bluuebunny/crossref_metadata_2025 huggingface dataset:
Reliability of measurements of pulmonary artery pressure obtained with patients in the 60 degrees lateral position
Authors: Aitken LM
Published: November 2019

BACKGROUND: Monitoring of pulmonary artery pressure is an essential component of the care of critically ill patients. The conditions under which reliable measurements can be obtained must be clarified. OBJECTIVES: To determine (1) whether reliable measurements of pulmonary artery pressure can be obtained with patients in the right or left 60 degrees lateral position and (2) which characteristics of patients preclude obtaining reliable measurements. METHODS: One hundred five patients (65 cardiac surgery, 40 general medicine) with pulmonary artery catheters were enrolled in a prospective, stratified, quasi-experimental study. Subjects were repositioned from supine (head of bed elevated < 30 degrees with 1 pillow) to the left and right 60 degrees lateral positions. Systolic, diastolic, and mean pulmonary artery pressures and pulmonary capillary wedge pressure were measured before and 5, 10, and 20 minutes after lateral repositioning. The zero reference was the phlebostatic axis when patients were supine and the dependent midclavicular line at the level of the fourth intercostal space when patients were in the lateral positions. RESULTS: In most patients, measurements obtained with patients in the lateral position differed significantly from measurements obtained with patients supine. None of the variables examined were reliable predictors of which patients would have these differences. More than 11% of the patients had clinically significant differences in addition to the statistically significant differences. CONCLUSION: Reliable measurements of pulmonary artery pressure and pulmonary capillary wedge pressure cannot be obtained with patients in the 60 degrees lateral position.
In-hospital mortality after acute myocardial infarction in patients with diabetes mellitus
Authors: Chyun D , Obata J , Kling J , Tocchi C
Published: November 2019

OBJECTIVES: To examine in-hospital mortality after acute myocardial infarction in patients with diabetes mellitus. METHODS: All patients in an 800-bed teaching hospital who had a discharge diagnosis of myocardial infarction, verified by creatine kinase levels at admission, between 1991 and 1993 made up the study population. All 118 such patients who died during this period made up the case group. Two control subjects (n = 236), survivors of the hospitalization, matched by sex, age, and length of hospitalization, were selected randomly for each case. Information on the presence of diabetes mellitus, medical history, and data related to myocardial infarction were obtained through retrospective chart review. RESULTS: The mean age of all subjects in the study was 76 years. Thirty-three percent of the patients in the case group and 31% of the control subjects had a history of diabetes mellitus (odds ratio = 1.04; 95% CI, 0.64-1.70), indicating that diabetes mellitus was not associated with an increased risk of in-hospital death. The adjusted odds ratio was 1.10 (95% CI, 0.48-2.51) in patients with non-insulin-treated diabetes mellitus and 0.80 (95% CI, 0.34-1.86) in insulin-treated patients. Multivariate analysis, with conditional logistic regression, confirmed that known prognostic factors for myocardial infarction, rather than diabetic status, are predictive of in-hospital mortality. CONCLUSIONS: Once the effects of age are accounted for, the risk of in-hospital mortality is not greater in patients with diabetes mellitus than in patients without diabetes; however, diabetes mellitus may be an important factor for long-term survival.
Differences between blacks and whites with coronary heart disease in initial symptoms and in delay in seeking care
Authors: Richards SB , Funk M , Milner KA
Published: November 2019

BACKGROUND: Mortality rates for coronary heart disease are higher in blacks than in whites. OBJECTIVES: To examine differences between blacks and whites in the manifestation of symptoms of coronary heart disease and in delay in seeking treatment. METHODS: Patients were directly observed as they came to an emergency department with symptoms suggestive of coronary heart disease. The sample included 40 blacks and 191 whites with a final diagnosis of angina or acute myocardial infarction. RESULTS: After controlling for pertinent demographic and clinical characteristics, logistic regression analysis revealed that blacks were more likely than whites to have shortness of breath (odds ratio = 3.16; 95% CI = 1.49-6.71; P = .003) and left-sided chest pain (odds ratio = 2.55; 95% CI = 1.10-5.91; P =.03). Blacks delayed a mean of 26.8 hours (SD = 30.3; median = 11 hours), whereas whites delayed a mean of 24.4 hours (SD = 41.7; median = 5 hours) in seeking care. Mean delay time was not significantly different for blacks and whites; differences in median delay time were of borderline significance (P = .05). CONCLUSIONS: Blacks were more likely than whites to have shortness of breath and left-sided chest pain as the presenting symptoms of coronary heart disease. Differences in delay in seeking treatment were not significant, although blacks tended to delay longer than did whites. The relatively small number of blacks may account for the lack of observed racial differences in both initial symptoms and in delay in seeking treatment.
Oral measurement of temperature in orally intubated critical care patients: state-of-the-science review
Authors: Fallis WM
Published: November 2019

