NCM 118

Lesson 2:
Nursing Care of Clients with Life Threatening
Conditions, Acutely ill / Multi Organ Problems , High
Acuity and Emergency Situation

Prof Dodie A. Dichoso

 The term “life-threatening condition” means any disease
or condition from which the likelihood of death is
probable unless the course of the disease or
condition is interrupted.

What is an appropriate response to a life-threatening situation?

Stay calm, and call your local emergency number (such as 911).
Start CPR (cardiopulmonary resuscitation) or rescue breathing,
if necessary and if you know the proper technique. Place a
semiconscious or unconscious person in the recovery position
until the ambulance arrives.
What is high acuity patient?
Purpose: High acuity units (HAU) are hospital units that provide
patients with more acute care and closer monitoring than a general
hospital ward but are not as resource intensive as an intensive
care unit (ICU).
 The Multiple Organ Dysfunction Syndrome (MODS) can be
defined as the development of potentially reversible physiologic
derangement involving two or more organ systems not involved in
the disorder that resulted in ICU admission, and arising in the
wake of a potentially life-threatening physiologic insult.
Multiple organ dysfunction syndrome (MODS) is defined as the
progressive physiological dysfunction of two or more organ systems
where homeostasis cannot be maintained without intervention. It is
initiated by illness, injury or infection and most commonly affects the
heart, lungs, liver and kidneys.
An Overview of Multiple Organ Dysfunction Syndrome - Ausmed
https://www.ausmed.com › cpd › articles › multiple-organ

The fundamental cause of MODS is attributed to the conditions

such as surgery, inflammation, accident, infection,
increased metabolic rate, metabolic activity, and decreased
perfusion.
What would happen if your organ systems stopped functioning
properly?
After one system shuts down, the others would slowly start to
shut down as well until the body can no longer maintain homeostasis
and the person would slowly die. 3. All systems would be working
together but the main ones would be muscular, nervous, and skeletal.
Interacting Body Systems and Homeostasis
http://sites.isdschools.org › useruploads › biology

Which organ fails first in multi organ failure?

Generally, the lung is the first organ to fail after injury (failure after
3.7 +/- 2.8 days). Significant renal failure and the need for dialysis
decreased to < 5%; other signs of organ dysfunction (gastric, central
nervous system) are difficult to verify.
Pattern of organ failure following severe trauma - PubMed
https://pubmed.ncbi.nlm.nih.gov › ..
 MODS can affect any organ, but the primary players are
the lungs, heart, kidneys, liver, brain, and blood. There are
many causes of MODS, but the general categories
include major trauma, severe illness, and widespread
infection.

What are signs of organ dysfunction?

The clinical signs of tissue hypoxia are largely non-specific.
However, increased respiratory rate, peripheries that are either warm and
vasodilated or cold and vasoconstricted, poor urine output, and mental
dullness may indicate organ dysfunction and should prompt a search for
reversible causes.
ABC of intensive care: Organ dysfunction - PMC - NCBI
https://www.ncbi.nlm.nih.gov › articles › PMC1115973
 Shock and Multiple Organ Dysfunction Syndrome

Shock is a life-threatening condition with a variety of underlying

causes. It is characterized by inadequate perfusion that,
if untreated, results in cell death. The progression of shock is
neither linear nor predictable, and shock states, especially
septic shock, comprise a current area of aggressive clinical research.
Nurses caring for patients with shock and for those at
risk for shock must understand the underlying mechanisms of
shock and recognize its subtle as well as more obvious signs.
Rapid assessment with early recognition and response to
shock states is essential to the patient’s recovery.
Shock can best be defined as a condition in which widespread
perfusion to the cells is inadequate to deliver oxygen
and nutrients to support vital organs and cellular function
Adequate blood flow to
the tissues and cells requires an adequate cardiac pump,
effective
vasculature or circulatory system, and sufficient blood
volume. If one of these components is impaired, perfusion to
the tissues is threatened or compromised. Without treatment,
inadequate blood flow to the cells results in poor delivery of
oxygen and nutrients, cellular hypoxia, and cell death that
progresses to organ dysfunction and eventually death.
Pathophysiology
Cellular Changes
In shock, the cells lack an adequate blood supply and are deprived
of oxygen and nutrients; therefore, they must produce
energy through anaerobic metabolism. This results in low
energy yields from nutrients and an acidotic intracellular environment.
Because of these changes, normal cell function
ceases . The cell swells and the cell membrane becomes
more permeable, allowing electrolytes and fluids to
seep out of and into the cell. The sodium–potassium pump
becomes impaired; cell structures, primarily the mitochondria,
are damaged; and death of the cell results.

