Palliative care is specialized medical care for people with life-limiting illness. The goals of palliative care are to improve symptom management, assess and support caregiver/family needs, and assist with care coordination. Palliative care consultations are appropriate for many hospitalized patients to provide extra support for the patient and family. Nurse practitioners should be discussing palliative care with patients and families when death within a year would not be surprising, and consider hospice when patients decline such that prognosis is likely to be death within 6 months. In fact, palliative care is increasingly being included in clinical practice guidelines as best practice. This chapter will help the Adult-Gerontology Acute Care Nurse Practitioner (AG-ACNP) learn overview of palliative care, key communication strategies, and SPIKES protocol for family meetings. It also helps the AG-ACNP learn the signs of the dying process, and symptom-management interventions.

The endocrine system can be confusing for many nurse practitioners. The pathophysiology and diagnostic interpretations can be challenging to commit to memory and are difficult to recall when needed in clinical situations. Many students memorize this information to successfully pass their academic exam and then rememorize for the national certification exam, only to realize that once in a great while the information is truly needed to care for a patient. This chapter helps the Adult-Gerontology Acute Care Nurse Practitioner (AG-ACNP) learn to differentiate between diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome; to manage diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome; and to interpret thyroid testing. It also helps the AG-ACNP learn the signs, symptoms, and treatment of thyroid storm and myxedema coma; and how to interpret a cosyntropin stimulation test.

Educational programs and scope of practice for Adult-Gerontology Acute Care Nurse Practitioners (AG-ACNPs) do not historically include obstetrical care. However, increasingly, obstetrical patients are requiring critical care services for a variety of conditions. To ensure AG-ACNPs remain within their scope of practice, a collaborative approach with the obstetrical team is required for optimal patient outcomes. Ongoing consultation with obstetrical physicians, midwives, nursing, pharmacy, and respiratory therapy should occur routinely throughout every shift. This chapter will help the AG-ACNP learn normal physiologic changes with pregnancy, drugs to use and avoid with pregnant patients, and to recognize and treat common obstetrical emergencies. Routine referencing of evidence-based resources should be done prior to any prescribing for pregnant or lactating patients.

Veterans of the armed forces are a special population and warrant special attention. Many who served do not consider themselves veterans, especially those who served during peace times, did not see combat, or were in the National Guard. Regardless, they have distinct needs due to physical or psychological injuries from the experiences and exposures that the average person doesn’t encounter. Many of these individuals seek care outside the Veterans Health Administration (VHA) healthcare system, thus Adult-Gerontology Acute Care Nurse Practitioners (AG-ACNPs) need to be able to meet their specific needs. This chapter will help the AG-ACNP learn questions pertinent to patients who have served in the armed services, specific illnesses/syndromes that are specific to each war, and management of veterans with posttraumatic stress disorder. The AG-ACNP should seek expert guidance from VHA providers to aid in meeting their needs.

Getting organized and staying organized throughout the shift are critical to providing care. And caring for acutely and critically ill patients requires flexibility to meet the patient and organizational needs. Some days start by seeing the most critical patients first to provide stabilization, while other shifts require discharging or transferring stable patients to make room for higher acuity patients. Thus, no two days are exactly the same. The key is having situational awareness and adjusting the routine accordingly. Communication with the charge nurse is critical to understanding the unit and institutional needs. This chapter helps the nurse practitioner to learn how to organize oneself to enhance efficiency. It describes a system of how to give and receive the handoff, and also how to triage patients. The chapter also helps the nurse practitioner to learn a systematic method to preround on their patients, and presents techniques to ensure follow-up on actionable items.