Many nurses are hesitant to use the oral site to measure body temperature when patients are orally intubated with an endotracheal tube. It is often thought that the temperature of the gases flowing through the tube and the patient's inability to form a tight seal around the tube may result in an inaccurate measurement that does not reflect body temperature. Consequently, other sites such as the rectum are used, resulting in embarrassment and increased stress for patients, increased use of resources, and inappropriate use of nursing time. An integrated review and synthesis of research on the validity of using the posterior sublingual site to measure temperature in critically ill patients intubated with an oral endotracheal tube were done to determine if a change in nursing practice is indicated for these patients. Of 10 studies that address this topic, 5 specifically investigated this nursing area. The results indicate that for critically ill patients with stable hemodynamic status, the posterior sublingual pocket is a valid site for measurement of body temperature in patients who are orally intubated with an endotracheal tube.
Analysis of factors related to the development of ventilator-associated pneumonia: use of existing databases
Authors: Byers JF , Sole ML
Published: November 2019

OBJECTIVE: To investigate factors related to ventilator-associated pneumonia to assist in the development and implementation of prevention strategies. METHODS: A retrospective, descriptive design was used. Power analysis determined sample size. A consecutive sample of 120 patients admitted to the critical care units of a level I trauma center who were receiving mechanical ventilation was used. Data were obtained from clinical and financial databases. Variables included demographic data, causative organism of the pneumonia, medications, comorbid conditions, complications, duration of therapies, length of stay, and cost per case. RESULTS: The average patient was a 49-year-old man. The sample was 54.9% trauma patients, and the prevalence of ventilator-associated pneumonia was 16.7%. Significant factors included duration of intubation (r = 0.28, P = .005), mechanical ventilation (r = 0.26, P = .005), and tube feeding (r = 0.30, P = .001); trauma (phi = 0.24, P = .009); and use of histamine2 receptor antagonists (phi = -0.25, P = .006). The only variable that significantly increased the odds ratio for ventilator-associated pneumonia was trauma. The only variable that significantly decreased the odds ratio was use of histamine2 receptor antagonists. Patients in whom ventilator-associated pneumonia developed had a 16-day increase in length of stay (t = -2.68, P = .008), and a $29,369 increase in cost per case (t = -3.649, P = .000). CONCLUSIONS: These findings provide a baseline for discussions about potential changes in practice to help prevent ventilator-associated pneumonia.
Assessment of professional development of critical care nurses: a descriptive study
Authors: Heath J , Andrews J , Graham-Garcia J
Published: November 2019

BACKGROUND: With much attention focused on nurses and the nursing profession, self-evaluation of nurses' contributions to their personal growth and the profession as a whole is needed. OBJECTIVE: To describe professional development characteristics of critical care nurses. METHODS: A descriptive, exploratory approach was used to assess the professional development characteristics of a select population of critical care nurses. A 20-item self-administered questionnaire was given to 169 participants at a regional conference of the American Association of Critical-Care Nurses. The survey was designed to determine the level of involvement in professional opportunities and the perception of factors that influence professional development. RESULTS: Mean age of the respondents was 39 years; 72% had at least a bachelor's degree, and 82% were certified in at least one specialty area. Seventy-three percent were members of at least one professional nursing organization; but only 31% reported active participation with meetings and activities. Fifty-two percent considered themselves mentors, yet only 14% participated in scholarly activities at a high level, and 58% had not recognized a peer for nursing contributions. Seventy-six percent reported a high level of "passion about nursing and promoting the profession." Self-motivation was the leading influential factor (72%) for fostering individual professional development. CONCLUSIONS: Critical care nurses have high levels of motivation for professional development in the areas of education, certification, and membership in professional nursing organizations. However, the level of involvement with professional nursing organizations, promotion of nursing peers, and participation in scholarly activities is less than expected.
Patients' perceptions and responses to procedural pain: results from Thunder Project II
Authors: Puntillo KA , White C , Morris AB , Perdue ST , Stanik-Hutt J , Thompson CL , Wild LR
Published: November 2019

BACKGROUND: Little is known about the painfulness of procedures commonly performed in acute and critical care settings. OBJECTIVE: To describe pain associated with turning, wound drain removal, tracheal suctioning, femoral catheter removal, placement of a central venous catheter, and nonburn wound dressing change and frequency of use of analgesics during procedures. METHODS: A comparative, descriptive design was used. Numeric rating scales were used to measure pain intensity and procedural distress; word lists, to measure pain quality. RESULTS: Data were obtained from 6201 patients: 176 younger than 18 years and 5957 adults. Mean pain intensity scores for turning and tracheal suctioning were 2.80 and 3.00, respectively (scale, 0-5), for 4- to 7-year-olds and 52.0 and 28.1 (scale, 0-100) for 8- to 12-year-olds. For adolescents, mean pain intensity scores for wound dressing change, turning, tracheal suctioning, and wound drain removal were 5 to 7 (scale, 0-10); mean procedural distress scores were 4.83 to 6.00 (scale, 0-10). In adults, mean pain intensity scores for all procedures were 2.65 to 4.93 (scale, 0-10); mean procedural distress scores were 1.89 to 3.47 (scale, 0-10). The most painful and distressing procedures were turning for adults and wound care for adolescents. Procedural pain was often described as sharp, stinging, stabbing, shooting, and awful. Less than 20% of patients received opiates before procedures. CONCLUSIONS: Procedural pain varies considerably and is procedure specific. Because procedures are performed so often, more individualized attention to preparation for and control of procedural pain is warranted.
Electrophysiology study: a comprehensive review
Authors: Attin M
Published: November 2019

