Patient-Centered Care in Acute and Critical Care Environments

This report examines the concept of patient-centered care within acute and critical care settings. It emphasizes the importance of patient-centered care in enhancing patient outcomes by addressing their specific needs, especially in critical care units where patients are highly vulnerable. The report delves into the eight principles of patient-centered care, highlighting essential skills like communication and critical thinking. It also discusses the Synergy Model and Fundamentals of Care (FOC) framework, along with a reflection on the student's learning journey using Driscoll's model. Additionally, the report addresses skin care issues, specifically pressure injuries, common in intensive care units, and their impact on patient mortality and morbidity. It outlines the causes of pressure injuries, emphasizing tissue ischemia and distortion. The report highlights the role of nurses in providing patient-centered care, including assessment, intervention, and collaboration with other healthcare professionals, and offers valuable insights into the practical application of patient-centered care in clinical practice.

Running head:ACUTE AND CRITICAL CARE
ACUTE AND CRITICAL CARE
Name of the Student
Name of the university
Author’s note

1ACUTE AND CRITICAL CARE
Assignment 1
The concept of patient-centered care has been discussed since 2000; however, the actual
implementation of patient-centered care is now becoming a prime focus of the health care sector,
especially in critical care (Kogan, Wilber and Mosqueda 2016). The institution of medicine
defined patient-centered care as the care provided to the patient which is responsive, respectful
and ensures you address the special preference and needs of the patients (Lines, Lepore and
Wiener 2015). Hence, in order to promote the patient-centered care as the quality standard in
the clinical setting, health care professionals should consider the patient-centeredness which also
includes the family members. The primary goal of patient-centered care is to improve individual
health outcome and improve the quality of the life of the patients (Smith, Swallow and Coyne
2015). While patient-centered care supports the wellbeing of the patient by promoting faster
recovery, it is also beneficial for health care providers (Landsperger et al. 2016). The health care
providers stand to benefit through improved patient satisfaction, high staff productivity, morale,
less job burnout and reduced cost of care (Hoffman and Guttendorf 2017). The growing body of
evidence highlighted that in critical care, the patient in critical care are vulnerable because of the
severity of the disease they are experiencing (Smith, Swallow and Coyne 2015). The critical
care received by patients when they are experiencing life threatening health conditions,
especially where they experience the risk of failing vital organs to live a healthy life. Another
factor highlighted by Kleinpell et al. (2015) is that in the critical care unit, a significant number
of patients are highly vulnerable due to the life-threatening health conditions. In these cases, the
autonomy of the patients and frequently compromised and sometimes health professionals failed
to consider the opinion or conduct shared decision making by incorporating the family members

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of the patients. Consequently, in a majority of the cases, the family members of the patients feel
offended, resulted in low patient satisfaction. The world health organization reported that
approximately 55,000 critically ill patients are admitted each day and 50% of them may be
subjected to sudden death because of lack of accurate patient-centered care (Smith, Swallow and
Coyne 2015). Consequently, patients are subjected to high psychological distress such as
anxiety, depression and other mental issues and usually lose hope of living a healthy life.
Hence, patient-centered care is one of the crucial parameters in the critical care unit which
enhance the quality of the life of the patients by considering the critical needs of the patients.
The critical care service providers’ address the specific needs of the patients by nursing advanced
therapeutic, monitoring and diagnosis where each of them incorporates the fundamental principle
of patient-centered care (Landsperger et al. 2016). There are eight principles of the patient
centered care which assists health professions to provide best patient centered care. The
principles include respect for patients’ preferences, coordination and integration of care, physical
comfort, information and education, emotional support involvement of family, community, and
transition, access to the health care services (Kogan, Wilber and Mosqueda 2016). In order to
incorporate these principles, health professionals are required to acquire a specific set of skills
which empower patients, boost their self-esteem, change their perspective towards living a
hopeful and healthy life. Lines, Lepore, and Wiener (2015) suggested that for providing patient-
centered care, health professionals, especially nurses should acquire communications, cultural
competency, professionalism, critical thinking, time management, attention to the details. While
others skills are mandatory for providing safe and responsive care, in the critical care unit, the
most desired skills are effective therapeutic verbal and nonverbal communication, time
management and critical thinking. Good communication between nurse and patient’s or family

