Welcome! My name is Diana Shenefield, and
the lecture that we're going to talk
about today, the topic is Illness Management.
So what all is encompassed by
wellness management? Well, as you can see on
the screen that the nurse manages and
provides for cares of patients with acute,
chronic and life threatening
illnesses. We know that. So this is just a
kind of an overview of what does that mean.
We're also going to talk about when should
we be calling the physician.
Failure to treat, failure to react is one of
the main reasons that we see
lawsuits in the United States, and I'm sure
in other countries as well.
If nurses aren't watching for certain symptoms,
certain signs, that are leading up to,
dramatic effects or different illnesses. So
again, what all do we need to know for
illness management? So what are our learning
outcomes for this lecture? We're going to
evaluate the effectiveness of treatment.
Part of our nursing process is to evaluate,
and we think that we do a
pretty good job of evaluation, but I think
we can do a lot better. So don't
forget when you're taking NCLEX test that it's
not just about assessment and
intervention, but that we need to go back
and we need to evaluate. Is what we're
doing, is the treatment plan effective? If it's
not, we need to change, maybe we need
to modify, maybe we need to start all over.
But again, we can't know that until we
evaluate. We need to identify patient data
that needs to be reported
immediately. That means watching our labs,
watching our vital signs, watching signs
and symptoms after giving medication. What
do I need to react on right away?
What patients do I need to go back and check
on more often than maybe hourly?
I need to apply knowledge of pathophysiology.
Again that just keeps,
that class just keeps popping in there, just
like pharmacology, but again if I don't
understand the disease process that my patient
has, I'm going to miss some signs
and symptoms. What about educating the
patient about managing their illness?
Sometimes patients come in to the hospital
and we assume that they know they
have COPD and they know what to do.
If we all assume that,
nobody has probably done teaching. So we're
going to talk a little bit about that.
So let's start off with a practice question,
an example of a question you
might see on the NCLEX exam: The nurse is
providing discharge instructions to a
patient going home on Lovenox. Again, be
thinking about Lovenox. What kind of
patients would be on Lovenox and then what
is special about Lovenox? Which of
the following responses by the patient
indicates to the nurse that they
understand? One of the things you're
going to want to watch on NCLEX is
sometimes they are going to ask you, how do
you know if they understand? Or how do
you know if your teaching was not effective?
Make sure you're reading your
question and make sure you understand, are
you looking for something wrong?
Or are you looking for something right? In
this case we're looking for something
right. So A, the patient says to you, "After
the injection, I'll rub the site with an
alcohol wipe." What about B, "I will use the
same site for each injection."
So again, be thinking about those times that
you gave Lovenox. What would be the right
response? C, the patient says to you, "I
will not pull back on the plunger after
inserting the needle into the skin." Or D,
"After the injection, I'll massage the site
to increase absorption." Again, if you
don't remember Lovenox, it's going to be
kind of hard for you to understand this
question. But again,
think about IM injections or subQ injections,
what do you know about those
injections and hopefully that will help you
narrow it down. The answer to this
question is C. You don't want them to pull
back, you don't want them to aspirate.
Again, this is a big red flag, if you don't
remember this go back and look.
Okay, generally what are we going to talk about?
As a nurse, I need to recognize symptoms
and I need to plan my interventions according
to those symptoms. I don't just
have a book in front of me that says do this,
do this, do this. My patient is
independent and they are different patient
from one room to the next room.
And even if I have five patients all with COPD,
each one of them is different. And
so I need to base what I do
for them, and with them, and medications that
I give, based on their
symptoms. So I need to be able to recognize
those symptoms in each of my
patients. I also need to understand pathophysiology,
which I said before.
A lot of times students will say to me, "How
can NCLEX expect me to know every
disease process?" And you know what? They know
that you don't know everything.
