monitor for metabolic conditions with adverse effects on defibrillators (acid-base disturbances, myocardial ischemia, hyperkalemia, severe hyperglycemia [greater than 600 mg/dl], renal failure, hypothyroidism)


• Instruct patient about potential defibrillator complications from electromagnetic interference (inappropriate discharges, potential proarrhythmic effects of defibrillator, decreased defibrillator generator life, cardiac arrhythmia, and cardiac arrest)


• Instruct patient about basic safety in avoidance of electromagnetic interference (e.g., keep at least 6 inches away from sources of interference, do not leave cell phones in the “on” mode in a shirt pocket over the defibrillator)


• Instruct patient about sources of highest electromagnetic interference (e.g., arc welding equipment, electronic muscle stimulators, radio transmitters, concert speakers, large motor-generator systems, electric drills, handheld metal detectors, magnetic resonance imaging, radiation treatments)


• Instruct patient regarding special considerations at airport or government building security gates (e.g., always inform security guard of implantable defibrillator, walk through security gates, DO NOT allow handheld metal detectors near the device site, always walk quickly through metal detection devices or ask to be searched by hand, do not lean on or stand near detection devices for long periods)


• Instruct patient that handheld metal detectors contain magnets that can reset the defibrillator and cause malfunction


• Instruct patient to check manufacturer warnings when in doubt about household appliances


• Instruct patient to carry manufacturer identification card at all times


• Instruct patient to wear a medical alert bracelet or necklace that identifies defibrillator


• Instruct patient about the need for regular checkups with primary cardiologist


• Monitor for defibrillator problems that have occurred between scheduled checkup visits (e.g., inappropriate discharges, frequent discharges)


• Instruct patient to keep a detailed log of all discharges (e.g., time, location, and activity of patient when discharge occurred, physical symptoms before and after discharge) to review with the physician


• Instruct patient to consult primary cardiologist for all changes in medications


• Instruct patient with new defibrillator to refrain from operating motor vehicles until permitted per primary cardiologist (usually 3 to 6 months after the last symptomatic arrhythmic event)


• Instruct patient about the need for regular interrogation of defibrillator by cardiologist for routine maintenance


• Instruct patient about the need to obtain chest x-ray annually for defibrillator placement confirmation


• Avoid frightening family or friends about unexpected shocks


• Instruct patient’s family (particularly sexual partners) that no harm comes to a person touching a patient who is receiving a defibrillator discharge (e.g., may feel the shock, but it is not harmful)


• Teach patient and family member(s) precautions and restrictions required


• Explore psychological responses (e.g., changes in self-image, depression due to driving restrictions, fear of shocks, increased anxiety, concerns related to sexual activities, changes in partner relationships)


• Encourage patient and family members to attend CPR classes


• Encourage attendance at support group meetings


5th edition 2008



7650


Delegation


Definition: Transfer of responsibility for the performance of patient care while retaining accountability for the outcome


Activities:



• Determine the patient care that needs to be completed


• Identify the potential for harm


• Evaluate the complexity of the care to be delegated


• Determine the problem-solving and innovative skills required


• Consider the predictability of the outcome


• Evaluate the competency and training of the health care worker


• Explain the task to the health care worker


• Determine the level of supervision needed for the specific delegated intervention or activity (e.g., physically present or immediately available)


• Institute controls, so that the nurse can review the interventions or activities of the health care worker and intervene, as necessary


• Follow up with health care workers on a regular basis to evaluate their progress in completing the specific tasks


• Evaluate the outcome of the delegated intervention or activity and the performance of the health care worker


• Monitor patient’s and family’s satisfaction with care


2nd edition 1996




6440


Delirium Management


Definition: Provision of a safe and therapeutic environment for the patient who is experiencing an acute confusional state


Activities:



• Identify etiological factors causing delirium (e.g., check hemoglobin oxygen saturation)


• Initiate therapies to reduce or eliminate factors causing the delirium


• Recognize and document the motor subtype of the delirium (e.g., hypoactive, hyperactive, and mixed)


• Monitor neurological status on an ongoing basis


• Increase surveillance with a delirium rating scale universally understood by nursing staff when confusion first appears so that acute changes can be easily tracked


• Use family members or friendly hospital volunteers for surveillance of agitated patients instead of restraints


• Acknowledge the patient’s fears and feelings


• Provide optimistic but realistic reassurance


• Allow the patient to maintain rituals that limit anxiety


• Provide patient with information about what is happening and what can be expected to occur in the future


• Avoid demands for abstract thinking if patient can think only in concrete terms


• Limit need for decision making if frustrating or confusing to patient


• Administer PRN medications for anxiety or agitation, but limit those with anticholinergic side effects


• Reduce sedation in general, but do control pain with analgesics, as indicated


• Encourage visitation by significant others, as appropriate


• Do not validate a delirium patient’s misperceptions or inaccurate interpretations of reality (e.g., hallucinations or delusions)


• State your perception in a calm, reassuring, and nonargumentative manner


• Respond to the tone, rather than the content, of the hallucination or delusion


• Remove stimuli, when possible, that create excessive sensory stimuli (e.g., television or broadcast intercom announcements)


• Maintain a well-lit environment that reduces sharp contrasts and shadows


• Assist with needs related to nutrition, elimination, hydration, and personal hygiene


• Maintain a hazard-free environment


• Place identification bracelet on patient


• Provide appropriate level of supervision and surveillance to monitor patient and to allow for therapeutic actions, as needed


• Use physical restraints, as needed


• Avoid frustrating patient by quizzing with orientation questions that cannot be answered


• Inform patient of person, place, and time, as needed


• Provide a consistent physical environment and daily routine


• Provide caregivers who are familiar to the patient


• Use environmental cues (e.g., signs, pictures, clocks, calendars, and color coding of environment) to stimulate memory, reorient, and promote appropriate behavior


