1
The Synergy Model
1) Basic Concepts
a) AACN(Amer. Assoc. of Cardiac/Critcal care nursing) Synergy Model for Patient Care
i) The needs or characteristics of clients and families influence and drive nurse’s competencies
ii) Synergy results in the needs & characteristics of a client, clinical unit or system are matched with a nurse’s
competencies
iii) It is about the patient and the family not about you!
iv) The goal of the nurse is always to return the patient to optimal level!
b) Client Characteristics are Unique to Each Care Situation
i) 8 Client Characteristics
(1) Resiliency* CHILDREN HAVE GOOD RESILIENCY!
(a) Capacity to return to a restorative level of functioning using compensatory/coping mechanisms
(b) The ability to bounce back quickly after an insult
-How fast do they bounce back? Factors that delay, immunocompromised?
(c) Some patients are very resilient and some are not
(d) Nurse must assess patient’s resiliency and the factors that affect it
(2) Vulnerability
(a) Susceptibility to actual or potential stressors that may adversely affect outcomes (COMORBID conditions)
effect outcomes
(3) Stability
(a) Ability to maintain a steady-state; equilibrium (HOMEOSTASIS)
(b) External and internal factors affect stability
(c) Determine why they are not returning to optimal level
(d) Many times this is beyond medical reasons
(4) Complexity
(a) Entanglement of 2 or > systems EX. Resp. and Cardiac problems, family issues?, ex. Dialysis therapy 3 days
q week 4hrs a day
(i) Body, family, therapies
(5) Resource Availability (SOCIAL WORKERS ARE GO TO!!)
(a) Extent of resources the client/family/community bring to situation
(i) Technical
(ii) Fiscal
(iii) Personal (Financial issues), Hotlines
(iv) Psychological
(v) Social PT. EDUCATION IS KEY!
(6) Participation in Care
(a) Extent to which client/family engages in aspects of care
-Can the patient make decisions for themselves, Cook, Get dressed, ADLs,
(b) Try to get the family engaged; it may decrease their stress level
(c) Have families and the patient participate in care; does not have to be hands on
(7) Predictability
(a) Allows one to expect a certain course of events or course of illness
(b) Examples
(i) A healthy 40-year-old female undergoing a pre-employment physical
- Finding something wrong would be a suprise
(ii) A critically ill infant with multi-system organ failure
-The ability for the infants organs to compensate for one another is challenged
2) Nurse Competencies: Concern to Clients, Clinical Units and Systems LEVEL 1,3,5
a) Level 1: novice nurse, less than < 1 year experience
b) Level 3: some experience, about 3 years
c) Level 5: expert
d) Clinical Judgment -use knowledge of the nurse to impact the patient’s outcomes
i) Clinical reasoning
, 2
ii) Decision making
iii) Critical thinking
iv) Global grasp of situation- If this then that, one implication/intervention impacts the next one
e) Advocacy & Moral Agency
i) Working on another’s behalf & representing concerns of the client/family & nursing staff, IMPORTANT!!!
ii) Serves as an agent in resolving ethical & moral dilemmas ex. RN to MD “Why this medication?”
f) Caring Practices
i) Creating a compassionate, supportive, & therapeutic environment for clients & staff
ii) Aim of promoting comfort & healing
g) Collaboration
i) Working with others
-Grand Rounds- when many disciplines round on patients at once EX MD, RN, Charge Nurse, Dietician
(1) Clients/families
(2) Health care providers
ii) Promotes each individual’s contributions
iii) Involves intra- and inter-disciplinary work with colleagues & community
h) Systems Thinking
i) Body of knowledge & tools that allow the nurse to manage environmental & system resources available
-Chain of Command
i) Responsiveness to Diversity
i) Sensitivity to recognize, appreciate, & incorporate differences into provision of care.
ii) Difference may include:
(1) Culture
(2) Spiritual
(3) Gender
(4) Race
(5) Ethnicity
(6) Lifestyle
(7) Socioeconomic status
(8) Age
(9) Values
j) Facilitation of Learning
i) Ability to facilitate learning for:
(1) Clients/families
(2) Nursing staff- competencies
(3) Members of health care team
(4) Community
ii) May include both informal & formal learning
k) Clinical Inquiry/Evaluator-
i) Ongoing process of questioning & evaluating practice
ii) Creating practice changes through research utilization & experiential learning
3) The goal of nursing is to restore a client to an optimal level of wellness as defined by the client.