An EPS provides valuable information about cardiac arrhythmias by recording intracardiac electrograms and using programmed stimulation techniques. Although the sequence of study protocols may vary with each institution, an EPS routinely begins with baseline measurement of conduction intervals. Subsequently, clinical arrhythmias are induced either by incremental or decremental pacing and extrastimulus techniques. Nurses must understand the technical and psychosocial aspects of an EPS to ensure adequate care. The primary role of nurses is to maintain a safe environment for the patient in the electrophysiology laboratory (i.e., maintain aseptic techniques and intervene when complications occur). Rapid technological advances and the increasing number of well-educated patients require that nurses be knowledgeable and skilled in providing progressive care, such as developing educational programs and support groups for patients and patients' families.
Comparison of fever treatments in the critically ill: a pilot study
Authors: Henker R , Rogers S , Kramer DJ , Kelso L , Kerr M , Sereika S
Published: November 2019

BACKGROUND: Fever in critically ill patients is often treated with antipyretics or physical cooling methods. Although fever is a host defense response that may benefit some critically ill patients, others may not tolerate the cardiovascular demands associated with fever. OBJECTIVES: To compare antipyretics and physical cooling for their effects on core body temperature and cardiovascular responses in critically ill patients. METHODS: The antipyretic administered was 650 mg of acetaminophen. Physical cooling was accomplished by anterior placement of a cooling blanket at 18 degrees C. Core temperature and cardiovascular responses were measured in 14 febrile (body temperature, 38.8 degrees C) critically ill patients at baseline before treatment and up to 3 hours after treatment. Patients able to receive acetaminophen were randomly assigned to receive either acetaminophen only (n = 5) or acetaminophen in combination with a cooling blanket (n = 3). Patients not able to receive acetaminophen were treated with physical cooling only (n = 6). RESULTS: Mean body temperature decreased minimally from baseline to 3 hours after treatment in the physical-cooling-only group (from 39.1 degrees C to 39.0 degrees C) and in the physical cooling and acetaminophen group (from 39.1 degrees C to 38.6 degrees C), but the mean body temperature increased in the acetaminophen-only group (from 39.2 degrees C to 39.4 degrees C). Other notable findings included a slight increase in systemic vascular resistance index in the physical-cooling-only group and in the physical-cooling-plus-acetaminophen group. CONCLUSIONS: Although the study included only 14 subjects, the findings will provide information for future studies in febrile critically ill patients.
End-tidal carbon dioxide measurements as a prognostic indicator of outcome in cardiac arrest
Authors: Ahrens T , Schallom L , Bettorf K , Ellner S , Hurt G , O'Mara V , Ludwig J , George W , Marino T , Shannon W
Published: November 2019

PURPOSE: To evaluate the use of end-tidal carbon dioxide values in predicting survival in cardiopulmonary arrest. BACKGROUND: The decision about when to terminate resuscitative efforts for patients with cardiopulmonary arrest is often subjective. End-tidal carbon dioxide values have been suggested as potential objective criteriafor making this decision. METHODS: This study was a cooperative effort of the St Louis chapter of the American Association of Critical-Care Nurses and its members and involved 6 hospitals and an air evacuation service. All adult patients who had a cardiopulmonary arrest were eligiblefor the study. Once a patient with cardiac arrest was intubated, end-tidal carbon dioxide and cardiac rhythms were measured and recorded every 5 minutes for 20 minutes or until resuscitation efforts were terminated. Patients' survival at the time of the arrest, survival 24 hours after the arrest, and discharge status were followed up. RESULTS: A total of 127 patients were enrolled in the study. All but 1 patient with end-tidal carbon dioxide values less than 10 mm Hg died before discharge. End-tidal carbon dioxide values greater than 10 mm Hg were associated with various degrees of survival. Overall survival to discharge was less than 14%, regardless of the end-tidal carbon dioxide value. CONCLUSION: Measurements of end-tidal carbon dioxide can be used to accurately predict nonsurvival of patients with cardiopulmonary arrest. End-tidal carbon dioxide levels should be monitored during cardiopulmonary arrest and should be considered a useful prognostic value for determining the outcome of resuscitative efforts.
Patient-Family-Nurse Interactions in the Trauma-Resuscitation Room
Authors: Morse Janice M. , Pooler Charlotte
Published: November 2019

• Background Controversy about the presence of patients’ family members in the emergency department has centered on the trauma-resuscitation room. Little is known about interactions of patients’ family members with the patients and with nurses or about the ramifications of the presence of patients’ family members at the bedside.

