High Dependency Nursing Care

Observation, Intervention and Support for Level 2 Patients

Tina Moore, Philip Woodrow

• Publisher: Routledge
• Year: 2009
• eBook ISBN: 9781134033911
• Edition: 2
• Topic: Medicine
• Subtopic: Health Care Delivery

Level 2 (highly dependent) patients are nursed in a variety of clinical areas. High Dependency Nursing Care has been written for pre qualified and post qualified students undertaking modules and placements to prepare them for nursing the acutely ill and nurses caring for these patients. Written by a team of nurses experienced in providing, supporting and developing high dependency care, it discusses practical issues and explores the current evidence base for clinical practice.

This essential textbook covers the context of care with chapters on fundamental aspects, such as sleep, nutrition, pain management and stress. It goes on to look at the main causes of critical illness and the treatments often given, as well as the skills necessary for monitoring patients. Completely updated throughout, this second edition also includes new chapters on infection control, heart failure, tissue removal and transferring the sicker patient.

High Dependency Nursing Care is:

Comprehensive: it covers all the key areas of knowledge needed

User-friendly: it includes learning outcomes, introductions, time out exercises, implications for practice, useful websites and up-to-date references

Clearly written: by a team of experienced nurses

Practically based: clinical scenarios provide stimulating discussion and revision topics

Part 1
Contexts for care

Chapter 1
Comprehensive critical care

Tina Moore

Contents

Learning outcomes

Fundamental knowledge

Introduction

Nature of high dependency nursing

Characteristics of high dependency nursing

Advocacy

Implications for practice

Summary

Bibliography

Learning outcomes

After reading this chapter you will be able to:

• demonstrate knowledge of the changes occurring within critical care;
• understand the principles of high dependency nursing;
• appreciate the role of advocacy and the critically ill patient.

Fundamental knowledge

Patient-centred care (Chapter 2); ethics (Chapter 3); rehabilitation (Chapter 36).

Introduction

The philosophy of high dependency unit (HDU) nursing pervades this book. This particular chapter will provide a summary/overview of the principles of high dependency nursing.

Time out 1.1

1. Think back to when you first cared for acutely/critically ill patients. What do you consider to be the main aspects of care?
2. Now write down the approaches to care you have been involved in today.
3. Have you noticed any changes in the way these patients are cared for?
4. If so, why do you think these changes have occurred?

The discontent regarding Intensive Care Unit (ICU) provision occurred during the 1990s, highlighting the failings of critical care services. Recently, healthcare professionals have seen many great changes in the way critical care is delivered. Today, there is a more consistent approach in the organisation of critical care services, achieved through the strategic document Comprehensive Critical Care (DOH, 2000a). This strategy led to a revision of critical care services and produced a complete process of care for the critically ill and focused on the level of care needed by individual patients and their families at any point during their illness. There is now a pro-active approach using a ‘whole systems’ approach which attends to the needs of those at risk of critical illness as well as those who are critically ill. Comprehensive Critical Care strategy is emerging as a uniform standard throughout the NHS, regardless of location or speciality, i.e. ‘no walls’ philosophy. It is now viewed as a new speciality based on the severity of illness that is focusing on the needs of the patient, central to the service provided.

While there has been significant improvement in caring for acutely/critically ill patients there are many improvements still to be done. There is still the possibility that patients who are, or become, acutely unwell may receive suboptimal care (NICE, 2007a). This is possibly due to unrecognised deterioration, lack of knowledge to interpret indications of clinical deterioration, lack of rapid intervention or indeed gross underfunding to provide adequate resources, including staff. In response the National Institute for Health and Clinical Excellence (NICE) has produced guidance and recommendations on a number of areas affecting the acutely ill adult in hospital. These include: physiological observations, physiological track and trigger, recognition of deterioration and transfer.

Nature of high dependency nursing

HDUs have been developed as a result of failure of hospitals to address the increased demand for intensive care services. In many hospitals there are no designated HDUs but instead they have ‘HDU bed areas’ within the ward. The term ‘critical care’ is used as a global term that covers a diverse set of services (DOH, 2000a), including both intensive care and high dependency care. Both units are now merging to become one managed Critical Care Unit. These units may be specialised, e.g. surgical, neurology, cardiac and hepatic.

Intensive (level 3) care provides detailed observation and treatment for patients with potential recoverable conditions, involving multiple organ failure or requiring mechanical ventilation. High dependency (level 2) care supplies an intermediate level of care between the ICU and the general wards, involving patients with single system failure (not respiratory). HDUs can be used as a ‘step-up’ facility (patient requiring greater monitoring, support and supervision than is available on a general ward). This may prevent the need for admission to the ICU. Alternatively, HDU care may provide a ‘step-down’ facility for patients no longer requiring ICU services but are not well enough to be discharged to the wards, with the lack of HDU beds, many of these patients are on general wards.