Hemodynamic Monitoring
1) Hemodynamic Monitoring
a) Critically ill patient require continuous assessment of the cardiovascular system to diagnose and manage medical
conditions
b) Achieved via direct pressure monitoring systems
i) Central venous pressure (CVP)- measure of pressure in the right atrium Purpose is to monitor for fluid volume
disturbances, NORMAL= 2-6 mmhg , to measure: a CVP line is inserted into either the subclavian or jugular vein
and advanced until the tip of the catheter is at the junction of the SVC and RA local anesthesia used and dry sterile
dressing is applied once placed and position confirmed by chest x-ray, CONNECT ONE OF THE PORTS OF THE
CENTRAL LINE TO THE TRANSDUCER TO GET WAVEFORM!!, low CVP is indicative of hypovolemia (vomiting,
, 3
diarrhea, dehydration, blood loss) , Elevated CVP mostly indicative of hypervolemia, cardiac tamponade or right
sided HF. Can give IV fluids, meds and draw blood specimens through CVP line
ii) Pulmonary artery pressure (PAP)- (SWAN-GANZ) PURPOSE: assess LV FUNCTION/PRELOAD, CARDIAC OUTPUT
MEASURE CO BY CONNECTING THERMISTOR TO BEDSIDE CARDIAC MOITOR 5-10 ML OF SALINE INJECTED IN 4
SEC INTO PROXIMAL PORT ex. dx etiology of shock. Pulmonary artery catheter and pressure monitoring used,
balloon at the tip (1.5ml), distal lumen opens into the pulmonary artery, proximal lumen has a port into the RA
used to admin meds or fluids. Catheter covered with sterile sleeve and inserted into subclavian vein through a
sheath which has a port for IV fluids/meds (PROX. PORT), catheter is passed through RA where the balloon is
inflated and carried all the way through to the PA where the balloon is deflated, and catheter is secured w/
sutures!!! Fluoroscopy used to monitor progression through the heart chambers.
PAP IS ACHIEVED BY INFLATING BALLOON TIP CAUSING IT TO FLOW DISTALLY AND WEDGE INTO POSITION, THIS
IMPEDES BLOOD FLOW SO THE PRESSURE IS MEASURED IMMEDIATELY AND BALLOON IS DEFLATED TO RESTORE
BLOOD FLOW!!!! DISTAL PORT CONNECTED TO TRANSDUCER FOR PRESSURE READINGS!!
iii) Intra-arterial blood pressure (Arterial line)- PURPOSE: DIRECT CONTINUOUS BP MEASUREMENTS in pts w/
SEVERE HYPER OR HYPOTENSION, as well as ABG measurements and blood samples. MUST BE CONNECTED TO
TRANSDUCER TO GET PRESSURE!! PTS THAT REQUIRE FREQUENT ABGS HAVE AN A-LINE (VENTED PTS)
Most common placement is RADIAL ARTERY OR YOU CAN DO FEMORAL: DISTAL TISSUE MAY BECOME ISCHEMIC
OR NECROTIC IN PT W/ DM, PVD, HYPOTENSION, SX , IV VASOPRESSORS
c) Nursing care
i) Ensure system is set up and maintained properly
(1) For example, the pressure monitoring system must be kept patent and free of air bubbles
, 4
ii) Ensure stopcock is at level of atrium before measurements obtained
(1) This landmark is referred to as the phlebostatic axis
iii) Establish zero reference point in order to ensure that the system is properly functioning at atmospheric pressure
measurements
(1) This is accomplished by placing the stopcock of the transducer at the phlebostatic axis, opening the
transducer to air, and activating the zero-function key on the bedside monitor
(2) HOB at 60 degrees
d) Complications
i) Uncommon
ii) Pneumothorax (MAY PUNCTURE A LUNG!)