Glucose is the primary substrate required for

the production
of cellular energy in the form of ATP.
Nursing care of patients with shock requires ongoing systematic
assessment. Many of the interventions required in
caring for patients with shock call for close collaboration
with other members of the health care team and rapid implementation
of prescribed therapies. Nurses must anticipate
these therapies because they need to be implemented
with speed and accuracy.
Stages of Shock
Shock is believed to progress
along a continuum of stages.
Shock can be identified as early or
late, depending on the
signs and symptoms and the
overall severity of organ
dysfunction.
A convenient way to understand
the physiologic
responses and subsequent clinical
signs and symptoms of
shock is to divide the continuum
into separate stages:
compensatory (stage 1),
progressive (stage 2), and
irreversible
(stage 3).
The sympathetic nervous system and
subsequent release of
catecholamines (epinephrine and
norepinephrine). Patients
display the often-described “fight or
flight” response.
The body shunts blood from organs such
as the skin, kidneys,
and gastrointestinal tract to the brain,
heart, and
lungs to ensure adequate blood supply to
these vital organs.
As a result, the skin is cool and clammy,
bowel sounds are
hypoactive, and urine output decreases
in response to the
release of aldosterone and ADH.
Clinical Manifestations
Despite a normal BP, the patient shows numerous clinical
signs indicating inadequate organ perfusion.
The result of inadequate perfusion is anaerobic metabolism
and a buildup of lactic acid, producing metabolic acidosis.
The respiratory rate increases in response to metabolic acidosis.
This rapid respiratory rate facilitates removal of excess
carbon dioxide but raises the blood pH and often causes a
compensatory respiratory alkalosis. The alkalotic state
causes mental status changes, such as confusion or
combativeness,
as well as arteriolar dilation. If treatment begins in
this stage of shock, the prognosis for the patient is better
than in later stages.
Medical Management
Nursing Management
Medical treatment is directed toward
As stated earlier, intervention as
identifying the cause
soon as possible along the
of the shock, correcting the underlying
continuum of shock is the key to
disorder so that
improving the patient’s
shock does not progress, and supporting
prognosis. The nurse must
those physiologic
systematically assess the patient
processes that thus far have responded
at risk for shock to recognize the
successfully to the
subtle clinical signs of the
threat. Because compensation cannot be
compensatory stage before the
maintained indefinitely,
patient’s BP drops. Special
measures such as fluid replacement and
considerations related to
medication
recognizing early signs of shock
therapy must be initiated to maintain an
in
adequate BP and
the elderly patient.
reestablish and maintain adequate tissue
perfusion (Otero,
et al., 2006).
 Monitoring Tissue Perfusion
In assessing tissue perfusion, the nurse observes for changes
in level of consciousness, vital signs (including pulse pressure),
urinary output, skin, and laboratory values (eg, base
deficit and lactic acid levels). In the compensatory stage of
shock, serum sodium and blood glucose levels are elevated
in response to the release of aldosterone and catecholamines

