bluuebunny/crossref_metadata_2025 huggingface dataset:
Teaching after CABG surgery: a family affair
Authors: Hill M
Published: November 2019

CABG surgery is a stressor that severely compromises the integrity of the family. In the role of teacher, the critical care nurse can function as a catalyst to facilitate the togetherness of the family. This goal may be achieved by the nurse using easily planned and presented teaching-learning strategies described in this article. Family wholeness can be encouraged by the nurse instructing both the patient and spouse in the basic skills and general knowledge necessary to perform postoperative care. In this capacity, the nurse can also establish a foundation for life-long commitment to healthful behaviors. Thus, the instruction of the nurse facilitates the mutual support needed by family members to achieve positive rehabilitation. Truly, teaching after CABG surgery is a family affair.
Sudden bereavement: nursing interventions in the ED
Authors: Mian P
Published: November 2019

When a sudden death occurs, families are faced with the enormous task of dealing with the loss of a significant relationship without warning or preparation. This article describes a Bereavement Program established by nurses in a busy emergency department to help the families and to facilitate the bereavement process.
Caring for the family of the critically ill surgical patient
Authors: Stanik JA
Published: November 2019

Surgery and the critical illness of a loved one can be a situational life crisis for family members. Establishing a meaningful nurse-family relationship is critical to the success of all other interventions. Close contact with families, and an awareness of the impact of the family on patient outcomes make nurses the ideal professionals to provide care to families during this crisis.
Mandatory HIV testing in critical care/emergency patients
Authors: Unkle DW
Published: November 2019

Testing for the presence of the human immunodeficiency virus (HIV) remains one of the most controversial issues of this decade. Among persons diagnosed to be HIV positive, social ostracism and exaggerated atypical behavior are common. The resulting impact on the delivery of healthcare services to the seropositive patient has raised many ethical and professional dilemmas. Discussion of HIV testing and the subsequent effects of seropositivity on the delivery of healthcare will be emphasized.
Wellens' syndrome: identification of critical proximal left anterior descending stenosis
Authors: Conover M
Published: November 2019

By understanding and recognizing the signs of Wellens' syndrome: 1) unstable angina; 2) little or no enzyme elevation; 3) little or no ST elevation; 4) no loss of precordial R waves; 5) progressive, symmetrical, deep T wave inversion in V2 and V3, the informed critical care nurse can make an important nursing diagnosis and, with the life-saving interventions now available, can save many individuals from massive anterior wall MI.
Intrapulmonary artery balloon pumping after CABG surgery
Authors: Holzum D
Published: November 2019

Involvement in complex patient care situations is commonplace in critical care settings today. Nurses come in contact with situations in which new techniques and innovative ideas are being implemented. Nursing management can favorably affect the prognosis of the CABG surgery patient with RV failure receiving intrapulmonary artery balloon pumping. Timing should be adjusted to promote pulmonary blood flow and decrease workload of the RV.
IV inotropic agents: dopamine, dobutamine, and amrinone
Authors: Budny J , Anderson-Drevs K
Published: November 2019

Three commonly used IV inotropic agents--dopamine, dobutamine, and amrinone--have been discussed in this article. Knowledge of their common mechanisms of action, individual actions, dosages, methods of preparation, precautions, and side effects can only help critical care nurses maintain or improve the quality of care given to patients receiving these medications.
Pathologic pupillary signs: self-learning module, Part 3
Authors: Bishop BS
Published: November 2019

Designed for independent study, this module explores some of the common, but often missed, pupillary abnormalities and eye movement irregularities. Part 3 concludes the module and provides the posttest and answer keys for the posttest and the three review exercises in Part 2.
Prolactinoma: a review and case study
Authors: Nalbach DA , Carson MA
Published: November 2019

Prolactinomas are often characterized by a slow, insidious onset of symptoms. This case study highlights the need for a thorough understanding of the endocrine system and reinforces the importance of history taking and detailed nursing assessment.
Critical care nurses need to know about abused women
Authors: Henderson A
Published: November 2019

Women in abusive relationships are often ignored by the healthcare system because of the unclear roles of healthcare workers when dealing with this population. This article provides guidelines for critical care nurses to help break this cycle of violence.
The role of the critical care nurse in noninvasive temporary pacing
Authors: Appel-Hardin S
Published: November 2019

Noninvasive temporary pacing is safe and easy to use, but must be utilized early to be maximally effective. Early implementation of NTP can be enhanced if the critical care nurse is given the autonomy to implement NTP from an established protocol or unit standing orders.
Indium-111 antimyosin antibody imaging: a promising new technique in the diagnosis of M.I
Authors: Cimini DM
Published: November 2019