• Objectives To describe behavioral responses of family members of patients and the interactions of the family members with nurses and the patient in the trauma room.

• Methods A secondary analysis was done of 193 videotapes of trauma room care. Of these, 88 tapes showed the presence of patients’ family members, for a total of 42 hours. Qualitative ethology and a model of suffering as a scaffold were used to analyze verbal and nonverbal interactions between nurses, patients’ family members, and patients. Behaviors and verbal interactions of patients and their families were coded as to persons who were enduring and persons who were emotionally suffering. Categories were described.

• Results Whether a patient’s family members entered the trauma room depended on the patient’s condition, the patient’s behavioral state, and the nature of the treatments. Categories of interactions were families learning to endure, patients failing to endure, family emotionally suffering and patient enduring, patient and family enduring, and resolution of enduring. The interaction style of the nurses involved was particular to each of these states. Two instances of inappropriate interactions occurred.

• Conclusions Nurses can use the Model of Suffering as a framework to assess behavioral and emotional states and to select appropriate strategies to comfort patients’ family members.
Celebrating the 100th Birthday of the Electrocardiogram: Lessons Learned From Research in Cardiac Monitoring
Authors: Drew Barbara J.
Published: November 2019

The electrocardiogram continues to be the gold standard for the diagnosis of cardiac arrhythmias and acute myocardial ischemia. The treatment of arrhythmias in critical care units has become less aggressive during the past decade because research indicates that antiarrhythmic agents can be proarrhythmic, causing malignant ventricular arrhythmias such as torsade de pointes. However, during the same period, the treatment of acute myocardial ischemia has become more aggressive, with the goal of preventing or interrupting myocardial infarction by using new antithrombotic and antiplatelet agents and percutaneous coronary interventions. For this reason, critical care nurses should learn how to use ST-segment monitoring to detect acute ischemia, which is often asymptomatic, in patients with acute coronary syndromes. Because the electrocardiographic lead must be facing the localized ischemic zone of the heart to depict the telltale signs of ST-segment deviation, the challenge is to find ways to monitor patients continuously for ischemia without using an excessive number of electrodes and lead wires. The current trend is to use reduced lead set configurations in which 5 or 6 electrodes, placed at convenient places on the chest, are used to construct a full 12-lead electrocardiogram. Nurse scientists at the University of California, San Francisco, School of Nursing are at the forefront in developing and assessing the diagnostic accuracy of these reduced lead set electrocardiograms.
Impact of a Prolonged Surgical Critical Illness on Patients’ Families
Authors: Swoboda Sandra M. , Lipsett Pamela A.
Published: November 2019

• Background Long-term effects on patients’ families after a prolonged stay in a surgical intensive care unit are unclear. We hypothesized that illnesses requiring more than 7 days’ stay in the surgical intensive care unit would have significant, long-lasting effects on patients’ families that would be related to patients’ functional outcome.

• Methods All patients who stayed in the general surgery intensive care unit 7 days or more between July 1, 1996, and June 30, 1997, were enrolled. A total of 128 patients met the entry criteria, and families of surviving patients were interviewed at baseline and 1, 3, 6, and 12 months later. Maximum dysfunction/impact was compared with patients’ functional outcome.

• Results Significant disturbances in the families’ lives occurred throughout the 12 months of this study. Almost 60% of responding families provided a moderate or large amount of caregiving between 1 and 9 months after a prolonged illness, 44.9% had to quit work after 1 month, and more than 36.7% of families had lost savings after 1 year. Some families moved to a less expensive home, delayed educational plans, or delayed medical care for another family member.

• Conclusions An acute surgical illness that results in a prolonged stay in an intensive care unit has a substantial effect on patients’ families that is maximal between 1 and 3 months and parallels the patient’s functional outcome. Systems that provide support to both patients and their families should be emphasized in the hospital and after discharge.
Outpatient Costs of Medications for Patients with Chronic Heart Failure
Authors: Hussey Leslie C. , Hardin Sonya , Blanchette Christopher
Published: November 2019

• Background The outpatient costs of medications prescribed for chronic heart failure are high and are often borne by individual patients. Lack of financial resources may force noncompliance with use of medications.

• Objective To compare the outpatient costs of medications for patients with different New York Heart Association classifications of chronic heart failure.

• Methods The charts of 138 patients with chronic heart failure were reviewed retrospectively. Outpatient costs of medications were obtained from the Web sites of commercial pharmacies. Medications were classified by type according to the system of the American Heart Association. A mean cost for each classification of medication was used for analysis.