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members of the patients contribute to the ability to provide patients with individualized care
which include inducing the feeling of safety, love, empowerment, and confidence during
treatment and making the center of decision making (Lines, Lepore, and Wiener 2015).
Nonverbal communication also plays a crucial in conveying a strong message to the patients,
reflecting empathy and compassion. Critical thinking is another crucial skills since the patients
in the critical care sometimes failed to provide their decision or preferences due to health issues
and nurses are required to use their critical thinking to take an appropriate decision for the
patients (Smith, Swallow and Coyne 2015). Hence, patient-centered care is one of the
fundamental quality standards in critical care.
Patient centred care in a hospital settings covers a range of activities starting from the
involvement of the in individual care to the involvement of the public in the health policy
decisions. However, there is no standard definition of patients centred care and is poorly
understood. It is to be found that nurses find it difficult to provide patient centred care to
critically ill patient, due to lack of the proper frameworks (Kitson 2018). There are literary
evidences of ,any frameworks that has been developed for providing care to the elderly people,
but attempts for applying them in the critical care context has found to be extremely difficult.
Swickard, et al. (2017) have developed a conceptual framework for practice which was based on
the needs of the patient. Such a framework would allow the nurses to contribute optimally to the
client outcome. The Synergy Model of patient centred care describes patient and characteristics
of the family spanning the continuum of health and illness (Cypress 2013). These characteristics
assists the nurse recognise the needs of the patients and the family members (Cypress 2013) .The
synergy model considers the following characteristics of the patient- Stability, complexity,
Vulnerability, Resiliency, Predictability, availability of the resources, patient participation in

4ACUTE AND CRITICAL CARE
care, participation in the decision making process (Jakimowicz and Perry 2015). Again the
Synergy model perceives the following characteristics of the nurses- Advocacy and moral
agency, clinical judgment, caring practices, collaboration, systemic thinking, response to
diversity, clinical enquiry, patients and family educator (Jakimowicz and Perry 2015).
For example, as per the Synergy model, in order to provide a person centred care to a
patient suffering from pressure ulcers, at first it is necessary to develop a rapport with the patient,
assess the patient for the development of any ski injury. Special attention should be given to
those patients having restricted mobility. The wound or the injury should be assessed by nurse,
deciding upon the type of dressings and medications that has to be administered. This would be
followed by the consulting with the dietician for chalking out a diet plan for the patient.
Feo and Kitson (2016) on the other hand have stated that, nurses at the point of care do
not generally engage or reflect on their practice, which has led to the generation of a dearth of
insights that is theoretically informed. Strategies used for explaining the deficits in nursing have
been derived from some other disciplines like the quality and safety movements. The
fundamentals of care theoretical framework (FOC) has been proposed as an ideal theoretical
framework. The core element of FOC framework in nurse-patient relationship, based on which
the foundation of a person centred care is built. Establishment of a caring relationship is not a
one -time process, but is an ongoing event creating a safe and a secured environment (Kitson,
Marshall, Bassett and Zeitz 2013). The other element of FOC framework is how the individual
care needs of the patients are addressed. The final dimension of the FOC framework is the
context of care. In order to cover the reasons for a documented failure in the fundamental of care
some scholars and clinicians are looking in to the environment, the care is taking place.

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Reflection
In this part, I will be following Driscoll’s model of reflection. Critical care units are for
patients who had been seriously ill and requires the rigorous monitoring and intensive medical
care. Patients are admitted in to critical care unit with various comorbidities often requiring
prolonged hospital stay along with restricted mobility. While studying about “patient centred
care”, I have come across the different elements that should be followed while providing care.
What?
Previously I had limited knowledge of what a person centred care is. I was of the notion,
that looking after the patient’s chart, acting in accordance with the standard protocol is all that
serves best, till I have come across this module.
So what?
My previous perspective had largely affected my nursing service. While I was caring for
an elderly patient suffering from terminal Illness, I tried my best of efforts address his pain, but
really did not bother of his sufferings, which could be due to the feeling of losing loved ones. I
had very little knowledge about a family centred care or shared decision making.
Now what?
Now that I have realised the effectiveness of a person centred care, I have decided to
consider certain elements like establishing a rapport with the patient to understand his/her
physical or emotional grievances, proper assessment and raising red flags against any adverse
issue, involving the patient and the family in the care regimen of the patient, taking proper
interventions, and often collaborating with other health care experts.