Extensive clinical research has demonstrated that the administration of indium-111 antimyosin antibodies is useful in the diagnosis of acute myocardial infarction. It is specific for acute myocardial necrosis, as opposed to ischemia or chronic infarction, and therefore identifies patients who have had an acute MI. It is most useful in patients whose ECGs are indeterminate for the diagnosis of acute myocardial infarction (eg, left bundle branch block or permanent pacemaker) or those with inconclusive CK or CK-MB. Diagnostic accuracy and safety of antimyosin imaging has been established. This new cardiac imaging agent holds great potential for future clinical use in the diagnosis and management of patients with known or suspected acute myocardial infarction. Presuming FDA approval, the critical care nurse will see antimyosin used as an innovative and viable alternative in the diagnosis of acute myocardial infarction. Critical care nurses need to continually increase their knowledge of technologic advances and clinical applications for their own professional development, as well as to provide accurate information to patients and their families. In the area of nuclear cardiology, this includes antimyosin imaging and other state-of-the-art imaging techniques such as magnetic resonance imaging, positron emission tomography and computed tomography.
Pneumocystosis in patients with acquired immunodeficiency syndrome
Authors: Timby BK
Published: November 2019

Nurses need to be aware that pneumocystosis is one of the most common and lethal opportunistic infections among AIDS patients. They are extremely susceptible because HIV impairs physiological mechanisms for microbial defense. Patients exhibit only minor symptomatology while the unchecked P carinii organisms accumulate and replicate. Eventually as the sporozoans create a physical barrier between the alveolar-capillary membranes, ventilation becomes impaired and severe hypoxemia develops. Early clinical and diagnostic studies mimic the findings characteristic of ARDS. Unless correct staining techniques are used on sputum specimens, the organism often escapes identification. Thus, the diagnosis and specific treatment of PCP is often delayed. While supporting ventilation, the treatment of choice is administration of antimetabolite drugs, either trimethoprim-sulfame-thoxazole or pentamidine isethionate. The search for more effective, as well as safer, treatment of PCP continues. Life-threatening nursing diagnoses such as impaired gas exchange urgently require priority attention. Besides physical care, the severe hypoxemia demands nursing approaches to help the critically ill patient deal with fear and powerlessness. The nurse also assumes a surrogate role to patients abandoned by family and friends. The psychosocial aspects of nursing care require enormous skill and finesse, because the blood and respiratory isolation precautions can communicate mixed messages to lonely, frightened patients.
Nursing care of a child following an arterial switch procedure for transposition of the great arteries
Authors: Jensen CA
Published: November 2019

The restoration of the left ventricle as the systemic pump and the lack of sinus node dysfunction (assessment with the Senning or Mustard procedure) have been suggested as the major advantages of the arterial switch procedure. Although the results are encouraging, children will require follow up to assess: long-term left ventricular function; coronary ostial growth; aortic and pulmonic anastomosis growth; long-term aortic valve (anatomical pulmonary valve) dysfunction. A learning curve is inherent to a new surgical procedure. During this learning period, both surgical technique and patient selection criteria improve, resulting in reduced morbidity and mortality. The arterial switch procedure for TGA is certainly not an exception. Expert nursing assessment and intervention during the postoperative period is imperative and may reflect on the long-term outcome of these children.
Continuous quality improvement and the acute myocardial infarction patient
Authors: Penney JB , Kolevar CM
Published: November 2019

Optimal outcomes for the AMI patient can be achieved by national and local healthcare organizations working together for quality care (see Figure). The JCAHO has provided hospitals with the 10-step process to guide quality improvement through a multidisciplinary, collaborative approach for planning and evaluating care. The ACC and AHA have established national standards for AMI care that can be used as guidelines for writing individual hospital AMI standards. The National AMI Registry Report provides current care statistics to participating hospitals. Hospitals can use the CQI dynamics to process the statistics to ensure that standards are met, ultimately facilitating clinical excellence along with cost-effective healthcare for patients with AMI. When caregivers take action to improve patient care based on these statistics, the time spent on data collection and evaluation will finally be worthwhile.
Updated care guidelines for patients with automatic implantable cardioverter defibrillators
Authors: Moser SA , Crawford D , Thomas A
Published: November 2019

Since its clinical introduction, AICD therapy has gained significant acceptance. Some physicians consider it the "gold standard" in treating malignant tachyarrhythmias associated with sudden cardiac death. As the technology and therapy application have grown, nursing responsibilities have evolved as well. And, with the forthcoming combinations of technology such as AICDs with antitachycardia pacing and bradycardia pacing, the sophistication of the therapy is expected to increase. However, the most critical role for nurses in AICD patient care remains education. Increased utilization has made AICD implants more common, but many patients still lack the initial information and acceptance needed for therapeutic success. Health-care professionals who continue to update and share their understanding of this life-saving technology make invaluable contributions to the care of these patients who have received a second chance at life.
Critical care experience for baccalaureate nursing students
Authors: Reynolds A , Wood SG , Gamero ML , Castaneda J
Published: November 2019