The nurse should monitor the patient’s hemodynamic

status and promptly report deviations to the physician,
assist in identifying and treating the underlying disorder
by continuous in-depth assessment of the patient, administer
prescribed fluids and medications, and promote patient
safety. Vital signs are key indicators of hemodynamic
status and BP is an indirect measure of tissue
hypoxia. The nurse should report a systolic BP lower than
90 mm Hg or a drop in systolic BP of 40 mm Hg from
baseline.
Pulse pressure correlates well with stroke volume. Pulse
pressure is calculated by subtracting the diastolic measurement
from the systolic measurement; the difference is the
pulse pressure (Cottingham, 2006). Normally, the pulse
pressure is 30 to 40 mm Hg. Narrowing or decreased pulse
pressure is an earlier indicator of shock than a drop in systolic
BP. Decreased or narrowing pulse pressure, an early indication
of decreased stroke volume, is illustrated in the following
example:
Systolic BP Diastolic BP Pulse pressure
Normal pulse pressure:
120 mg Hg 80 mm Hg 40 mm Hg
Narrowing of pulse pressure:
90 mm Hg 70 mm Hg 20 mm Hg
Elevation of the diastolic BP with release of catecholamines
and attempts to increase venous return through
vasoconstriction is an early compensatory mechanism in
response to decreased stroke volume, BP, and overall
cardiac output.
 Promoting Safety
The nurse must be vigilant for potential threats to the patient’s
safety, because a high anxiety level and altered mental
status impair judgment. In this stage of shock, patients
who were previously cooperative and followed instructions
may now disrupt IV lines and catheters and complicate
their condition. Therefore, close monitoring and frequent
reorientation interventions are essential.

NURSING ALERT
By the time BP drops, damage has already been occurring
at the cellular and tissue levels. Therefore, the
patient at risk for shock must be assessed and monitored
closely before the BP falls.
Continuous central venous oximetry (Scv–O2) monitoring
may be used to evaluate mixed venous blood oxygen
saturation and the severity of tissue hypoperfusion states.
A central catheter is introduced into the superior vena
cava (SVC), and a sensor on the catheter measures the
oxygen saturation of the blood in the SVC as blood returns
to the heart and pulmonary system for reoxygenation.
A normal Scv–O2 value is 70%. Body tissues use approximately 25%
of the oxygen delivered to them during normal metabolism.
During states of stress, such as shock, more oxygen is
consumed and the Scv–O2 saturation is lower, indicating
that the tissues are consuming more oxygen.
Interventions focus on decreasing tissue oxygen requirements
and increasing perfusion to deliver more oxygen
to the tissues. For instance, sedating agents may be
administered to lower metabolic demands, the patient’s
pain may be treated with intravenous (IV) opioid agents,
or measures to prevent shivering, decrease metabolic demands
for oxygen. Supplemental oxygen and mechanical
ventilation may be required to increase the delivery of
oxygen in the blood. Administration of IV fluids and medications
supports blood pressure and cardiac output, and
the transfusion of packed red blood cells enhances oxygen
transport.
 Monitoring tissue oxygen consumption with
Scv–O2 is a minimally invasive measure to more accurately
assess tissue oxygenation in the compensatory stage of
shock before changes in vital signs detect altered tissue
perfusion (Dellinger, et al., 2008; Goodrich, 2006; Otero,
et al., 2006).
New technologies allow clinicians to detect changes in
tissue perfusion before changes in classic signs (BP, heart
rate, and urine output) indicative of hypoperfusion occur.