• Results The overall mean monthly cost of medications for chronic heart failure was $438. Patients with class II and class III chronic heart failure had the highest costs: $541 and $514, respectively. Analysis of variance indicated that the differences in monthly costs of medications between the patients with the 4 stages of chronic heart failure were significant (F = 4.86, P = .003). A post hoc Scheffé test revealed significant differences in costs between patients with class I and patients with class II heart failure (P=.02) and between patients with class I and those with class III heart failure (P=.02).

• Conclusions The outpatient costs of medications for chronic heart failure are significant. Ability to pay for prescribed medications must be determined. Healthcare professionals must maintain an awareness of the costs of medications and patients’ ability to pay.
Infection as a complication of liver transplant
Authors: Vargo RL , Rudy EB
Published: November 2019

The prognosis for recipients of a liver transplant has been vastly improved by the advent of cyclosporine therapy, and the future holds even more promise with improvements in drug therapy and surgical techniques. The transition from experimental procedure to accepted clinical practice requires nursing to develop standards of care to promote quality care in transplant nursing. With postoperative infection identified as a major cause of mortality for this patient group, nurses will be expected to be skillful in assessing and monitoring for signs and symptoms of infection. Nurses will also need to understand what is involved in the clinical diagnosis of infection, the role of immunosuppressive drug therapy, and the laboratory findings that predispose or herald infection. Infection control standards and methods to manage the risk of infection are appropriate areas of research for critical care nursing and hold the potential for improved patient outcomes for this vulnerable group of transplant patients.
Mechanisms of arrhythmias: enhanced automaticity and reentry
Authors: Weller DM , Noone J
Published: November 2019

Table 2 provides an overview of the classifications of antiarrhythmic agents, their actions, and their uses against reentrant arrhythmias and those caused by enhanced automaticity. Table 3 reviews many of the differences between the two mechanisms of arrhythmias: enhanced automaticity and reentry. Clinical distinction will assist in the most appropriate choice of therapy for terminating cardiac arrhythmias.
Autotransfusion systems (ATS)
Authors: Martin E , Harris A , Johnson N , Lester L , Nelles S , Patton S , Walton M
Published: November 2019

Due to the large number of patients undergoing cardiac surgical procedures and the subsequent increase in demand for blood volume replacement, the use of autotransfusion is increasing in the postoperative setting. In a study conducted by Roche and Stengel it was estimated that the country's blood resources could be depleted by these surgical procedures. The use of autotransfusion offers a viable solution for this problem. Studies suggest that with autotransfusion, bank blood requirements may decrease as much as 50 percent. The ready availability and economic advantages associated with autotransfusion may also ensure continued use of systems of this type. It has been the authors' experience thus far that both systems presented have been safe and effective when used in postoperative management of the cardiac surgical patient.
The ethics of clinical judgment in critical care
Authors: Gaul AL
Published: November 2019

Ethical decision making is an inherent part of the clinical judgment process in critical care nursing. It can cause considerable mental discomfort and stress. Although applying ethical theories to the clinical decision-making process does not provide absolute solutions, it does increase the nurse's confidence in the basis on which the decisions are made. Increasing the awareness of the ethical component of clinical decisions will increase the nurse's ability to deal with the perplexing ethical issues that permeate critical care nursing.
Critical care nursing in the 21st century
Authors: Alspach JG
Published: November 2019

This paper has explored some of the major trends that we can anticipate encountering as we enter the 21st century. Critical care nurses who wish to participate proactively in shaping their professional destiny will listen closely to what futurists have to say about life in the decades ahead. The more we know about what to anticipate, the more informed our decisions will be, and the more likely we will make our desired future a reality.
Marfan's syndrome
Authors: Anderson JK
Published: November 2019

Although Marfan's syndrome is not a frequent occurrence in critical care, serious cardiovascular problems can exist, requiring intensive care. This article has identified the manifestations in those coping with Marfan's syndrome. Critical care nurses need to be aware of the clinical presentation and pathophysiology of the problem to understand the treatment and assist in patient education.
Magnesium metabolism: a case report and literature review
Authors: Friday BA , Reinhart RA
Published: November 2019

Magnesium has been shown to play an important role in the body. In the critical care setting of particular concern is the role of Mg++ in the treatment of malignant tachydysrhythmias such as ventricular tachycardia and ventricular fibrillation. Research is being conducted to determine appropriate methods of assessing Mg++ status, the relationship of altered Mg++ states to clinical manifestations, and the treatment of the abnormalities associated with Mg++ deficiency. Safe and effective forms of parenteral and oral Mg++ supplements are currently available.
Traumatic injury during pregnancy
Authors: Oakley LE , Johnson JD
Published: November 2019

Because of the dual nature of care required for pregnant trauma patients, it is important for the nurse to be informed about appropriate nursing and medical management. Optimal care is based on collaboration among all healthcare members. Interventions are aimed at maximizing potential for both mother and fetus.
Biventricular assist devices
Authors: Vaska PL
Published: November 2019

Ventricular assistance and its effect on the human body are described in this article. Nursing care based on the physiology of device influence and prevention of complications is also discussed.
Quality assurance and the critical care nurse
Authors: Brown-Stewart P
Published: November 2019