The projected need for critical care nurses can be met through the collaborative efforts of nursing education and nursing service. An approach as implemented at our institution with the support of community agencies can be mutually beneficial. It is generally recognized that new graduates tend to seek employment where they had positive student experiences. Although few students may choose critical care as a career, the majority will have a positive memory, which is supportive of the unique contribution of critical care nursing within the scope of the health and care of patients and their families.
Rhythm disturbances in the patient with pulmonary disease
Authors: Schactman M , Greene J
Published: November 2019

Many factors contribute to cardiac dysrhythmias in patients with pulmonary disease. The treatments themselves, as well as the clinical state of hypoxemia, can produce rhythm disturbances. A thorough understanding and awareness of the causes and treatments of the dysrhythmias of this patient population will guide the nurse in the delivery of care.
Converting cardiac surgery patients from dopamine to dobutamine
Authors: Madsen K
Published: November 2019

Dobutamine may benefit normotensive patients with cardiac decompensation due primarily to loss of ventricular contractility or when left ventricular afterload reduction is needed. Dopamine is useful when perfusion pressure must be increased to compensate for loss of vascular tone and hypotension. The bedside nurse often must make crucial drug choices to optimize the patient's hemodynamic status. Table 2 provides an easy reference to this guideline in an algorithm. Even less experienced cardiovascular nurses have been able to apply this tool appropriately. As a standing hospital procedure, approved by our cardiovascular surgeons and related committees, it provides a legal standard whereby the nursing staff can convert from dopamine to dobutamine when the need arises.
Assessing the five points of the intra-aortic balloon pump waveform
Authors: Wojner AW
Published: November 2019

IABP timing challenges the nurse not only with a waveform analysis but also an understanding of complex physiologic concepts crucial to patient management. Optimizing timing through assessment of the five points of the IABP waveform permits the critical care nurse to increase the hemodynamic benefits of IABP therapy, potentially improving patient outcome.
Transesophageal echocardiography: implications for the critical care nurse
Authors: Brown LM , Brown AS
Published: November 2019

TEE is an exciting and useful diagnostic tool that is rapidly gaining widespread acceptance in both teaching centers and community hospitals. Because of the semi-invasive nature of the procedure, nursing expertise is essential to ensure patient safety and comfort during the TEE examination.
Sodium balance in very-low-birth-weight infants
Authors: Maguire D , Doyle P
Published: November 2019

Maintaining sodium balance in the VLBW infant is not straightforward. Several predisposing factors appear in more than one imbalance constellation. In addition, the same patient circumstance can produce two types of imbalance. Understanding the physical properties of electrolytes and water enables critical care nurses to anticipate outcomes of specific situations in the neonatal ICU. Careful assessment of renal function, urine output, and water balance are crucial in determining proper treatment of sodium balance disorders. The high potential risk of errors in the neonatal ICU requires verification of all fluid and electrolyte orders, as well as serial safety checks of IV fluids and additives to avoid complications. An expert nurse's ability to predict the needs of VLBW infants places the nurse in a pivotal position to recognize subtle changes before actual physiologic change occurs. Although the multiple variations can be confusing to the bedside clinician, sorting through them helps in selecting interventions that are timely and improve the outcomes and morbidity of our smallest patients at risk.
Measles pneumonia in the critically ill child: application of alternative ventilation strategies
Authors: Claytor D , Margherita L , Penn K , Franck LS
Published: November 2019

Measles pneumonia is a life-threatening complication in children infected with the measles virus. The increased number of reported cases over the last several years suggests a need for heightened awareness of the complication among pediatric critical care nurses. Application of alternative ventilation strategies in the critical care setting continues to be explored in children with ARDS refractory to more conventional ventilation support, because the mortality and morbidity associated with ARDS in children remain high. Patients who present with diffuse, bilateral lung injury, such as in measles pneumonia, may be candidates for alternative ventilation strategies. Few investigators have studied alternative ventilation strategies in the pediatric ICU setting. Therefore, nursing research related to the impact of nursing interventions during alternative ventilation strategies is needed. Specifically, evaluation of ET suctioning practices and other interventions that influence oxygen delivery and consumption are necessary to plan effective care during alternative ventilation strategies and improve patient outcome. Prevention of measles pneumonia is clearly the preferred "treatment." Preventive healthcare is paramount in providing optimal care for children. However, until we can address the environmental factors that predispose children to communicable diseases such as measles, critical care nurses must be knowledgeable about the assessment and management of measles pneumonia.
Care: an ethical foundation for critical care nursing
Authors: Gaul AL
Published: November 2019

Critical care nursing by definition focuses on human responses to life-threatening problems. An increasing number of ethical dilemmas confronts the critical care nurse. A traditional principled orientation to ethical reasoning requires detachment that does not acknowledge the special nature of the nurse-patient relationship and, by itself, does not give satisfactory direction in resolving ethical dilemmas. An ethic of care that acknowledges the special relationship and connection of one human being with another may provide the necessary guidance to assist the nurse in resolving these dilemmas. Critical care nursing practice based on an ethic of care acknowledges and legitimizes care for patients as well as oneself.
Removal of femoral sheaths by registered nurses: issues and outcomes
Authors: Schickel S , Cronin SN , Mize A , Voelker C
Published: November 2019