Clinical Manifestations
Chances of survival depend on the patient’s general health
before the shock state as well as the amount of time it takes
to restore tissue perfusion. As shock progresses, organ systems
decompensate.
1. Respiratory Effects
The lungs, which become compromised early in shock, are
affected at this stage. Subsequent decompensation of the
lungs increases the likelihood that mechanical ventilation
will be needed. Respirations are rapid and shallow. Crackles
are heard over the lung fields. Decreased pulmonary blood
flow causes arterial oxygen levels to decrease and carbon
dioxide levels to increase. Hypoxemia and biochemical
mediators
cause an intense inflammatory response and pulmonary
vasoconstriction, perpetuating pulmonary capillary
hypoperfusion and hypoxemia. The hypoperfused alveoli
2. Gastrointestinal Effects
Gastrointestinal (GI) ischemia can cause stress ulcers in
the stomach, putting the patient at risk for GI bleeding. In
the small intestine, the mucosa can become necrotic and
slough off, causing bloody diarrhea. Beyond the local
effects of impaired perfusion, GI ischemia leads to bacterial
toxin translocation, in which bacterial toxins enter the
bloodstream through the lymphatic system. In addition to
causing infection, bacterial toxins can cause cardiac
depression,
vasodilation, increased capillary permeability,
and an intense inflammatory response with activation of
additional biochemical mediators. The net result is interference
with healthy cellular functioning and their ability
to metabolize nutrients (Stapleton, Jones & Heyland,
2007).
3. Hematologic Effects
The combination of hypotension, sluggish blood flow,
metabolic acidosis, coagulation system imbalance, and
generalized hypoxemia can interfere with normal hemostatic
mechanisms. In shock states, the inflammatory cytokines
activate the clotting cascade, causing deposition
of microthrombi in multiple areas of the body and consumption of clotting factors.
The alterations of the hematologic system, including imbalance of the clotting
cascade, are linked to the overactivation of the inflammatory
response of injury. Disseminated intravascular coagulation (DIC) may
occur either as a cause or as a complication of shock. In
this condition, widespread clotting and bleeding occur
simultaneously. Bruises (ecchymoses) and bleeding
(petechiae) may appear in the skin. Coagulation times
(eg, prothrombin time [PT], activated partial thromboplastin time are prolonged.
Clotting factors and
platelets are consumed and require replacement therapy to achieve hemostasis.
Medical Management
Specific medical management in the progressive stage
of
shock depends on the type of shock and its underlying
cause. It is also based on the degree of decompensation
in
the organ systems. Medical management specific to
each
type of shock is discussed later in this chapter. Although
there are several differences in medical management by
type of shock, some medical interventions are common
to
all types.
 Medical Management
These include the use of appropriate IV fluids and
medications to restore tissue perfusion by the following
methods:
• Supporting the respiratory system
• Optimizing intravascular volume
• Supporting the pumping action of the heart
• Improving the competence of the vascular system
Other aspects of management may include early enteral
nutritional support, aggressive hyperglycemic control with
IV insulin (Hafidh, Reuter, Chassels, et al., 2007; Vanhorebeek,
Langouche & Van den Berghe, 2007), and use of
antacids, histamine-2 (H2) blockers, or antipeptic agents to
reduce the risk of GI ulceration and bleeding.
Subjective nursing assessment is an
individualized, qualitative approach that does
not use objective, measurements, tools or
equipment. Rather, it is based on individualized
clinical observation relating to the physical,
emotional and behavioural characteristics of the
child and family.
 What objective data does the nurse collect during a physical
assessment?
Objective data in nursing is data that is measured or observed by
the 5 senses. Examples include blood pressure, temperature,
skin color and texture, and heart sounds.
Subjective Data Vs. Objective Data in Nursing - The Nerdy Nurse
https://thenerdynurse.com › subjective-data-vs-objective-d..

What is objective data in nursing assessment?

Objective data in nursing refers to information that can be
measured through physical examination, observation, or
diagnostic testing. Examples of objective data include, but
are not limited to, physical findings or patient behaviors
observed by the nurse, laboratory test results, and vital signs.
Subjective VS. Objective Nursing Data: What's The Difference
https://www.nursingprocess.org › subjective-vs-objective-.
 Subjective Nursing Data
Subjective nursing data are collected
from sources other than the nurse's
observations. This type of data
represents the patient's perceptions,
feelings, or concerns as obtained
through the nursing interview. The
patient is considered the primary
source of subjective data. Other
sources, including the patient's family
or caregivers, and other members of
the healthcare team, are called
secondary sources.
Objective Nursing Data
Objective data in nursing refers to
information that can be
measured through physical
examination, observation, or
diagnostic testing. Examples of
objective data include, but are
not limited to, physical findings or
patient behaviors observed by
the nurse, laboratory test results,
and vital signs.
Examples Of Subjective Data In Examples Of Objective Data In
Nursing Nursing
Ambulation
Chills Bleeding
Congestion or Runny Nose
Blood Urea and Creatinine Levels
Constipation Vomiting
Coughing Sweating Blood Pressure
Diarrhea Sore throat Body Temperature
Dizziness Demeanor
Exhaustion and Fatigue Full Blood Count
Feeling Sleepy or Dizzy
Heart Rate
Itching
Level of Consciousness Height and Weight
Loss of Appetite Overall Appearance
Loss of Taste or Smell Respiratory Rate
Muscle or Body Aches Wound Appearance
Nausea
X-Ray or Computed Tomography (CT)
Numbness
Pain Scans
Shortness of Breath
Subjective Data is Important In
Nursing
Because the patient is the primary source of
subjective data in nursing, this data can paint
a more thorough picture of what the patient is
experiencing, making it an essential part of
care plan development. Subjective data may
signal possible issues with the patient's
psychological, physiological, and sociological
wellness. Subjective data signals the nurse
about things that may be problematic for the
patient and can also indicate specific patient
strengths that could be useful when
communicating with and caring for patients.
Objective Data is Important In
Nursing
Objective nursing data is an essential
part of patient assessments. Objective
data is the view of the patient's status
through the eyes of the assessing nurse.
While a patient may state, "My
stomach hurts," the nurse may observe
changes in his vital signs or abnormal
lab results that signal abnormal
changes in the patient's body and give
practitioners an idea of where to start
the diagnosis process.
 Objective physical assessment
Examples of objective assessment include observing a client's gait ,
physically feeling a lump on client's leg, listening to a client's heart,
tapping on the body to elicit sounds, as well as collecting or reviewing
laboratory and diagnostic tests such as blood tests, urine tests, X-ray
etc.
Objective Assessment – Physical Examination Techniques: A Nurse's ...
https://pressbooks.library.torontomu.ca › ippa › chapter-1