Care of the critically ill has become increasingly challenging due to demands from external sources to measure the quality and appropriateness of care provided. Quality assurance is the responsibility of every critical care nurse and requires vigilance as well as a knowledge of the principles of standards, monitoring and evaluation. Through quality assurance activities, the contribution of critical care nurses in the achievement of patient outcomes can be measured. Quality assurance challenges us to evaluate the way we practice, and assists us to continuously improve the way we provide care to critically ill patients.
Critical incident stress management for care providers in the pediatric emergency department
Authors: Back KJ
Published: November 2019

Critical Incident Stress (CIS) is any event that evokes a critically high level of stress and makes usual coping skills ineffective. Programs to manage this stress have been developed. Due to the unique stressors encountered in the pediatric emergency department, this article proposes a CIS management program for these healthcare providers.
Overcoming the obstacles to caring for the long-term critical care patient
Authors: Recker D
Published: November 2019

Caring for the critically ill long-term patient is a challenge. Although such patients must remain in the critical care environment because of the nursing expertise they require, they are often viewed as low-priority patients by the staff because of two factors. One factor relates to the nurse. Critical care nurses, typically action-oriented, function best during crisis intervention and are rewarded for technical skills and efficiency. The other factor relates to the patient. The critically ill long-term patient's needs are different from those of patients most often seen in critical care units; therefore, required nursing interventions are different. These interventions may not be within the nurse's usual repertoire of knowledge and skills and may also be physically and psychologically draining. Implementation of appropriate strategies has the potential for reducing length of stay, cost to the patient and the hospital, and stress for the critical care staff.
Evaluating quantitative research problems
Authors: Finnick M , Haughey BP
Published: November 2019

By focusing on criteria for evaluating quantitative research problems and by understanding their evolution from prior research and their placement within a theoretical context, nurses should realize that good research depends to a great degree on good questions. Unless an investigator has a "good, workable, significant topic, the most carefully and skillfully designed research project will be of no value.
The Basic Knowledge Assessment Tool (BKAT) for critical care nursing: its use and effect on orientation programs
Authors: Toth JC , Dennis MM
Published: November 2019

Findings from this study of 54 subjects who used the BKAT-3 in their professional practice indicate that it is being used most frequently in orientation programs conducted in critical care units, and that content and scores of the BKAT have resulted in changes in those programs. Scores are also being used for placement of nurses with previous critical care experience. In addition, findings from this study and from the literature indicate that research continues to be conducted using scores on the BKAT as a dependent variable, and that moderate to moderately high correlations exist between intended and actual use of the BKAT.
Epidural sympathetic blockade to relieve vascular insufficiency in an infant with purpura fulminans
Authors: Chiafery MC , Stephany RA , Holliday KJ
Published: November 2019

The patient in septic shock who develops vascular insufficiency secondary to purpura fulminans is a challenge to the healthcare team. Initial management is directed toward reversing the disease process by administering antibiotics immediately and initiating life-support measures. Emergency measures include optimizing oxygenation and ventilation, reestablishing and/or maintaining circulation and end-organ perfusion and correcting electrolyte imbalances and coagulopathies. After the emergent life-saving needs of the patient have been addressed, attention may be directed toward saving extremities. Epidural sympathetic blockade proved to be successful as an essential adjunctive intervention in preserving the lower extremities of our patient. We encourage other healthcare providers to consider this treatment to help decrease the morbidity of vascular insufficiency secondary to meningococcal purpura fulminans.
Weaning a patient from mechanical ventilation
Authors: Weilitz PB
Published: November 2019

The process of weaning a patient from mechanical ventilation is complex. Assessment of respiratory mechanics, oxygenation and ventilation, medical problems, nutrition, physical therapy and psychologic needs are important prior to developing the weaning plan. The weaning technique should be individualized to the patient and may be combined with other techniques for optimal outcome. Successful weaning depends on the nurse's attention to detail, careful assessment of patient responses to weaning trials, and coordination of and collaboration with other healthcare team members.
Approaches and limitations of medication delivery in patients with enteral feeding tubes
Authors: Estoup M
Published: November 2019

The hypertonicity of liquid medications must be evaluated in conjunction with the required dosage volume. Some medications require a minimal dosing volume and can be adequately diluted in gastric fluids or tube-flush volumes to a tolerable osmotic load. Other medications such as diphenoxylate, loperamide, and paregoric have a pharmacologic influence on motility and can be administered undiluted into the small bowel. Still others can require dilution to a final volume of 4 to 10 oz to reduce osmolality to a level tolerable by the GI tract. Bolus administration of a large volume of medication is impractical for many patients, especially if it must be administered three or four times a day. For these patients, an alternate route of drug administration is often preferable. In some instances, the IV route is most appropriate. In others, crushing the appropriate oral form, mixing it in a slurry with a suitable diluent, and administering the slurry through the feeding or NG tube can be an acceptable alternative. Regardless of the method of drug delivery, one must be cognizant of the limitations of the administration strategy, the potential for complications that can result from the administration of a medication by the enteral route, and alternative means of medication administration, should complications ensue. A vast number of pharmaceutical products are marketed in a wide array of dosage forms. For these reasons, a pharmacist or other knowledgeable healthcare provider should be consulted for information regarding product availability, bioavailability, compatibility, and potential for drug-nutrient interactions when drugs are given in conjunction with enteral feeding.
Age-based limitation for ICU care: is it ethical?
Authors: Baltz J , Wilson JL
Published: November 2019