The categories of patients requiring HDU care are explained in Box 1.1. These patients will require continuous or intermittent (but regular) observation, care and intervention. Nurses provide highly specialised, technological care to the very ill patient, therefore, skill mix should be determined upon the needs of the patient and levels of dependency rather than determined by numbers of beds (DOH, 2000a).

It is clear that some patients may not benefit from HDU nursing because they are ‘too sick to benefit’ (extremely poor prognosis or a level 3 patient) or ‘too well to benefit’. Box 1.1 provides a non-exhaustive list of those patients who would benefit from HDU admission.

Box 1.1 Examples of patients requiring HDU provision

• Patients requiring level 2 type care
• Patients requiring single organ support, e.g. non-invasive ventilation (excluding artificial mechanical ventilation), high-risk surgical patients, patients with major uncorrected physiological abnormalities
• Patients requiring more detailed observation/monitoring
• Patients who no longer need intensive care but are not well enough for a general ward

Characteristics of high dependency nursing

The distinguishing features of intensive care, high dependency care and ward care can be determined through the intensity of nursing input (namely, the amount of time spent with any one patient) in delivering both the nursing and medical plan of care. Nursing intensity will vary depending upon the patient’s condition, for example, weaning patients from non-invasive ventilation may require more intensity than patients who are fully sedated or unconscious. The recommended nurse—patient ratios are ICU 1:1 (ICS, 1997), HDU 1:2 (Garfield et al., 2000); on the wards no ratio has been agreed, but staff should determine the degree of nursing intensity by the amount of monitoring and nursing intervention required. Comprehensive Critical Care recommends flexible use of staff with a move away from the use of rigid ratios to determine nurse staffing for patients requiring level 2 and 3 care to the use of more flexible systems of assessing nursing workload (DOH, 2000a). The expert group suggests tools such as the System Of Patient Related Activity (SOPRA). The RCN has provided guidance for nursing staff in critical care. It is a cautious document and is non-committed in terms of providing ratios. It supports the concept of flexibility and provides factors that should be considered when determining staffing levels (RCN, 2003b). In practice, the general view is that of comprehensive critical care.

Nonetheless, the RCN’s guidance could be manipulated into expecting minimal and potentially unsafe nurse—patient ratios. Flexibility could become a ‘slippery slope’ potentially affecting quality of patient and safety. The British Association for Critical Care Nursing rightly voiced concerns relating to the pressure of working with less than desirable nurse—patient ratios and subsequent inability to cope with demands (Pilcher and Odell, 2000). Currently, this debate appears dormant.

There is also no recognition of ‘invisible’ work, such as continuous observation. Patient allocation should be based on skill mix and competency within the nursing ratio, enabling those observations to be understood, analysed and acted upon 24 hours per day.

Critical care nurses (registered) should have the right knowledge, skills and competence to meet the needs of the critically ill patient without direct supervision (RCN, 2003b). Critical care skills (which acute care nurses should possess) are not only important in providing appropriate and safe nursing care but should also aid the prevention of critical illness. Constant observation of the vulnerable critically ill is imperative. This involves assimilation, interpretation and evaluation of patients’ physical and psychological status.

Nurses caring for acutely ill patients need to be able to:

• collect the data, interpret information and act appropriately;
• ask for physiological parameters (desired outcomes) to be set (NCEPOD, 2007), e.g. BP, heart rate, respiratory rate from the Medical team;
• make decisions quickly, accurately and often independently, based on patient cues;
• be attentive to the minute detail of patient care for prolonged periods of time;
• be pro-active and make predictions and prevent complications; make prompt and skilled intervention in the event of sudden deterioration (RCN, 2003b);
• have a specialist body of knowledge pertinent to the care of critically ill patients and promote competent care;
• respond quickly and effectively in a variety of emergency situations;
• be an effective team member;
• work efficiently within a potentially stressful environment;
• deliver holistic care including family and significant others.

Advocacy

Time out 1.2

1. Write down your definition of advocacy, highlighting the key words. Now compare your views with a dictionary definition.
2. Consider h...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• List of figures
• List of tables
• List of boxes
• List of contributors
• Preface to the second edition
• Abbreviations
• Part 1: Contexts for care
• Part 2: Neurological
• Part 3: Respiratory
• Part 4: Cardiovascular
• Part 5: Abdominal
• Part 6: Positive outcomes