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Assignment 2
Skin care issues in Intensive care setting
Patients who had been admitted to intensive care units suffer from complex health care
needs. The role of dermatology in the intensive care unit has not been studies much. Sin disease
itself might lead to the admission in the ICU in case of certain emergencies. The mortality rate
due to dermatological condition can be as high as 27 % and 39.6 % who has died before an
ultimate discharge from the hospital. Various types of skin irritations and skin infection can be
observed in hospital care setting. Some of the major clinical symptoms of skin injury are
pruritus, excoriations, desquamation and redness. Some of the other clinical symptoms might
include asteatotic eczema, pressure injury. My chosen clinical setting for this discussion is, the
Intensive care unit and the topic of discussion that has been chosen are pressure injury.
Pressure injury or pressure ulcer is a common condition in intensive care units, in patients
who had been sedated or ventilated or have been in a status condition for a longer period of time.
Reader and Gillespie (2013) have stated that 63% of the mortality in patients with pressure ulcers
and 15 % without pressure ulcers has been found in a study. Patients who develop hospital
acquired pressure injuries also experience added comorbidities like morbidity, psychological
distress and pain that is associated with loss of independence and social isolation.
There are many actors that led to the development of pressure ulcers, but the most
common pathway to ulceration is tissue ischemia. The tissues are capable to sustain pressure on
the arterial side of about 30-32 mm hg for only a small span of time. If the pressure increases

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even slightest above that, this would cause microcirculatory occlusion and this in turn initiates
ischemia, ulceration and tissue death (Bhattacharya and Mishra 2015).
Pressure ulcer can develop when a large amount of pressure is applied over a longer
period of time. Tissue distortion occurs as less pressure is applied over a longer period of time
(Bhattacharya and Mishra 2015). The distortion of the tissue occurs either because the soft
tissues are compressed or are sheared between the support and skeleton , such as a person sitting
or lying as something is pressing in to the body, or a shoe, prosthesis, a surgical appliance, or
elastic of a clothing (Bhattacharya and Mishra 2015). The blood vessel present in the distorted
tissues are compresses, stretched out or angulated out of their usual shape, and the blood cannot
pass through the blood vessels. The tissue supplied by the blood vessels might become ischemic.
Apart from occluding the blood flow, the distortion of the tissue the obstructs the lymphatic
flow, which in turn leads to the accumulation of the metabolic waste products, enzymes and
proteins in the affected tissue.
Most of the pressure ulcers are device related. Patients who are intubated in critical care
units are at risk of developing pressure ulcers on patients lips (Cooper 2013). Other devices like
cervical collars increases the risk of development of pressure ulcer at the contact points on the
chin. Collars that are made up of rigid foams or plastic are associated with a higher risk of
pressure injury, that that of the padded collars. According to Cooper, (2013) tracheostomy tubes
has also been found to be responsible for the development of pressure ulcers in patient in critical
care units, receiving mechanical ventilation. Positioning and turning of the tube creates tension
in the tubing, promoting displacement of the faceplate of the tracheostomy tube. There are no
published studies to describe the preventive measures other than making sure, that the straps are
not too tight, alternating a partial face mask. Burman, Robinson and Hart (2013) have stated that

8ACUTE AND CRITICAL CARE
some of the strategies for the development of the pressure ulcer at the point where the mask
touch the face of the patients. Studies have shown that rigid transfer boards might produce
pressure injuries since, the patient slides over a rigid surface.
Bariatric patients might provide challenges to critical care nurses and thee is a higher risk
of pressure ulcers due to the moisture in the skin folds and inability to change positions. Children
admitted in critical care units. The adipose tissue present has decreased supply of blood in
comparison to the muscle tissues and the weight increase the pressure on the tissues. Other risk
factors for the development of pressure ulcers such as diabetes and the vascular disease, chronic
evaluation, length stay at the ICU, presence of mechanical ventilation, use of sedatives and the
use of sedatives or use of any instruments for measuring the pressure at the interface between the
patient and the bed. Nutrition can be an important risk factor for pressure injury (Posthauer et al.
2016). Studies have found that patients who are malnourished have large portions of bony
prominences and hence the risk of contracting the pressure injury is greater. It has been found
that lower level of albumin is an indicator of malnutrition. Lower pre-albumin level can be a
reflection of the present nutritional condition of the patient. It is necessary that the albumin levels
and the prealbumin level are assessed routinely, indicating the trends in the adequacy of the
nutrition level (Posthauer et al. 2016).
Pressure injury in intensive care unit might often acts as a quality care indicator in an
institution and failure to provide a standard of care in this respect might increase the case of
litigation. Again intensive care acquired pressure injury has also been associated to increased
health care costs. The nursing standards for the prevention of the hospital acquired infection in
intensive care unit has been taken.