(1) Observe for signs during insertion of catheters using a central venous approach
iii) Infection
(1) Longer catheters left in place the greater risk for infection
(2) See care bundle, page 687
(a) Hand hygiene
(i) Soap and water or alcohol-based rubs before and after contact with catheter
(b) Dressing
(i) Wear clean or sterile gloves when changing dressing
(ii) Cleanse the skin during dressing changes with a >0.5% chlorhexidine preparation with alcohol
(iii) Dress site with sterile gauze or sterile transparent semipermeable dressing
(iv) Change gauze dressing every 2 days or transparent every 7 days and whenever damp, loosened, or
soiled
(v) Do not use topical antibiotic ointment or creams
(c) Catheter site
(i) Assess regularly
(ii) Remove dressing if patient has tenderness, fever without source, or other signs of infection
(d) Pressure monitoring system
(i) Keep all components sterile
(ii) Replace transducers, tubing, and continuous flush device, and flush solution evert at 96-hour interval
(iii) Do not infuse dextrose containing solutions through monitoring systems
(e) Bathing
(i) Do not submerge the catheter in water
(ii) Showering is permitted if the catheter and tubing are placed in impermeable cover
(f) Patient education
(i) Report any new discomforts
iv) Air embolism
(1) If stopcocks attached the pressure transducers are mishandled during blood drawing, administration of meds,
or other procedures open to air
2) Hemodynamic monitoring: what does it measure?
a) Hemodynamic monitoring measures:
i) Heart chamber pressures
ii) Cardiac output
iii) Preload
iv) Afterload
v) Contractility
b) Cardiac Output= Stroke Volume x HR
i) Cardiac Output
(1) Total amount of blood ejected by the ventricle in liters per minute
(2) Resting adult: 4-6L/min
(3) Varies based on metabolic need
(4) Decrease cardiac output results in decrease perfusion to target organs
ii) Stroke Volume
(1) Total amount of blood ejected by the ventricle per heartbeat
(2) Resting adult: 60-130 mL
The Synergy Model
1) Basic Concepts
a) AACN(Amer. Assoc. of Cardiac/Critcal care nursing) Synergy Model for Patient Care
i) The needs or characteristics of clients and families influence and drive nurse’s competencies
ii) Synergy results in the needs & characteristics of a client, clinical unit or system are matched with a nurse’s
competencies
iii) It is about the patient and the family not about you!
iv) The goal of the nurse is always to return the patient to optimal level!
b) Client Characteristics are Unique to Each Care Situation
i) 8 Client Characteristics
(1) Resiliency* CHILDREN HAVE GOOD RESILIENCY!
(a) Capacity to return to a restorative level of functioning using compensatory/coping mechanisms
(b) The ability to bounce back quickly after an insult
-How fast do they bounce back? Factors that delay, immunocompromised?
(c) Some patients are very resilient and some are not
(d) Nurse must assess patient’s resiliency and the factors that affect it
(2) Vulnerability
(a) Susceptibility to actual or potential stressors that may adversely affect outcomes (COMORBID conditions)
effect outcomes
(3) Stability
(a) Ability to maintain a steady-state; equilibrium (HOMEOSTASIS)
(b) External and internal factors affect stability
(c) Determine why they are not returning to optimal level
(d) Many times this is beyond medical reasons
(4) Complexity
(a) Entanglement of 2 or > systems EX. Resp. and Cardiac problems, family issues?, ex. Dialysis therapy 3 days
q week 4hrs a day
(i) Body, family, therapies
(5) Resource Availability (SOCIAL WORKERS ARE GO TO!!)
(a) Extent of resources the client/family/community bring to situation
(i) Technical
(ii) Fiscal
(iii) Personal (Financial issues), Hotlines
(iv) Psychological
(v) Social PT. EDUCATION IS KEY!