Every nurse doesn't know everything. But what
they are looking for are main,
disease processes, main body systems. But
then are they looking at, are you a
competent safe nurse that if you don't know a
disease process that you'll go
look it up? The nurse is going to use clinical
judgement. I know you've heard that a lot
from your instructors about clinical judgement,
critical thinking. This is where
it all comes together, and so NCLEX isn't going
to ask you plain and simple
questions. They are going to want to see are you
thinking through your patient, and
are you thinking through when is it
important that I need to let the
physician know right away, or when is it
important that I have parameters that I
can follow. And then teaching. Teaching is a
huge part of what we do as nurses.
We owe it to our patients to make sure that they
understand what's happening to them.
What the process of their disease process is,
what the medications are going
to do to them, and what they need to do at home.
And we need to look at each part,
and we know discharge teaching begins
the minute we first see the patient.
So again, as you're looking at NCLEX questions,
make sure you're thinking
Will this patient be safe? Do they have the
knowledge that they need to take
care of themselves? So reporting to the physician.
Again, as I've mentioned, a lot of
lawsuits are based on physicians saying they
weren't notified in time and the
patient then coded or the patient bled out.
So again, as nurses there are certain
things that we can do. We are autonomous in
a lot of things, but then there are a
lot of things that we need to make sure we're
alerting the physician in a timely
manner, and one of them is any changing
Lot of units, if you work in the ICU, what
they have as a change of condition might
be different than the OB, might be different
than the med/surg floor, might
be different than ER. But again, there are
certain things that you're watching
for that the physician needs to know about.
What about stable versus unstable. Stable
patients we can handle pretty well.
Once that patients switches to unstable,
again that's a change in condition and
the physician needs to be made aware.
Acute and chronic. There are some
symptoms that a chronic patient might have
that may not need to be called to
the physician. That same symptom in a patient
that's in the acute phase might
need to be. So NCLEX is looking, and your patients
are relying on you to know the
difference, to know when is an emergency and when
is it a prediction. Critical lab
values, we get pretty used to that, but we can't
always use to rely on the lab to call us
or to put up a red flag because we know
what our patient is doing. We put
together the lab value with their assessment,
and so again, putting those
two together, do you understand for your
patient when it's critical to
notify the physician? And then breaches of patient safety.
Did the patient fall?
Was there a needle stick? Was there a skin
tear? A pressure ulcer?
Again making sure that you're letting the
physicians know so that they can
prescribe the right treatment, and then
also that you're reporting it
and communicating it to the rest of the
health care team. Effectiveness. We like
to think as nurses that everything we do is
effective. Most of the time it is. But if
it's not effective, we need to make sure that
we're evaluating that right away so
that changes can be made. We don't want to
extend a patient's length of stay
because we weren't on top of the
effectiveness or non-effectiveness of
certain medications or certain treatments.
So again, keep that in mind
as you're looking at questions. Make sure
that what you're doing is effective and
safe and that you're going back and you're
evaluating that. Patient education.
We can talk for days on patient education.
We know that patients always
want, I can't say always, usually want to
know how to take care of themselves.
But we also know that they don't hear everything
that we say to them. We know
that we don't always hear everything that they
say to us. As humans we block
some things, but as a nurse I need to make
sure that when that patient
leaves me that I am as sure as I can that they
understand everything about their
illness. Now you're going to have patients that
don't want to know. You're
going to have patients that have already looked
everything up and think they know
everything. But again, my job as a nurse is to
make sure that they are educated
on their illness. So what is it about their
illness, what caused it? Is it
something that they can prevent? Is it something
that they can stop doing, like
smoking? And how important it is to quit smoking.
Not just you know, you need to
quit, but why? What is it doing to their
bodies that's causing this disease
process. You need to take the time to
explain that to them.
Medications. Many times we get into a rush.
The patient has ten medicines at 9 AM
and we go in and we start giving them
medications because we've got other
things that we have to get done. But again,
does that patient understand why
you're giving them these medications? If
they don't understand it, sometimes the
compliance issue goes along with that. If I
don't understand why I need to take
it, am I that motivated to pay the cost of buying
it? Or that motivated to take
it every day? I need to understand. And they
can't understand unless I show them
and tell them how that medication is affecting
their disease process. What are
the side effects?