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Apart from this, there are several complications that can arise from pressure ulcers. One
of the most important complication is the development of sepsis. If a patient has go bacteraemia,
the pressure ulcer is the most primary source of infections. Some of the additional complications
related to pressure injury includes cellulitis,osteomyelitis, and localised infections. Both pain has
been found to be associated with a decreased healing of wound. Literatures have stated that here
are literatures that have listed the development of pressure ulcers (Posthauer et al. 2016). There
are certain intrinsic and extrinsic factors that determines that the tolerance of the softer tissues.
The psychological factors of the disease states, that poor nutritional status and decreased
arteriolar blood pressure increases the risks. Some of the extrinsic factors that damages the skin
are friction and shear with the surface, urinary incontinence (Riley, White, Graham and
Alexandrov 2014). Depending of the myriad of risk factors, various scales have been developed
for quantifying the risk of a person. Some of the scales that are present in the critical care units
are Norton Scale or Braden Scale.
There are multiple factors behind the development of pressure ulcersin intensive care
unit. The association of the pressure ulcers are the factors of skin barriers have still not been
fully characterised. A skin plays important role in the homeostasis and provides a barrier against
skin infection. It also protects against noxious chemical and physical stimuli of the environment.
The epidermis, especially corneum stratum is mainly responsible for protective properties of the
skin. It has been found that the prognosis of the patients for pressureinjury might be less
favourable for surgical intensive care unit, in comparison to the other types of ICUs or long term
rehabilitation care units.
Studies say that despite of the increase in technologies and medical advances, the
incidence and the cost of the hospital acquired infection are gradually increasing. In spite of the

10ACUTE AND CRITICAL CARE
knowledge of the nurses and the health care workers, the incidence of the pressure ulcers are
gradually increasing exponentially.
Recommendations
Imperial studies have recommended many strategies like, the bed and the chair bound
patients or those who have very restricted mobility should be positioned often. Prowle, Kirwan
and Bellomo (2014) on the other hand have stated that proper training to the critical care unit
nurses about the identification of risk factors and the stages of pressure ulcers. Nurse handoff
reports and assessments on admission and shift change or conduction of the skin assessment,
reinforcing the individual accountability to prevent pressure injuries. Critical care nurses faces
unique challenges for the identification of the perfect interventions to challenge the pressure
ulcers. The nurses should be knowledgeable about the recommendation of the manufacturers for
the devices used in the patient care.
It is the duty of the nurses to identify the patients upon admission, the nutritional status of
the patient and is accountable to advocate the earliest possible supplementation of the nutrients.
It should be ensured the adequate nutrition is particularly difficult in patients receiving the
vasopressors. This is because the vasoconstrictive action of the vasopressors constricts the
gastric mucosa, causing the prevention of the absorption of the nutrients. According to Prowle,
Kirwan, and Bellomo (2014) loose stools are often caused by enteral nutrition. If the patients
cannot indicate the requirement of a bedpan, patients should depend on frequent nursing
assessment of the contingency status of the patient.
Groah et al. (2015) have suggested that patients, on admission should have to undergo a
skin assessment. All the existing wounds has to be documented and the treatment goals has to be