Only under utilitarian analysis can age-based limitation to ICU care be justified. In all other frameworks, age is only one consideration in the decision to admit or not admit. Because Americans are reluctant to give larger shares of money to healthcare when it means excluding other social needs, the utilitarian argument will continue to be debated.
Clinical pathways and coronary artery bypass surgery
Authors: Zevola DR , Raffa M , Brown K , Hourihan EC , Maier B
Published: November 2019

Use of a multidisciplinary clinical pathway helps eliminate variations in patients' care. Organizing the care delivered each day of the patient's hospitalization may lead to fewer complications, a quicker recovery, and an earlier discharge. In today's healthcare arena, much attention is being focused on improving the quality of care and decreasing the need for acute care. Clinical pathways facilitate patients' outcomes and earlier discharge and thus reduce the cost of care.
Sternal wound infection: a case study of a devastating postoperative complication
Authors: Hussey LC , Leeper B
Published: November 2019

Patients with a sternal wound infection are often admitted to the ICU or to a telemetry unit. The case of MW is extreme; most patients with a sternal wound infection can be successfully treated with antibiotic therapy and debridement. However, this case illustrates what devastating effects a sternal wound infection can have and the importance of nursing care and prevention. Nurses have a key role in minimizing the severity of sternal wound infection by being aware of the risk factors and providing thorough discharge teaching to patients so that signs and symptoms are reported early.
Inhaled nitric oxide therapy for adult respiratory distress syndrome
Authors: Burke-Martindale CH
Published: November 2019

The selective pulmonary vasodilatory effects of inhaled nitric oxide decrease pulmonary artery hypertension and improve arterial oxygenation in patients with ARDS without causing concomitant systemic vasodilation. Inhaled nitrix oxide therapy may decrease the prevalence of pulmonary edema, pulmonary barotrauma, and oxygen toxicity that occur with current ARDS treatment. The effect of nitric oxide on oxygenation and pulmonary artery pressure may allow more time for the lungs to recover. Initial results of clinical trials are encouraging; however, the impact of inhaled nitric oxide therapy on patients with ARDS remains unclear. Further research is needed to develop safe delivery systems and monitoring techniques for routine clinical use, to determine potential adverse and toxic effects of nitric oxide therapy on patients, and to determine the effects of long-term exposure to nitric oxide among healthcare workers. Concomitant administration of other medications with inhaled nitric oxide should also be investigated.
Preventing prehospital delays in seeking care for acute myocardial infarction: a patient education program
Authors: Alspach G
Published: November 2019

Critical care nurses often lament about patient situations in which their ability to provide definitive nursing care is limited. In the care of the patient vulnerable to AMI, however, a number of concrete interventions are available to ameliorate the potentially devastating effects of this disorder. Implementation of the patient education program described here is one sure way that critical care nurses can assist in effectively reducing the mortality and morbidity associated with AMI. Adopt it and make a difference.
Early enteral feeding of patients with multiple trauma
Authors: Cheever KH
Published: November 2019

The case study illustrates the recovery of a patient with multiple trauma who was fed a peptide-based formula via the enteral route soon after the trauma. Although the clinical course might have been worse if D.H. had not received this treatment, his generally excellent recovery might be partly attributable to this therapy. Although stress hypermetabolism occurs in most patients with multiple trauma within 48 hours after injury, no known treatment can arrest or reverse this problem. However, the lethal catabolic and septic effects of stress hypermetabolism can be at least partly thwarted through delivery of enteral nutrients within 72 hours after trauma.
Monitoring pulmonary artery pressures: just the facts
Authors: Bridges EJ
Published: November 2019

Numerous research-based guidelines for PA pressure monitoring are available. Despite the availability of this large body of literature related to PA pressure monitoring, critical care nurses continue to demonstrate insufficient knowledge and ability to apply information related to the collection and interpretation of data obtained with a PA catheter. This article focuses on these problematic areas, and reinforces the need to continue to include the basic principles of PA pressure monitoring in education and training programs.
Understanding advanced concepts in atrioventricular block
Authors: Paul S
Published: November 2019