Objective data includes observations of nonverbal indications of

pain, such as restlessness, facial grimacing and wincing, moaning, and
rubbing or guarding painful areas.
11.5 Applying the Nursing Process – Nursing Fundamentals
https://wtcs.pressbooks.pub › chapter › 11-5-applying-the
 Analysis/Nursing Diagnosis of multi Organ Failure
 Multi-Organ Failure syndrome (MOF) is a reason for
admission to intensive care or can occur during hospitalization. It is
characterized by associated failures of several organs (heart,
lungs, liver, kidneys, brain). The prognosis is all the more gloomy as
the number of affected organs is high. It is due to an alteration of
the microcirculation responsible for an acute and lasting cellular
hypoperfusion, encountered during an aggression (trauma,
pancreatitis, burns, states of cardiogenic or hypovolemic septic
shock) requiring substitutive treatments, artificial ventilation, renal
replacement therapy, hemodynamic support and appropriate
nutritional intake.
 Analysis/Nursing Diagnosis of multi Organ Failure
Objectives of Nursing Care
The therapeutic nursing objective is to anticipate clinical changes, notify the resuscitator
as soon as possible, in order to limit the aggravation of failures by the rapid introduction
of specific therapies [1]. This patient care involves close collaboration between the
doctor and the paramedical team. Clinical monitoring and monitoring are the main axes,
associated with the monitoring of specific treatments.
First time surveillance: The management of patients with MOF requires increased
nursing supervision, requiring theoretical and technical knowledge.
Cardio-Circulatory Failure: Cardiocirculatory failure is characterized by persistent
arterial hypotension despite adequate vascular filling. The objective is to assess the
impact of this failure on perfusion and therefore on tissue oxygenation.
Clinical monitoring: Involves mottling (signs of impaired peripheral circulation),
cyanosis, pinkish foaming bronchial secretions, and swollen jugular joints (signs of
heart failure). Biological monitoring is carried out on medical prescription by a dosage
of lactates (signs of cellular suffering), an arterial gas, a blood count, a blood ionogram,
a liver and kidney test.
Analysis/Nursing Diagnosis of multi Organ Failure

Non-Invasive Monitoring Includes

One cardioscope per patient connected to a
central monitoring unit: heart rate monitoring
and alarm settings allow rapid identification of
any rhythmic change, type of atrial fibrillation,
extrasystoles,tachycardia or bradycardia,
justifying medical intervention to initiate
appropriate therapy; Taking blood pressure in
the cuff every 15 minutes with recording of
systolic, diastolic and mean blood pressure.
The alarms are set according to the therapeutic
objectives to be achieved. The parameters
provided by these different techniques are
recorded on a monitoring sheet or in a
computerized memory of patient parameters.
 Analysis/Nursing Diagnosis of multi Organ Failure