The results of this evaluation indicate that specially trained critical care nurses can remove femoral sheaths with an acceptable margin of safety. As a result, these nurses can provide quality, cost-effective care to angioplasty patients. However, before this procedure is included as part of the RN's responsibility, written protocols are needed to identify appropriate patients, proper removal technique, and specific actions to take if complications occur. In addition, plans must be developed for initial education and ongoing competency evaluation to ensure that each nurse involved maintains an adequate knowledge base and skill level.
Liquid ventilation: new frontiers in the treatment of ARDS
Authors: Dirkes S
Published: November 2019

At our institution, PLV continues to be used as an investigational therapy for patients with ARDS who meet the protocol criteria. Since this is the beginning of the first nonneonatal clinical trial of PLV, results of this therapy are not yet available. Adverse effects on hemodynamic parameters have not been documented in the current literature for patients treated with liquid ventilation. In addition, further clinical studies using PLV therapy will be necessary to determine whether it will significantly change the morbidity and mortality of ARDS in infants or adults. Other questions to be answered include the cost-effectiveness of using this therapy for patients with ARDS, as well as what type of program will be required to carry out this therapy. It is hoped that this type of ventilatory therapy will offer an effective, simple method of treatment for patients with ARDS in the future.
Viral myocarditis in children
Authors: Suddaby EC
Published: November 2019

Viral myocarditis is the result of a viral infection that produces myocardial necrosis and triggers an immune response to eliminate the viral agent. Many pathogenic mechanisms may contribute to myocardial cell loss including the following: cytokine production contributing to disease severity; viral persistence, which may produce an autoimmune response to cardiac myosin; and viral invasion of vascular endothelium causing vascular spasm with reperfusion injury. The compensatory response of the myocardium to these mechanisms of cell loss is hypertrophy, which results in fibrosis, scarring, and dilation. The myocardial cell loss and physiological response produces a child with fever, lethargy, symptoms of congestive heart failure, cardiogenic shock, or new onset arrhythmias. The initial presentation may be subtle, but if left untreated will go on to produce severe symptoms. The focus of diagnostic studies is to evaluate cardiac function, identify the viral agent, and eliminate other causes of global cardiac dysfunction. Treatment must provide for support of cardiac function through inotropic and afterload-producing agents while providing rest for the stressed cardiac muscle. The nursing care of children with viral myocarditis must focus on continual assessment of the cardiovascular system while supporting the recovery of myocardial function.
Gastric tonometry: evaluating tissue oxygenation
Authors: Ferguson A
Published: November 2019

Critically ill patients require vigilant monitoring of tissue oxygenation, particularly oxygenation of the gut mucosa, because of the mucosa's fragile blood supply. With the advent of gastric tonometry, splanchnic tissue oxygenation can be measured in a minimally invasive and cost-effective manner. Requiring only a gastric tonometer (approximately $70) and facilities to measure arterial blood gases, this method allows early detection of covert compensated shock by determining pHi. Thus, early intervention and correction of deficits in tissue oxygenation are possible and may improve patients' outcome.
Chest tube removal after cardiac surgery
Authors: Thomson SC , Wells S , Maxwell M
Published: November 2019

Prompt remove of chest tubes by RNs has allowed earlier and more aggressive ambulation of our patients and, along with other interventions, has decreased length of stay by 1.5 days while improving quality of care. Proper education, both didactic and clinical, is the key component in preparing RNs to safely and effectively perform this procedure.
The pacemaker and defibrillator codes: implications for critical care nursing
Authors: Morton PG
Published: November 2019

Scientific advances in the past few decades have resulted in the development of complex devices capable of treating both brady-dysrhythmias and tachydysrhythmias. Because critical care nurses play a vital role in the safe and effective functioning of these devices, they must understand the operation of the devices and patients' physiological and psychosocial responses to the technology. Careful monitoring, open and caring communication, and relevant patient education will make the important difference in patients' adjustment to use of an antidysrhythmic device.
A self-medication administration program for transplant recipients
Authors: Traiger GL , Bui LL
Published: November 2019

Cardiothoracic transplant recipients must follow a complex medication regimen after discharge. Patients, particularly heart transplant recipients who have a shorter postoperative length of stay than other organ recipients, have a limited time to master this regimen. The SMAP has shown benefits in patients' mastery of medication information, increased patient satisfaction, better preparation for discharge, and home adjustment. The program offers a structured approach for teaching patients complex medication regimens.
Renal replacement therapy in critical care: implementation of a unit-based continuous venovenous hemodialysis program
Authors: Giuliano KK , Pysznik EE
Published: November 2019