Not all atrioventricular blocks occur in the atrioventricular node. Understanding the physiological concept behind the various blocks makes recognizing the relevant ECG indications easier. Furthermore, the implications to patients are clear when healthcare providers understand the level of the block and the dangers the block may impose. Until a more accurately descriptive classification system of conduction blocks becomes universally accepted, the current labels will continue to be used. It is imperative that nurses, particularly those caring for cardiac patients, recognize and understand the ECG indications of various degrees of block.
Using liquid ventilation to treat patients with acute respiratory distress syndrome: a guide to a breath of fresh liquid
Authors: Schlicher ML
Published: November 2019

Research with liquid ventilation indicates that this technology may benefit patients with acute lung diseases such as ARDS. In addition to improving gas exchange, this novel therapy may enhance the delivery of antibiotics and other drugs and thus hasten the recovery from other serious diseases. Additional research on using perflubron in combination with other developing therapies is under way. Clearly, liquid ventilation is not a cure for ARDS. However, it may be helpful in the supportive management of patients with ARDS. As the phase 3 clinical trials are completed, liquid ventilation may become a part of treatment in the intensive care unit. Understanding how liquid ventilation works and knowing what to look for in patients treated with PLV will help ensure better outcomes for patients when this therapy becomes part of clinical practice.
Achieving Quality Health Outcomes Through the Implementation of a Spontaneous Awakening and Spontaneous Breathing Trial Protocol
Authors: Jones Kimmith , Newhouse Robin , Johnson Karen , Seidl Kristin
Published: November 2019

Background:

Continuous sedation infusions can lead to prolonged treatment with mechanical ventilation (MV), resulting in serious complications. Spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) are strategies that limit the amount of sedative agents a patient receives and promote extubation.

Objective:

The objective of this performance improvement project was to evaluate the outcomes of an evidence-based practice protocol that included SATs and SBTs on the duration of treatment with MV, ventilator utilization ratio (VUR), intensive care unit (ICU) length of stay (LOS), and incidence of self-extubations and reintubations.

Methods:

A convenience sample of 112 discharged patients’ medical records was used for this descriptive, comparative secondary data analysis. An evidence-based SAT/SBT practice protocol was designed by a multidisciplinary team and implemented. Three months after the implementation, a retrospective medical record review was conducted to evaluate patient outcomes.

Results:

The median duration of treatment with MV was significantly lower in the postprotocol group (3.8 days vs 2.7 days, U = 1222, Z = −2.013, P = .04, r = 0.19). A significant decrease was found in the VUR (0.68 vs 0.52, U = 2.5, Z = −2.293, P = .02, r = 0.69). No difference was found in the ICU LOS and frequency of self-extubation or reintubation after a self-extubation between the preprotocol and postprotocol groups. Ten of 45 SAT opportunities (22%) and 67 of 130 SBT opportunities (52%) were missed by the nurse or the respiratory therapist.

Conclusion:

The duration of treatment with MV and the VUR were reduced in patients who received the SAT/SBT protocol. The incidence of self-extubation was not different when an SAT was implemented. The ICU LOS was not reduced in patients who received SATs and SBTs.
Improving Nurses’ Knowledge of Continuous ST-Segment Monitoring
Authors: Chronister Connie
Published: November 2019

Background:

Continuous ST-segment monitoring can result in detection of myocardial ischemia, but in clinical practice, continuous ST-segment monitoring is conducted incorrectly and underused by many registered nurses (RNs). Many RNs are unable to correctly institute ST-segment monitoring guidelines because of a lack of education.

Purpose:

To evaluate whether an educational intervention, provided to 32 RNs, increases knowledge and correct clinical decision making (CDM) for the use of continuous ST-segment monitoring.

Methods:

At a single institution, an ST-segment monitoring class was provided to RNs in 2 cardiovascular units. Knowledge and correct CDM instruments were used for a baseline pretest and subsequent posttest after ST-segment monitoring education.

Results:

Statistical significance between pretest and posttest scores for knowledge and correct CDM practice was noted with dependent t tests (P = .0001).

Conclusions:

Many RNs responsible for electrocardiographic monitoring are not aware of evidence-based ST-segment monitoring practice guidelines and cannot properly place precordial leads needed for ST-segment monitoring. Knowledge and correct CDM with ST-segment monitoring can be improved with focused education.
Role of the Clinical Nurse Specialist in Improving Patient Outcomes After Cardiac Surgery
Authors: Soltis Lisa M.
Published: November 2019

Health care reform continues to focus on improving patient outcomes while reducing costs. Clinical nurse specialists (CNSs) should facilitate this process to ensure that best practice standards are used and patient safety is enhanced. One example of ensuring best practices and patient safety is early extubation after open heart surgery, which is a critical component of fast track protocols that reduces may reduce the development of pulmonary complications in the postoperative period while decreasing overall length of stay in the hospital. This project was an interdisciplinary endeavor, led by the CNS and nurse manager, which combined early extubation protocols with enhanced rounding initiatives to help decrease overall length of ventilation time as well as reduce pulmonary complications in patients in the cardiac surgery intensive care unit. The project resulted in a significant decrease in length of stay and a decrease in pulmonary complications in the postoperative period.