Invasive Monitoring Includes

Sterile placement of catheters by the doctor according to department
protocols. The nurse prepares the necessary material and serves the
operator sterilely. Changes of tubing and dressings are redone in
accordance with the protocol of the service. There are several
catheter devices: Arterial catheterization is an invasive device
allowing the continuous monitoring of blood pressure, the realization
of iterative blood samples, the monitoring of the repulsed pressure
delta (Delta PP), measurement of the systolic-diastolic differential
during a respiratory cycle in the patient who is intubated, ventilated,
adapted to the ventilator and in sinus rhythm. It informs us about the
need for a filling (›13% = signs of hypovolaemia)
•Pulse Pressure = Systolic Blood Pressure – Diastolic Blood
Pressure

The systolic blood pressure is defined as the maximum

pressure experienced in the aorta when the heart contracts and
ejects blood into the aorta from the left ventricle
(approximately 120 mmHg).
The diastolic blood pressure is the minimum pressure
experienced in the aorta when the heart is relaxing before
ejecting blood into the aorta from the left ventricle
(approximately 80 mmHg).
Normal pulse pressure is, therefore, approximately 40 mmHg.
A change in pulse pressure (delta Pp) is proportional to volume
change (delta-V) but inversely proportional to arterial compliance.
Planning
1. Planning for Health Promotion
How do you manage multiple
organ failure?
The management of MODS requires a
multidisciplinary approach that includes
antibiotics for sepsis control,
microcirculatory and respiratory support
for reperfusion, organ-targeted drugs,
and the correction of coagulation
abnormalities, acid-base imbalance;
metabolic issues, and electrolyte
imbalance.
Multiple organ dysfunction syndrome: Contemporary
insights ...
https://www.ncbi.nlm.nih.gov › articles ›
PMC7884906
The multiple organ dysfunction syndrome is both
a syndrome and a form of clinical shorthand for
the approach to patient care that is exemplified by
contemporary ICU practice. As a syndrome, it is
intimately linked to the adaptive host response to
injury or infection, and it is to be expected that
interventions that can modulate the expression of
this response will ultimately prove effective in
improving clinical outcome. As a clinical
shorthand, it categorizes the range of
interventions available to support critically ill
patients, and underlines the prime importance of
recognizing the potential for iatrogenic harm
implicit in the increasingly complex and
technological repertoire we use to care for them.
Planning 2. Planning for Health Restoration and Maintenance

MODS is difficult to treat, escalates quickly and is often

fatal. Therefore, early detection is crucial in preventing
its progression (Wang et al. 2017).
Positive patient outcomes rely on immediate
recognition, ICU admission and invasive organ
support.
Management and treatment may include:
•Identifying and treating the underlying causes,
comorbidities or complications;
•Fluid resuscitation to increase perfusion
•Support care and monitoring:
• Multi-organ support;
• Mechanical or non-invasive ventilation;
• Maintaining fluid homeostasis; and
• Renal replacement therapy
 Implementation of Care of Clients

1.Independent Nursing Care

a. Physiologic Care
b. Psychosocial Care
c. Spiritual Care
2. Independent Care
a. Pharmacological Therapeutics
b. Complementary and alternative Therapies
c. Nutritional and Diet Therapy
d. Surgical Intervention
e. Immunologic Therapy
 Implementation of Care of Clients
1.Independent Nursing Care
Independent nursing interventions are the tasks that a nurse can
perform without input from another discipline, particularly without a
physician's order. These interventions include many basic comfort care
actions such as providing water, repositioning a patient, providing
toileting assistance, and bathing.Nursing Intervention Examples & Classification -
Study.com
https://study.com › ... › The Profession of Nursing

Common nursing interventions include:

•Bedside care and assistance.
•Administration of medication.
•Postpartum support.
•Feeding assistance.
•Monitoring of vitals and recovery progress.
 Implementation of Care of Clients
1.Independent Nursing Care
a. Physiologic Care
•Physiological Adaptation - managing and providing care
for clients with acute, chronic or life threatening physical
health conditions.
• Related content includes but is not limited to:
• Alterations in Body Systems
• Medical Emergencies
• Fluid and Electrolyte Imbalances
• Pathophysiology
• Hemodynamics
• Unexpected Response to Therapies
• Illness Management
 Implementation of Care of Clients
1.Independent Nursing Care

a. Physiologic Care

How do you prepare a patient physiologically for surgery?