Implementing a program as complex as continuous venovenous hemodialysis without the involvement of nephrology nurses is a challenge. However, with proper planning, appropriate staff support, and the ability to make changes as implementation proceeds, a successful program can be developed. Our reward is that we are now able to offer a therapy that is important and potentially lifesaving to those critically ill patients with renal failure who are unable to tolerate intermittent hemodialysis.
How to succeed in job interviewing
Authors: Welton RH , Morton PG , Amig A
Published: November 2019

Effective interviewing skills are critical for any nurse seeking a position in today's challenging job market. The successful applicant is more than just poised, appropriately dressed, and courteous. Jobs go to applicants who are well prepared, qualified, confident, and motivated. To win a competitive edge, convince employers of your genuine desire for the position, your ability to do the job, your positive attitude, and the strengths that distinguish you from other applicants.
Use of measurements of myoglobin and cardiac troponins in the diagnosis of acute myocardial infarction
Authors: Murphy MJ , Berding CB
Published: November 2019

Research indicates that no tests of a single cardiac marker are 100% specific and sensitive for diagnosis of AMI in all patients. Each biomarker has advantages and disadvantages (see Table). Over-reliance on a single diagnostic test is risky. Specific tests should be ordered on the basis of the individual patient's assessment and medical history. Nurses are an important link in the collection of patients' medical history and in assessment as well as in the interpretation of patients' laboratory results. A knowledge of diagnostic tests commonly used in the care of patients with ischemic heart disease is imperative if patients are to receive appropriate, timely, cost-effective care.
Nutrition support for the mechanically ventilated patient
Authors: Parrish CR , McCray SF
Published: November 2019

Nutrition support is a hotly debated topic in most intensive care units. Is enteral nutrition or TPN best? Is gastric or small-bowel feeding safer? Are specialized formulas needed? These are only some of the issues, and the fact remains that there is a paucity of clear, solid data. Folklore has become the standard of practice in many areas of medicine; it is richly found in nutrition support. We must be careful not to get caught up in the trappings of our beliefs about nutrition support. Instead, we must continue to evaluate our own practices and fine-tune our skills of clinical assessment and common sense.
Mucormycosis: a case study
Authors: Bell S , Mahoney L
Published: November 2019

Throughout the history of mucormycosis, from the first case in humans reported in 1885 by Paltauf, through publication by Gregory et al of the first observation of rhino-orbital cerebral mucormycosis in 1943, to the report by Harris in 1955 of the first known survivor, little has changed in the diagnosis and outcome of this disease. Although mucormycosis of any form--cerebral, cutaneous, rhinocerebral, intestinal, or pulmonary--is still a rarity, it should be suspected in patients who are diabetic or immunocompromised. Administration of amphotericin B, surgical debridement of infected tissue, correction of the underlying cause, and use of adjunctive HBO therapy remain the standard treatments.
Does "ICU psychosis" really exist?
Authors: Justic M
Published: November 2019

In summary, ICU psychosis does not develop in all patients. Instead, many patients are at risk for hypoactive, hyperactive, or mixed hypoactive and hyperactive delirium. Prevention of delirium should always be foremost, including recognition of patients at high risk, minimal use of causative medications, and treatment of physiological conditions that are often unrelated to a patient's admitting diagnosis. When prevention fails, early diagnosis and treatment can make a marked difference in patients' outcomes. The potential adverse outcomes of delirium are well documented. These include increased mortality; increased length of stay; reduced level of functioning in the elderly, which often leads to placement in a nursing home; and stress response syndrome after hospitalization. The value of nursing in preventing delirium is evident when nurses apply their knowledge of potential causes and develop strategies to avoid these causes in their patients. Nurses provide early detection and coordinate with other members of the healthcare team to initiate a plan of care that includes prompt treatment of delirium to reduce the signs and symptoms, duration, and potential adverse sequelae of this disorder. Nursing interventions are designed to enhance patients' cognitive status, sense of security, safety, and comfort. Nurses are instrumental in providing appropriate choices, doses, and administration of medications and in recognizing side effects. Use of medications ordered to treat delirium is often left to nurses' discretion because the orders specify that the drugs should be given as needed. Finally, nurses are the ones who recognize the need for additional assistance via psychiatric consultations or for more intensive observation and management of patients to ensure quality care.
Managing heart failure: a case study approach
Authors: MacKlin M
Published: November 2019

Heart failure is a common reason for admission to the hospital and to critical care units. The care of patients with heart failure is changing almost daily as new research and therapies become available. Nurses caring for these patients must use available information and assessment findings to discern which type of heart failure exists in each patient. In this way, the care provided can be enhanced, and outcomes can be optimized. Critically thinking nurses can positively influence patients' quality of life and potentially reduce the devastating morbidity and mortality associated with heart failure.
Use of nasal cannula versus face mask after extubation in patients after cardiothoracic surgery
Authors: Zevola DR , Maier CB
Published: November 2019