Again, we know that there are side effects
to medications that are rare.
We also know that there are some that happen
all the time. Our patients need to
know that. We don't want to send the patient
home and have them call us and
be all upset because they've got a lot of nausea
and vomiting, and we say to them,
"Oh yeah, we knew that." That's not fair to them.
So again, make sure you're educating
about side effects. So when you're looking at
questions on NCLEX, is your
patient informed? Are there answers to
questions that will inform your
patient even more? What are the outcomes?
A lot of patients come in to our walls,
whether it's a physician's office, whether
it's a hospital, nursing home, and
assume that once they leave they'll be completely
cured or that they will be
back to the way that they were before, and that's
not always possible. But they
don't know that unless we tell them, unless
we teach them what the outcomes
are going to be. What is it going to be
like when you go home?
And then again, health literacy is a big
thing that nurses need to remember.
Not everybody understands like we understand.
Not everybody has a college education.
Not everybody works in the medical field.
So we can't use medical jargon, and we
have to be able to use words and write things
down that anybody can understand.
So again, taking into effect your patient's
education and whether they are
developed mentally as well.
Gastric lavage is one of the things that falls
underneath this category as an
example. And so thinking through gastric lavage,
putting down an NG tube, do you
remember how to do that? If not, you're going to
go back and look into your fundamentals
book. But what kind of things are you watching for?
What's evidence based practice
when you're checking the position and the site placement?
What kind of things are
you watching for? Things like aspiration. Are you
aspirating content? What contents are
coming out? So again, make sure you review that
and make sure you're familiar,
especially if you haven't done it in a while.
And then oxygen therapy. NCLEX is
going to be full of questions that has oxygen
involved with it. Whether you're
treating a patient with COPD, respiratory distress,
post-op patient, or whether they're
just asking you a question about oxygen and how
you're going to give it, in what
liter. So again,
oxygen is very, very important. We know as nurses
we deal with people on oxygen all
the time. So they really want to make sure that
you're safe and that you understand.
So make sure you review all the different ways
to give oxygen, whether it's nasal
cannula, whether it's simple mask, whether it's
a non-rebreather, whether it's a
venturi. So make sure you're going back and
you're looking at those. And then
what's the purpose? Why do we give people oxygen?
And is there limits on how much
oxygen? And then also, if I have a patient on a
nasal cannula, what is the maximum
amount of liters I can give them? What's the
minimum amount for a mask? And being
able to understand that because again, that
goes back to safety and your
patient care. What about ventilation and gas
exchange? Do you understand what
happens in the alveoli? Do you understand about
CO2 and oxygen and what drives us
to breathe? Maybe what drives
a person with COPD to breathe? Again, make sure
that you're understanding that, because
oxygen, we know airway, breathing is our
top two priorities. So NCLEX
wants to make sure and your future employers
want to make sure that you
understand airway and breathing. And then pulse
oximetry. We slap pulse oximetry on
everybody, but do you understand what it's
measuring? And do you understand what can
cause a high alarm or a low alarm that maybe
might not have anything to do with the
condition of the patient. Again, go back
and look at that in your med/surg
books. So in closing, you know, illness management,
it seems like that's all that
we do as nurses. But again, be thinking about
not only our management but also
how we're teaching our patients to manage
at home. Make sure you're looking
at critical values in stable and unstable,
so that you are prepared to
notify the physician when they need to.
One thing about watching NCLEX questions
is NCLEX is looking for, what do you do
as a nurse? They are not really
interested in what the physician's going
to do, social work,
respiratory therapy. They want to know that
you know what to do as a nurse.
So as you're reading questions don't always
just jump to, "Call the physician."
If there is another option of something that
you can do as a nurse, but if it's a
critical value, if it's a change in your
patient that you need to notify the
physician, then don't be afraid to pick that.
So again, that just goes back to
reading the question and reading every answer completely
before you make your decision. Good luck on the NCLEX.