Preparing for Surgery

1.Stop drinking and eating for a certain period of time before the
time of surgery.
2.Bathe or clean, and possibly shave the area to be operated on.
3.Undergo various blood tests, X-rays, electrocardiograms, or
other procedures necessary for surgery.
 Implementation of Care of Clients
1.Independent Nursing Care
b. Psychosocial Care
Psychosocial interventions include such strategies as stress
management, self-coping skills, relapse prevention, and
psychoeducation. They also include psychological therapies, such
as cognitive behavioral strategies or motivational interviewing
techniques.
Psychosocial Treatments
The term psychosocial refers to an individual’s psychological
development in and interaction with their social environment.
Psychosocial treatments (interventions) include structured counseling,
motivational enhancement, case management, care-coordination,
psychotherapy and relapse prevention
 Implementation of Care of Clients
1.Independent Nursing Care
c. Spiritual Care
Spiritual care is an important component of holistic nursing care. To
implement spiritual care, the nurse must assess, diagnose, and
respond to the needs of each patient and her or his significant others.
Meeting the spiritual care needs of the patient can lead to physical
healing, reduction of pain, and personal growth. Nurses providing
spiritual care experience lower stress and less burnout.
THE ROLE OF THE NURSE IN SPIRITUAL CARE
To provide spiritual care, the nurse needs to be able to conduct a
spiritual assessment; recognize the difference between religious and
spiritual needs; identify appropriate spiritual care interventions; and
determine when it is appropriate to deliver spiritual care.
The Essence of Spiritual Care | Springer Publishing
https://connect.springerpub.com › entity_view › node › ful
 Implementation of Care of Clients
2. Independent Care

a. Pharmacological Therapeutics

Nursing responsibilities in drug therapy

The 7 responsibilities are: (1) Management of therapeutic
and adverse effects of medication; (2) Management of
medication adherence; (3) Management of patient
medication self-management; (4) Management of patient
education and information; (5) Prescription management;
(6) Medication safety management.
Nurses' responsibilities and tasks in pharmaceutical care: A scoping ...
https://onlinelibrary.wiley.com › doi › full › nop2
 Implementation of Care of Clients
The nurse’s responsibilities
Drug therapy plays a major part in the treatment of patients.
Traditionally, medicines have been prescribed by doctors and the nurse’s
responsibility has been to ensure safe and reliable administration and to
monitor side-effects. However, in 1994 the law was changed to allow district
nurses and health visitors employed in pilot sites throughout England to
prescribe from a limited formulary. Many of the preparations they were
initially able to prescribe were for over-the-counter preparations. In 1998 it
became possible for all appropriately qualified community nurses to
prescribe from a limited nursing formulary. From 2003, any registered nurse
could undertake training to enable them to become a nurse prescriber and
prescribe from a broader Nurse Prescribers’ Extended Formulary. In 2006
the law changed again, enabling nurses who had undergone the requisite
training to prescribe from the full range of drugs in the British National
Formulary (with the exception of most controlled drugs) provided this was in
their sphere of competence.
 Implementation of Care of Clients
2. Independent Care
Nursing aspects of administration
The nurse is responsible for interpreting the prescription accurately,
recording that the drug has been given and observing the patient’s
response. Prior to administration the nurse must know the reason for,
action and usual dosage of the drug; this should enable him or her to
recognize and question mistakes in prescribing. When in doubt about a
prescription, advice should be sought and, if necessary, the doctor should
be consulted. Observations should be made for therapeutic and adverse
effects. The nurse should realize that the patient’s condition may alter the
effect of a drug and that there may be interactions with concurrent
treatment. The nurse is greatly assisted in these circumstances by the
pharmacist, with whom a good working relationship will enhance the safety
of patient care.