Continuous reevaluation of protocols for patients' care is necessary to maintain high quality and cost-effectiveness in today's healthcare environment. A study of patients who had cardiothoracic surgery proved that after early extubation, patients could safely be given oxygen via nasal cannula with maintenance of acceptable oxygen saturation. The positive outcomes of this study were shorter exposure to oxygen at higher concentrations, greater compliance by patients, greater comfort for patients, and cost savings for the institution. This project was the result of thoughtful consideration and a willingness to question a standard practice that had been in existence in this cardiothoracic program for 20 years. Both patients and the institution benefit when we question why we do things and thoroughly evaluate our daily practice. All practitioners should always look for ways to change and improve practice for the betterment of patients.
Understanding chest radiographs of infants and children: the AIR systematic approach
Authors: Beckstrand RL
Published: November 2019

A plain radiograph of the chest is the most frequently requested radiological image in infants and children. Assessing chest radiographs of infants and children can be challenging because of the age-related differences in normal anatomic structures, the effect of inhalation and exhalation during the imaging, and the direction of rotation. An understanding of basic radiographic principles is necessary before beginning to interpret chest films of infants and children. Use of the AIR approach can help nurses begin to understand and assess chest radiographs of infants and children in an orderly and systematic manner.
Evaluation of Nurse Engagement in Evidence-Based Practice
Authors: Davidson Judy E. , Brown Caroline
Published: November 2019

The purpose of this project was to explore nurses’ willingness to question and change practice. Nurses were invited to report practice improvement opportunities, and participants were supported through the process of a practice change. The project leader engaged to the extent desired by the participant. Meetings proceeded until the participant no longer wished to continue, progress was blocked, or practice was changed. Evaluation of the evidence-based practice change process occurred. Fifteen nurses reported 23 practice improvement opportunities. The majority (12 of 15) preferred to have the project leader review the evidence. Fourteen projects changed practice; 4 were presented at conferences. Multiple barriers were identified throughout the process and included loss of momentum, the proposed change involved other disciplines, and low level or controversial evidence. Practice issues were linked to quality metrics, cost of care, patient satisfaction, regulatory compliance, and patient safety. Active engagement by nurse leaders was needed for a practice change to occur. Participants identified important problems previously unknown to hospital administrators. The majority of nurses preferred involvement in practice change based on clinical problem solving when supported by others to provide literature review and manage the process through committees. Recommendations include supporting a culture that encourages employees to report practice improvement opportunities and provide resources to assist in navigating the identified practice change.
Chest Pain
Authors: King Joan E. , Magdic Kathy S.
Published: November 2019

When a patient complains of chest pain, the first priority is to establish whether the situation is life threatening. Life-threatening differential diagnoses that clinicians must consider include acute coronary syndrome, cardiac tamponade, pulmonary embolus, aortic dissection, and tension pneumothorax. Nonthreatening causes of chest pain that should be considered include spontaneous pneumothorax, pleural effusion, pneumonia, valvular diseases, gastric reflux, and costochondritis. The challenge for clinicians is not to be limited by “satisfaction of search” and fail to consider important differential diagnoses. The challenge, however, can be met by developing a systematic method to assess chest pain that will lead to the appropriate diagnosis and appropriate treatment plan.
Transferring Patients With Refractory Hypoxemia to a Regional Extracorporeal Membrane Oxygenation Center
Authors: Schulman Christine S. , Bibro Christopher , Downey Diane Braxmeyer , Lasich Christine
Published: November 2019

Because of technological advancements and encouraging experiences during the 2009 influenza A (H1N1) epidemic, many critical care clinicians consider extracorporeal membrane oxygenation (ECMO) a reasonable strategy for managing patients with refractory hypoxemia when standardized therapies have failed. Although the literature remains unclear as to whether it should be considered a routine or a rescue strategy in the management of patients with severe acute respiratory distress syndrome, experts agree that ECMO therapy is most likely to result in positive outcomes and fewer complications when provided at regional ECMO centers. Some institutions have developed the expertise and resources required to provide this sophisticated therapy, but significantly more facilities may choose to send their patients to a tertiary ECMO center when they do not respond to usual care. This article provides information essential for health care teams who refer their patients to such centers. The clinical indications for, and the use of, ECMO therapy in the management of refractory hypoxemia is briefly reviewed, followed by a description of how ECMO works to provide gas exchange and tissue perfusion. The primary considerations for circuit management, hemodynamic support, and pulmonary care are described, and significant complications of the therapy are identified. The remainder of the article focuses on the patient care and preparatory activities that occur before and during ECMO initiation, so that health care teams, patients, and their families can be confident of an efficient, safe, and highly skilled transfer of care between institutions.
Management of Blunt Pulmonary Injury
Authors: Gallagher John J.
Published: November 2019