(6) Participation in Care
(a) Extent to which client/family engages in aspects of care
-Can the patient make decisions for themselves, Cook, Get dressed, ADLs,
(b) Try to get the family engaged; it may decrease their stress level
(c) Have families and the patient participate in care; does not have to be hands on
(7) Predictability
(a) Allows one to expect a certain course of events or course of illness
(b) Examples
(i) A healthy 40-year-old female undergoing a pre-employment physical
- Finding something wrong would be a suprise
(ii) A critically ill infant with multi-system organ failure
-The ability for the infants organs to compensate for one another is challenged
2) Nurse Competencies: Concern to Clients, Clinical Units and Systems LEVEL 1,3,5
a) Level 1: novice nurse, less than < 1 year experience
b) Level 3: some experience, about 3 years
c) Level 5: expert
d) Clinical Judgment -use knowledge of the nurse to impact the patient’s outcomes
i) Clinical reasoning
, 2
ii) Decision making
iii) Critical thinking
iv) Global grasp of situation- If this then that, one implication/intervention impacts the next one
e) Advocacy & Moral Agency
i) Working on another’s behalf & representing concerns of the client/family & nursing staff, IMPORTANT!!!
ii) Serves as an agent in resolving ethical & moral dilemmas ex. RN to MD “Why this medication?”
f) Caring Practices
i) Creating a compassionate, supportive, & therapeutic environment for clients & staff
ii) Aim of promoting comfort & healing
g) Collaboration
i) Working with others
-Grand Rounds- when many disciplines round on patients at once EX MD, RN, Charge Nurse, Dietician
(1) Clients/families
(2) Health care providers
ii) Promotes each individual’s contributions
iii) Involves intra- and inter-disciplinary work with colleagues & community
h) Systems Thinking
i) Body of knowledge & tools that allow the nurse to manage environmental & system resources available
-Chain of Command
i) Responsiveness to Diversity
i) Sensitivity to recognize, appreciate, & incorporate differences into provision of care.
ii) Difference may include:
(1) Culture
(2) Spiritual
(3) Gender
(4) Race
(5) Ethnicity
(6) Lifestyle
(7) Socioeconomic status
(8) Age
(9) Values
j) Facilitation of Learning
i) Ability to facilitate learning for:
(1) Clients/families
(2) Nursing staff- competencies
(3) Members of health care team
(4) Community
ii) May include both informal & formal learning
k) Clinical Inquiry/Evaluator-
i) Ongoing process of questioning & evaluating practice
ii) Creating practice changes through research utilization & experiential learning
3) The goal of nursing is to restore a client to an optimal level of wellness as defined by the client.
Hemodynamic Monitoring
1) Hemodynamic Monitoring
a) Critically ill patient require continuous assessment of the cardiovascular system to diagnose and manage medical
conditions
b) Achieved via direct pressure monitoring systems
i) Central venous pressure (CVP)- measure of pressure in the right atrium Purpose is to monitor for fluid volume
disturbances, NORMAL= 2-6 mmhg , to measure: a CVP line is inserted into either the subclavian or jugular vein
and advanced until the tip of the catheter is at the junction of the SVC and RA local anesthesia used and dry sterile
dressing is applied once placed and position confirmed by chest x-ray, CONNECT ONE OF THE PORTS OF THE
CENTRAL LINE TO THE TRANSDUCER TO GET WAVEFORM!!, low CVP is indicative of hypovolemia (vomiting,
, 3
diarrhea, dehydration, blood loss) , Elevated CVP mostly indicative of hypervolemia, cardiac tamponade or right
sided HF. Can give IV fluids, meds and draw blood specimens through CVP line
ii) Pulmonary artery pressure (PAP)- (SWAN-GANZ) PURPOSE: assess LV FUNCTION/PRELOAD, CARDIAC OUTPUT
MEASURE CO BY CONNECTING THERMISTOR TO BEDSIDE CARDIAC MOITOR 5-10 ML OF SALINE INJECTED IN 4
SEC INTO PROXIMAL PORT ex. dx etiology of shock. Pulmonary artery catheter and pressure monitoring used,
balloon at the tip (1.5ml), distal lumen opens into the pulmonary artery, proximal lumen has a port into the RA
used to admin meds or fluids. Catheter covered with sterile sleeve and inserted into subclavian vein through a
sheath which has a port for IV fluids/meds (PROX. PORT), catheter is passed through RA where the balloon is
inflated and carried all the way through to the PA where the balloon is deflated, and catheter is secured w/
sutures!!! Fluoroscopy used to monitor progression through the heart chambers.
