The CARES tool, in addition to assisting nurses with delivery of evidence-based care of the dying and viewing the care of the dying as an acute event, also needed to be portable and readily accessible. An extensive review of the literature found the most basic common needs of the dying included pain management and comfort measures, breathing assistance, control of delirium, emotional and spiritual support, and self-care for caregivers. This chapter discusses some issues: Nurses receive little to no education on care of the dying and feel they have minimal time to attend in-services, and can be resistant to learning new skills; communication is the foundation for end-of-life care; the nurses’ past personal and professional experiences with death can greatly impact the care they provide dying patients and their families. These issues and concerns helped organize and shape the final version of the CARES tool.
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Embracing the role of a nurse practitioner with a doctorate in nursing practice (DNP) requires taking on the additional challenge of acting as an effective change agent. A DNP’s primary role is to act as a bridge between research and the bedside nurse. A strong clinical background assists in translating research findings into realistic evidence-based practices that nurses can readily incorporate into their daily routines. Nurses needed to learn what resources were available to meet the specific needs of the dying and how to promote a peaceful death. The CARES tool attempts to give some sense of order and structure to the care of the dying. The CARES tool is based on the immense educational resources provided by experts from the End-of-Life National Education Consortium (ELNEC), the National Consensus Project for Quality Palliative Care, and from evidence-based literature reviews.
In the postpartum period, secondary postpartum hemorrhage (SPPH) and endometritis are two conditions that frequently present to an obstetric triage unit. These complications may coexist and can occur from 24 hours postpartum to 6 weeks postdelivery. SPPH is typically not as severe as a primary bleeding episode. Postpartum women ultimately diagnosed with endometritis are generally stable, but less commonly can present in septic shock. This chapter discusses presenting symptomatology, history and data collection, physical examination, laboratory and imaging studies, differential diagnosis, and clinical management and follow-up of secondary postpartum hemorrhage and postpartum endometritis. Prompt treatment of both SPPH and postpartum endometritis can reduce maternal morbidity and mortality. SPPH is managed with the same guiding principles as primary postpartum hemorrhage. Initial treatment for postpartum endometritis is intravenous clindamycin and gentamicin.
Pregnant women presenting with abdominal pain to an emergency department or obstetric triage setting frequently have a diagnostic ultrasound (US) to assess fetus, placenta, and adnexae. In the first trimester, symptomatic adnexal masses typically present with unilateral or bilateral pelvic cramping or pressure. Obtaining a history in a pregnant woman with abdominal pain is similar to doing so for the nonpregnant patient. In addition to routine cardiopulmonary examination, abdominal examination, and assessment for costovertebral angle tenderness, a sterile speculum and vaginal examination are performed to evaluate for adnexal or uterine tenderness, cervical dilation, and potential rupture of membranes. If a mass is suspected, US is the preferred imaging modality. Magnetic resonance imaging can be employed if additional imaging is needed. Differential diagnosis of abdominal pain in pregnant women must include other obstetric and nonobstetric causes of pain. This chapter describes clinical management and follow-up of pregnant women with adnexal masses.
Maternal sepsis is a common pregnancy-related condition; in the United States, it is a leading cause of maternal mortality, accounting for up to 28” of maternal deaths and up to 15” of maternal admissions to the intensive care unit. One contributing and modifiable factor to these deaths is failure to recognize sepsis, leading to delays in treatment. Therefore, rapid and accurate diagnosis and initial management of sepsis in pregnancy in the emergency department (ED) is paramount. Pregnancy poses a unique challenge given the baseline physiologic changes and the need to care for the mother while simultaneously caring for the fetus. Therefore, without clear pregnancy-specific data, recommendations are to follow the current guidelines for nonpregnant adults, yet be cognizant of the ways in which pregnancy may change maternal physiology and affect fetal well-being. Prompt identification and treatment of maternal sepsis will undoubtedly lead to the best possible maternal and neonatal outcomes.
Intimate partner violence (IPV) and sexual assault are common violent crimes perpetrated on women. Obstetric (OB) complications associated with trauma include miscarriage, preterm labor, and placental abruption. Ongoing mental health issues, including depression and anxiety, are more prevalent in pregnant women subjected to any form of IPV, whether or not direct physical violence is involved. One study showed that pregnant women subjected to verbal threats were twice as likely to deliver low-birth-weight infants. All women who present to an OB triage unit or an emergency department (not just those who present with an injury or complication) must be screened for IPV. An organized plan for providing the victim with resources must be readily available when a screen is positive. This chapter discusses presenting symptomatology, history and data collection, physical examination, laboratory and imaging studies, differential diagnosis, clinical management and follow-up care of IPV and sexual assault.
Critical and acute care nursing practice is intellectually and emotionally challenging, requiring quick judgments and responses to life-threatening conditions where little margin for error exists. Developing expertise in acute and critical care practice requires experiential learning under pressure and ‘thinking-in-action’. This book briefly describes the nature of engaged ethical and clinical reasoning. Experiential clinical learning and situated coaching are central to the formation of the nurse’s skills, perceptual acuities, knowledge and relational qualities required in nursing practice. The book also provides an educational planning document to assist nurses in developing expert clinical practice. Multiple aspects of clinical judgment and skillful comportment are highlighted in each of the domains of practice. Clinical reasoning requires reasoning-in-transition about particular patients and families. Perceptual acuity is linked with emotional engagement with the problem and interpersonally with patients and families.
This chapter illustrates how comforting patients forms a backdrop for clinical judgment and care of acute and critically ill patients, whether they are in the hospital, in transport, or at home. Central to nursing practice are many comfort measures. The chapter provides many examples about the everyday comfort measures of caring for the body: grooming, shampooing hair, positioning, range of motion exercises, and back rubs. Comforting another person through connection and relationship refers to meeting another in ways that sustain a sense of trust and being cared for. The chapter offers an example of weighing the issues of providing pain relief and managing the risks of respiratory depression through human presence and gentle stimulation to highlight the ethical role of providing human solace and comfort. Discerning how close and how far away to be with patients and being available without being intrusive are critical distinctions in learning to be comforting.
This chapter describes nurses’ care of acute and critically ill patients’ families, highlighting the clinical judgment and skill required for this important relational work. A crucial aspect of family care is ensuring that a family can be with their ill loved one, as family access promotes family cohesion, connection, and closure, fosters patient well-being and provides the family with information. Commonly cited rationales to limit family access include: concerns regarding patient stability, infection, rest, privacy, the effect of visitation on the family, space limitations and healthcare providers’ performance abilities. Encouraging family involvement in care giving activities is another essential aspect of family care, and can range from minor involvement to major involvement. An excerpt highlights some of the difficulties associated with shifting care giving responsibilities from healthcare providers to family members who may be unable to see other options.
Crisis situations are common in the care of acutely and critically ill patients. A psychiatric crisis calls for de-escalation strategies, security personnel, sedation, and restraints. During a crisis, in addition to providing direct care in response to the patient’s urgent physiological needs for intervention, the nurse must also prepare, orchestrate, and coordinate multiple aspects of the environment. Acute and critical care environments are generally set up at all times for a possible emergency. Experiential leadership is seeing what needs to or must be done before or during a crisis and doing it, even though a physician is present. Recognizing clinical talent and marshaling skilled clinicians requires astute clinical judgment and skill and is a pervasive aspect of caring for critically ill patients in crisis. An aspect of skilled know-how required for smooth management of a crisis is modulating one’s emotional responses to assist others in their ability to function well.