Thoracic injuries account for 25% of all civilian deaths. Blunt force injuries are a subset of thoracic injuries and include injuries of the tracheobronchial tree, pleural space, and lung parenchyma. Early identification of these injuries during initial assessment and resuscitation is essential to reduce associated morbidity and mortality rates. Management of airway injuries includes definitive airway control with identification and repair of tracheobronchial injuries. Management of pneumothorax and hemothorax includes pleural space drainage and control of ongoing hemorrhage, along with monitoring for complications such as empyema and chylothorax. Injuries of the lung parenchyma, such as pulmonary contusion, may require support of oxygenation and ventilation through both conventional and nonconventional mechanical ventilation strategies. General strategies to improve pulmonary function and gas exchange include balanced fluid resuscitation to targeted volume-based resuscitation end points, positioning therapy, and pain management.
Clinical Nurse Specialist Regulation
Authors: Thurman Paul
Published: November 2019

High-quality care will continue to be a driver in the evolution of today’s health care environment. Ensuring effective, cost-conscious, quality care is the core of clinical nurse specialist (CNS) practice. The CNS practice varies by state, depending on each state’s Nurse Practice Act. Some states have separate scopes of practice for CNSs, including prescriptive authority, whereas some states do not recognize CNS practice as different from the practice of the registered nurse. The journey to state recognition and title protection for the CNS role in the state of Maryland is described.
Certifiably Excellent
Authors: Teal Jan
Published: November 2019

The purpose of this article is to provide a road map for individuals and chapters to use in beginning a certification program. The Heart of the Piedmont Chapter used the mission, vision, and values of the American Association of Critical-Care Nurses to create an environment of safety and expert care for patients and their families. The journey began when our chapter realized that there were only a few certified nurses in our chapter and hospital. As a chapter, we decided to use a survey to determine interest in certification. We invited all interested nurses to attend a certification meeting. Eighty nurses attended. Collaborating with nursing administration, we held study groups, brought in a national speaker, and assisted with payment of the certification examination. This article describes how 1 chapter can make a positive difference in the lives of nurses and patients. Although our chapter’s journey is ongoing, we hope to share our strategies for success with others.
Falls Resulting in Traumatic Injury Among Older Adults
Authors: Grimm Dawn , Mion Lorraine C.
Published: November 2019

Falls among community-dwelling older adults are common and dangerous, often leading to traumatic brain injury, cervical fractures, and spinal cord injury. Physical and physiologic changes with aging, preexisting diseases, and treatments result in increased morbidity and mortality for this population. Trauma critical care nurses can expect to see increasing numbers of older adults in intensive care units as the US population of those older than 65 years increases to 53 million by 2020. Older adults pose additional dilemmas in care. This article reviews falls, mechanism of injury, and nursing care issues of particular significance to this vulnerable population in the critical care setting.
Dyspnea
Authors: Campbell Margaret L.
Published: November 2019

Patients experiencing a dyspnea exacerbation will often report feeling smothered or suffocated. This highly distressing, prevalent, multidimensional symptom is the chief complaint signifying pulmonary dysregulation. Increasing dyspnea intensity heralds the onset of respiratory failure, leading to hospitalization and/or admission to the intensive care unit (ICU). Dyspnea can only be known from the patient’s report about the personal experience. However, many ICU patients experience temporary or permanent cognitive impairment precluding a symptom report; thus, a behavioral assessment is indicated. Comprehensive dyspnea assessment informs subsequent treatment. Conventional treatment of dyspnea includes reducing or eliminating the underlying cause, mechanical ventilation, supplemental oxygen, balancing rest with activity, and positioning. Opioids and benzodiazepines reduce dyspnea and the associated fear or anxiety and are most often used to maintain ventilator–patient synchrony, in terminal illness or during the withdrawal of mechanical ventilation. Inhaled furosemide is under investigation as an alternative to opioids. The focus of this article is to provide an evidence-based approach to nursing assessment and management of dyspnea.
Management of Nausea, Vomiting, and Diarrhea During Critical Illness
Authors: Makic Mary Beth Flynn
Published: November 2019

Symptoms are subjective patient experiences that may negatively impact the patient’s hospitalization, treatment plan, and quality of life. Critically ill patients frequently experience nausea, vomiting, and diarrhea related to underlying disease, procedures, and medical interventions (eg, medication, enteral feeding, surgery). Optimally, the nurse performs a subjective assessment that explores the patient’s perception and impact of these symptoms to develop a comprehensive plan of care. Unfortunately, little evidence is available to guide assessment of nausea, vomiting, and diarrhea in critically ill nonverbal patients. Understanding the disease processes, medical treatments, and pathophysioglogy of these symptoms will assist the critical care nurse in the anticipation of symptoms and development of a proactive plan to alleviate the symptom-associated discomfort.
Nutritional Supplements in Critical Illness
Authors: Hayes Genevieve Luehrs , McKinzie Brian P. , Bullington Wendy Moore , Cooper Tanna B. , Pilch Nicole Ann
Published: November 2019