PAP IS ACHIEVED BY INFLATING BALLOON TIP CAUSING IT TO FLOW DISTALLY AND WEDGE INTO POSITION, THIS
IMPEDES BLOOD FLOW SO THE PRESSURE IS MEASURED IMMEDIATELY AND BALLOON IS DEFLATED TO RESTORE
BLOOD FLOW!!!! DISTAL PORT CONNECTED TO TRANSDUCER FOR PRESSURE READINGS!!
iii) Intra-arterial blood pressure (Arterial line)- PURPOSE: DIRECT CONTINUOUS BP MEASUREMENTS in pts w/
SEVERE HYPER OR HYPOTENSION, as well as ABG measurements and blood samples. MUST BE CONNECTED TO
TRANSDUCER TO GET PRESSURE!! PTS THAT REQUIRE FREQUENT ABGS HAVE AN A-LINE (VENTED PTS)
Most common placement is RADIAL ARTERY OR YOU CAN DO FEMORAL: DISTAL TISSUE MAY BECOME ISCHEMIC
OR NECROTIC IN PT W/ DM, PVD, HYPOTENSION, SX , IV VASOPRESSORS
c) Nursing care
i) Ensure system is set up and maintained properly
(1) For example, the pressure monitoring system must be kept patent and free of air bubbles
, 4
ii) Ensure stopcock is at level of atrium before measurements obtained
(1) This landmark is referred to as the phlebostatic axis
iii) Establish zero reference point in order to ensure that the system is properly functioning at atmospheric pressure
measurements
(1) This is accomplished by placing the stopcock of the transducer at the phlebostatic axis, opening the
transducer to air, and activating the zero-function key on the bedside monitor
(2) HOB at 60 degrees
d) Complications
i) Uncommon
ii) Pneumothorax (MAY PUNCTURE A LUNG!)
(1) Observe for signs during insertion of catheters using a central venous approach
iii) Infection
(1) Longer catheters left in place the greater risk for infection
(2) See care bundle, page 687
(a) Hand hygiene
(i) Soap and water or alcohol-based rubs before and after contact with catheter
(b) Dressing
(i) Wear clean or sterile gloves when changing dressing
(ii) Cleanse the skin during dressing changes with a >0.5% chlorhexidine preparation with alcohol
(iii) Dress site with sterile gauze or sterile transparent semipermeable dressing
(iv) Change gauze dressing every 2 days or transparent every 7 days and whenever damp, loosened, or
soiled
(v) Do not use topical antibiotic ointment or creams
(c) Catheter site
(i) Assess regularly
(ii) Remove dressing if patient has tenderness, fever without source, or other signs of infection
(d) Pressure monitoring system
(i) Keep all components sterile
(ii) Replace transducers, tubing, and continuous flush device, and flush solution evert at 96-hour interval
(iii) Do not infuse dextrose containing solutions through monitoring systems
(e) Bathing
(i) Do not submerge the catheter in water
(ii) Showering is permitted if the catheter and tubing are placed in impermeable cover
(f) Patient education
(i) Report any new discomforts
iv) Air embolism
(1) If stopcocks attached the pressure transducers are mishandled during blood drawing, administration of meds,
or other procedures open to air
2) Hemodynamic monitoring: what does it measure?
a) Hemodynamic monitoring measures:
i) Heart chamber pressures
ii) Cardiac output
iii) Preload
iv) Afterload
v) Contractility
b) Cardiac Output= Stroke Volume x HR
i) Cardiac Output
(1) Total amount of blood ejected by the ventricle in liters per minute
(2) Resting adult: 4-6L/min
(3) Varies based on metabolic need
(4) Decrease cardiac output results in decrease perfusion to target organs
ii) Stroke Volume
(1) Total amount of blood ejected by the ventricle per heartbeat
(2) Resting adult: 60-130 mL