11ACUTE AND CRITICAL CARE
established. An assessment toll can be used for screening pressure injury. However, clinicians
sometimes use their experience and the clinical judgement skill to prevent the tissue damage. If
the patients is more prone to pressure ulcers, appropriate referrals to the nutritional services and
the wound care experts should be given. A critical care protocol for preventing pressure ulcers
development should include relief of pressure, management of moisture and nutritional support.
Nurses should conduct skin infection in each shift, especially for those patients at risk of
developing pressure ulcer. One of the important factor in managing pressure ulcer is the wound
dressing. Critical nurses should have appropriate competence and knowledge of applying
appropriate dressing. The dressing used for the various stages of wound healing is specialised in
all the stages. A whole range of dressing is available for different stages of pressure injury.
Nurses who are in the critical care sector have many opportunities for developing studies
on the preventive measures and the treatment of pressure ulcer. Further research is required to
study the incidence of device related pressure ulcers and effective nursing measures for
preventing the development of pressure ulcers. Researches has to be de regarding the release of
vasoactive mediators , using of the risk scales of the pressure ulcers, appropriate to critical care
nursing.
Education of the formal and the informal caregivers plays an important part in the
prevention and the management of pressure injury. The families and the patients should have a
comprehensive understanding of the possible impact of pressure injury in one’s life. This of
special importance, when a patient is in care of a home based environment after the discharge
from the critical care unit (Reader and Gillespie 2013). Families and the carers who have been
discharged with risk factors should be given a pressure injury prevention parent factsheet and
should be consulted with appropriate prevention strategies that are relevant to their child before

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the discharge. Patient has to be suitably positioned, such that the pressure is redistributed. Patient
who are unable to move on their own should be repositioned after every two hours (Gillespie et
al., 2014). Patients suffering from pain due to pressure injury should be monitored and ensured a
pain relief is given. Heels must be suspended of the bed with the help of pillows. For high risk
patients it has been recommended that the time spend in sitting on the bed should be limited with
head elevated at angle greater than thirty degree to no more than two hours for enhancing the
pressure on the sacrum (Gillespie et al. 2014). Patient should be frequently hydrated. Nurses, in
the critical care unit can consult with a dietician to chalk out a proper meal plan. Nutritional
support should be provided for fulfilling the nutritional deficits, maintain a proper nitrogen
balance, restoration of the serum albumin level (Prowle, Kirwan and Bellomo 2014). According
to Latimer, Chaboyer and Gillespie (2014) some of the nutrients that have received primary
interest in the prevention and the treatment of pressure injury are protein , Zinc and vitamin C.
The multifactorial nature of the pressure ulcer makes it difficult for identification by the
newly graduate nurses. Hence it is the necessary, the nurses are educated about the patients,
devices and the assessment techniques , the identification and the categorisation of the ulcers, the
physiology and the anatomy, the variations and the differentiability of the damages that have
occurred how, proper documentation of the information (Barker et al. 2016). The knowledge and
the skills of the nurses need to be monitored appropriately.
Reflection
A critical care setting can be considered as one of the most complicated environment in a
hospital care setting as we have to manage several patients with comorbidities. On top of this
disease burden, pressure ulcers come as an additional disease burden that may affect the quality

13ACUTE AND CRITICAL CARE
of living in a hospital. Being a critical care nurse, it is my duty to skilfully balance the
occurrence of pressure injury in an environment with multiples component and the lifesaving
techniques that often take precedent. Despite of various strategies taken for them, pressure
injuries are common in the intensive care unit. In this section, I would use Driscoll’s model of
reflection to reflect on my learning experience.
What?
While searching for some narrow critical issues that are common in critical care units, I
came across the most common condition- Pressure injury. Previously I has less idea as well as
knowledge of how dangerous can a pressure injury be. While brainstorming through the data, I
was surprised by the data about mortality caused due to pressure injury. During my placement as
an intern in the critical care unit, I have realised how pain and pressure injury affects the quality
of life of critically ill patients. This learning module has helped me to understand about skin
homeostasis in details and the underlying pathophysiology of pressure ulcer.
So what?
Understanding the pathophysiology of the disease has increased my ability of critical
thinking skills. This has encouraged me to research about the different tools that are used for
assessing pressure ulcers. While going through this module, I have come across different ways of
managing pressure ulcer in critically ill patients, such as repositioning, using specific devices for
patients having very restricted mobility. I have also learnt how use of artificial devices can
exacerbate the effects. This module has helped me to understand about the ways of wound
dressing and debriment.

14ACUTE AND CRITICAL CARE
Now what?
I believe that nurses need to have a critical understanding of a condition before planning the
interventions. I strongly believe, the occurrence of pressure ulcers to be a clinical performance
indicator, as without proper knowledge nurses would not reposition the patients or would assess
the wound. Moreover, this knowledge would help me in my future clinical practice, while
providing service to the geriatric patients.

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