Poor nutritional intake during critical illness can contribute to increased morbidity and mortality. Although nutrition strategies for critically ill patients attempt to provide essential macronutrients, recent evidence suggests that certain micronutrients and supplements may improve wound healing and decrease infectious and inflammatory complications. This review will focus on mechanism of action, adverse effects and drug interactions reported in the literature, and appropriate dosing and outcomes data for specific nutritional supplements in various critically ill adult populations.
Oncologic Emergencies
Authors: Demshar Regan , Vanek Rachel , Mazanec Polly
Published: November 2019

The picture of oncologic emergencies in the intensive care unit has changed over the past decade. The classic emergencies, that is, superior vena cava syndrome, spinal cord compression, tumor lysis syndrome and life-threatening hypercalcemia, are now routinely managed on the general oncology unit or in an outpatient setting. Vigilant monitoring for early signs of complications, proactive interventions to prevent complications, and aggressive management account for this change. Currently, emergent conditions that necessitate intensive care unit admission or transfer in the patient with cancer include respiratory failure, cardiac emergencies, hemorrhagic events and coagulopathies, sepsis, and hemodynamic instability. This article will present the current evidence-based management of these conditions, a brief summary of classic oncologic emergencies, and the role of the critical care nurse in meeting the multidimensional needs of the patient and family during the life-threatening episode, based on Ferrell’s quality of life model.
Advances in Oncology Care
Authors: Beatty Kristi , Winkelman Chris , Bokar Joseph A. , Mazanec Polly
Published: November 2019

The start of the 21st century has produced advances in cancer care that have improved both survival rates and quality of life for many persons diagnosed with cancer. Targeted therapy has given new hope for controlling cancer as a chronic illness. Alone, or in combination with traditional therapies such as surgery, radiation, and/or chemotherapy, this new form of therapy targets malignant cells, halting tumor growth and the potential metastatic spread of disease. Toxicities are limited, but some are serious and may require intensive care. It is imperative for the experienced critical care nurse to have an understanding of these new treatment options and those on the horizon, as these therapies are the future of cancer care. Whereas in previous decades, patients with cancer may not have survived an intensive care admission for treatment complications or advanced disease, many patients now are recovering from life-threatening events, continuing treatment for their disease, and going on to live meaningful, good-quality lives.
The Meaning of Our Work
Authors: Wiencek Clareen A. , Ferrell Betty R. , Jackson Molly
Published: November 2019

The prevalence and survival rates of critically ill patients with cancer in the intensive care unit have increased considerably in the past 2 decades; yet, the meaning of caring for cancer patients in this setting may fall along a continuum. This article addresses the nurse’s experience in caring for the critically ill patient with cancer by presenting a current profile of these patient in the intensive care unit in the context of the historical development and mission of critical care and the evolution of cancer as a chronic disease. The moral distress that can result when these 2 “cultures” or “realities” collide and the meaning of the nurse’s work will be examined. Strategies and resources for critical care nurses to incorporate into their practice when caring for the critically ill patient with cancer, and themselves, will be addressed.
Continuous-Flow Left Ventricular Assist Device and the Right Ventricle
Authors: Puhlman Mark
Published: November 2019

Left ventricular assist devices (LVADs) have become accepted as treatment for heart failure as a result of improvements in diagnosing and treating left ventricular failure and limited donor availability. In the Pivotal Study of the HeartMate II in the bridge to transplantation population, the incidence of right ventricular failure without the implantation of a right ventricular assist device was 14%, with an additional 6% of the participants ill enough that they required implantation of a right ventricular assist device. This complication increases mortality, cost, and length of stay. This article reviews the screening of LVAD candidates for the probability of right ventricular failure postoperatively, the evaluation of right ventricular function in LVAD candidates, and the optimal management of the right ventricle during the perioperative care of LVAD patients.
Controversies in the Management of Adults With Severe Traumatic Brain Injury
Authors: Blissitt Patricia A.
Published: November 2019

Despite progress in the management of adults with severe traumatic brain injury, several controversies persist. Among the unresolved issues of greatest concern to neurocritical care clinicians and scientists are the following: (1) the best use of technological advances and the data obtained from multimodality monitoring; (2) the use of mannitol and hypertonic saline in the management of increased intracranial pressure; (3) the use of decompressive craniectomy and barbiturate coma in refractory increased intracranial pressure; (4) therapeutic hypothermia as a neuroprotectant; (5) anemia and the role of blood transfusion; and (6) venous thromboembolism prophylaxis in severe traumatic brain injury. Each of these strategies for managing severe traumatic brain injury, including the postulated mechanism(s) of action and beneficial effects of each intervention, adverse effects, the state of the science, and critical care nursing implications, is discussed.