Hospitals are routinely at or exceeding capacity. With beds in high demand and emergency rooms overflowing, triaging, admitting and transferring patients to the appropriate level of care can be challenging. Understanding the institutional admission, discharge, and transfer criteria and processes is critical to ensuring appropriate utilization of resources and ensuring optimal patient outcomes. This chapter helps the Adult-Gerontology Acute Care Nurse Practitioner (AG-ACNP) to learn the criteria for appropriate placement of patients to intensive care, intermediate care, and ward care, with or without telemetry. It describes the considerations for triaging patients; options and criteria for post-hospital discharge facilities (long-term acute care hospital, acute rehab, subacute rehab, skilled nursing facility, home healthcare, hospice). The chapter also helps to identify the Centers for Medicare & Medicaid Services’ six conditions/procedures in the unplanned readmission measures.

A hospitalized patient’s baseline renal function can worsen secondary to acute conditions of dehydration, sepsis, and heart failure. Additionally, diagnostic and therapeutic interventions such as the use of contrast dye to enhance imaging modalities and medications like diuretics, antibiotics, or antihypertensives can propagate renal dysfunction. Acute kidney injury is one of the most common complications experienced by acutely and critically ill patients. This chapter will help the Adult-Gerontology Acute Care Nurse Practitioner (AG-ACNP) learn to identify the stages of chronic kidney disease; identify pre-, intra-, and postrenal causes of acute kidney injury;and define the diagnostic criteria for acute kidney injury. It also helps the AG-ACNP to classify acute kidney injury using RIFLE criteria; evaluate patient findings for the indications associated with the need for hemodialysis and continuous renal replacement therapy; and differentiate anion-gap and nonanion-gap metabolic acidosis.

Infectious disease management of hospitalized patients is a constant challenge for Adult-Gerontology Acute Care Nurse Practitioners (AG-ACNPs) to master. Mastery takes years to achieve and requires AG-ACNPs to remain abreast of emerging threats, evolving organisms which create new drug resistances, and new antibiotics being developed. The first step is to learn the normal flora found in each body system, as these commonly become pathogenic. The second step is to learn the clinical practice guidelines for common infections. As one gains experience, one will add to this knowledge base. This chapter helps the AG-ACNP learn the common infectious organisms by body location, the antibiotic choices prescribed to treat common organisms, treatment of common community-acquired infections, and treatment of common hospital-acquired infections. It also helps the AG-ACNP to identify the risk factors for fungal infections, and to recognize concerning multidrug-resistant organisms.

Adult-Gerontology Acute Care Nurse Practitioners (AG-ACNPs) commonly encounter conflicts while caring for acutely and critically ill patients and their families. Majority of such conflicts are easily resolved with effective communication and enhanced education. Unresolved conflicts can lead to ethical dilemmas and legal challenges. This chapter will help the AG-ACNP to learn the definitions of common ethical terms, and indications for ethics committee consultations. It also helps the AG-ACNP learn to differentiate between capacity and competency, the elements of informed consent, and to distinguish between claims made and occurrence malpractice insurance policies. Disclosure of medical errors is expected when harm is caused to a patient. This should be done as soon as facts are known and upon consultation with the risk-management department. AG-ACNPs will continue to encounter legal and ethical dilemmas throughout the tenure of their careers. Recognition of the issues and mobilization of resources are key to resolving the situation.

For most Adult-Gerontology Acute Care Nurse Practitioners (AG-ACNPs), the gastrointestinal (GI) system is a straightforward and logical system once anatomy and functionality are mastered. This chapter covers common situations such as GI prophylaxis indication and gastrointestinal bleeding. Additionally, some of the more challenging aspects of the GI tract are included, such as liver function test interpretation, hepatitis testing interpretation, calculating model for end-stage liver disease (MELD) scores, and Ranson’s criteria for pancreatitis. The chapter will help the AG-ACNP learn to evaluate patients for the indications to prescribe stress ulcer prophylaxis and Helicobacter pylori treatment options. It will also help the AG-ACNP, to interpret liver function tests, to interpret hepatitis laboratory testing, and how to calculate a MELD score. Patients with end-stage liver disease and elevated MELD scores should be referred to a hepatologist for evaluation and management, and possible workup and listing for liver transplant.