Illness Management

by Diana Shenefield, PhD

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    00:01 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.

    00:24 We're also going to talk about when should we be calling the physician.

    00:28 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.

    00:38 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.

    00:58 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.

    02:13 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.

    03:47 Again, this is a big red flag, if you don't remember this go back and look.

    03:52 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.

    04:12 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.

    04:33 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.

    04:41 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.

    05:27 We owe it to our patients to make sure that they understand what's happening to them.

    05:30 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.

    05:44 So again, as you're looking at NCLEX questions, make sure you're thinking about, 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 in condition.

    06:19 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.

    06:33 What about stable versus unstable. Stable patients we can handle pretty well.

    06:39 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.

    08:22 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.

    08:33 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.

    09:26 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.

    10:08 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.

    11:02 Not everybody understands like we understand. Not everybody has a college education.

    11:06 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.

    11:17 So again, taking into effect your patient's education and whether they are developed mentally as well.

    11:24 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.

    12:27 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.

    14:21 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.

    About the Lecture

    The lecture Illness Management by Diana Shenefield, PhD is from the course Physiological Integrity. It contains the following chapters:

    • Illness Management
    • Reporting to Physician
    • Patient Education
    • Specific Care

    Included Quiz Questions

    1. Raise the head of the bed
    2. Encourage deep breathing
    3. Notify the practitioner
    4. Administer oxygen
    1. Orthopnea
    2. Productive cough
    3. Sore throat
    4. Eupnea
    1. Report the change to the physician
    2. Continue to assess hourly as ordered
    3. Repeat a neurologic assessment in 15 minutes
    4. Notify the OR of the need for surgery

    Author of lecture Illness Management

     Diana Shenefield, PhD

    Diana Shenefield, PhD

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