• Provide a low-stimulation environment for patient in whom disorientation is increased by overstimulation


• Encourage use of aids that increase sensory input (e.g., eyeglasses, hearing aids, and dentures)


• Approach patient slowly and from the front


• Address the patient by name when initiating interaction


• Reorient the patient to the health care provider with each contact


• Communicate with simple, direct, descriptive statements


• Prepare patient for upcoming changes in usual routine and environment before their occurrence


• Provide new information slowly and in small doses, with frequent rest periods


• Focus interpersonal interactions on what is familiar and meaningful to the patient


1st edition 1992; revised 2013




6450


Delusion Management


Definition: Promoting the comfort, safety, and reality orientation of a patient experiencing false, fixed beliefs that have little or no basis in reality


Activities:



• Establish a trusting, interpersonal relationship with patient


• Provide patient with opportunities to discuss delusions with caregivers


• Avoid arguing about false beliefs; state doubt matter-of-factly


• Avoid reinforcing delusional ideas


• Focus discussion on the underlying feelings, rather than the content of the delusion (“It appears as if you may be feeling frightened.”)


• Provide comfort and reassurance


• Encourage patient to validate delusional beliefs with trusted others (e.g., reality testing)


• Encourage patient to verbalize delusions to caregivers before acting on them


• Assist patient to identify situations where it is socially unacceptable to discuss delusions


• Provide recreational, diversional activities that require attention or skill


• Monitor self-care ability


• Assist with self-care, as needed


• Monitor physical status of patient


• Provide for adequate rest and nutrition


• Monitor delusions for presence of content that is self-harmful or violent


• Protect the patient and others from delusionally-based behaviors that might be harmful


• Maintain a safe environment


• Provide appropriate level of surveillance/supervision to monitor patient


• Reassure the patient of safety


• Provide for the safety and comfort of patient and others when patient is unable to control behavior (e.g., limit setting, area restriction, physical restraint, or seclusion)


• Decrease excessive environmental stimuli, as needed


• Assist patient to avoid or eliminate stressors that precipitate delusions


• Maintain a consistent daily routine


• Assign consistent caregivers on a daily basis


• Administer antipsychotic and antianxiety medications on a routine and as needed basis


• Provide medication teaching to patient/significant others


• Monitor patient for medication side effects and desired therapeutic effects


• Educate family and significant others about ways to deal with patient who is experiencing delusions


• Provide illness teaching to patient/significant others, if delusions are illness-based (e.g., delirium, schizophrenia, or depression)


2nd edition 1996




6460


Dementia Management


Definition: Provision of a modified environment for the patient who is experiencing a chronic confusional state


Activities:



• Include family members in planning, providing, and evaluating care, to the extent desired


• Identify usual patterns of behavior for such activities as sleep, medication use, elimination, food intake, and self-care


• Determine physical, social, and psychological history of patient, usual habits, and routines


• Determine type and extent of cognitive deficit(s) using standardized assessment tool


• Monitor cognitive functioning, using a standardized assessment tool


• Determine behavioral expectations appropriate for patient’s cognitive status


• Provide a low-stimulation environment (e.g., quiet, soothing music; nonvivid, simple, familiar patterns in decor; performance expectations that do not exceed cognitive processing ability; and dining in small groups)


• Provide adequate nonglare lighting


• Identify and remove potential dangers in environment for patient


• Place identification bracelet on patient


• Provide a consistent physical environment and daily routine


• Prepare for interaction with eye contact and touch, as appropriate


• Introduce self when initiating contact


• Address the patient distinctly by name when initiating interaction, and speak slowly


• Give one simple direction at a time


• Speak in a clear, low, warm, respectful tone of voice


• Use distraction, rather than confrontation, to manage behavior


• Provide unconditional positive regard


• Avoid touch and proximity if this causes stress or anxiety


• Provide caregivers that are familiar to the patient (e.g., avoid frequent rotations of staff assignments)


• Avoid unfamiliar situations when possible (e.g., room changes and appointments without familiar people present)


• Provide rest periods to prevent fatigue and reduce stress


• Monitor nutrition and weight


• Provide space for safe pacing and wandering


• Avoid frustrating patient by quizzing with orientation questions that cannot be answered


• Provide cues—such as current events, seasons, location, and names—to assist orientation


• Seat patient at small table in groups of three to five for meals, as appropriate


• Allow to eat alone, if appropriate


• Provide finger foods to maintain nutrition for patient who will not sit and eat


• Provide patient a general orientation to the season of the year by using appropriate cues (e.g., holiday decorations; seasonal decorations and activities; and access to contained, out-of-doors area)


• Decrease noise levels by avoiding paging systems and call lights that ring or buzz


• Select television or radio activities based on cognitive processing abilities and interests


• Select one-to-one and group activities geared to the patient’s cognitive abilities and interests


• Label familiar photos with names of the individuals in photos


• Select artwork for patient rooms featuring landscapes, scenery, or other familiar images


• Ask family members and friends to see the patient one or two at a time, if needed, to reduce stimulation


• Discuss with family members and friends how best to interact with the patient


• Assist family to understand it may be impossible for patient to learn new material


• Limit number of choices patient has to make, so not to cause anxiety


• Provide boundaries, such as red or yellow tape on the floor, when low-stimulus units are not available


• Place patient’s name in large block letters in room and on clothing, as needed


• Use symbols, other than written signs, to assist patient to locate room, bathroom, or other areas


• Monitor carefully for physiological causes of increased confusion that may be acute and reversible


• Remove or cover mirrors, if patient is frightened or agitated by them


• Discuss home safety issues and interventions


2nd edition 1996; revised 2004

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