bluuebunny/crossref_metadata_2025 huggingface dataset:
Baccalaureate nurse educators' and critical care nurse managers' perceptions of clinical competencies necessary for new graduate baccalaureate critical care nurses
Authors: Porte-Gendron RW , Simpson T , Carlson KK , Van de Kamp ME
Published: November 2019

BACKGROUND: Although nurse educators and nurse managers have disagreed about which clinical competencies are necessary for new graduates to begin working in critical care, the competencies are in need of revision and reassessment. OBJECTIVES: To validate a list of beginning-level competencies and to compare baccalaureate nurse educators' and critical care nurse manager's current perceptions of beginning clinical competencies for new baccalaureate graduates in critical care settings. METHODS: An expert panel of nurses from across the United States critiqued a questionnaire about which clinical competencies were considered relevant to critical care nursing practice. The revised questionnaire, containing 105 clinical competencies, was mailed to a randomly selected sample across the United States. Forty-one baccalaureate nurse educators and 41 critical care nurse managers completed the mail survey questionnaire (94% response rate) by rating the necessity ("essential," "desired," or "not required") of the clinical competencies for new baccalaureate nurses. RESULTS: A high degree of agreement was generally seen between nurse educators and nurse managers on the necessity ratings of the 105 competencies. The majority of nurse educators and nurse managers rated 81 of the 105 competencies as either "essential" or "desirable." Only five competencies showed considerable disagreement between nurse educators and nurse managers, and none of these competencies were rated "essential" by more than a few raters in either group. CONCLUSIONS: The agreement between nurse educators and nurse managers supports a competency list for baccalaureate nursing curricula and hospital inservice programs to integrate new graduates into critical care.
Current practices regarding visitation policies in critical care units
Authors: Simon SK , Phillips K , Badalamenti S , Ohlert J , Krumberger J
Published: November 2019

BACKGROUND: Previous research has emphasized the importance of visitation in critical care units and its beneficial effects on patients and their families. However, nurses' attitudes and beliefs about visitation did not correlate with those of patients and their families, nor did actual visitation practices correlate with written policy. OBJECTIVE: To investigate nurses' perceptions about open vs restricted visiting hours and the effects on the patient, the patient's family, and the nurse. METHODS: Quantitative and qualitative data were collected from 201 nurses who completed a survey instrument about nurses' perceptions of visitation at five metropolitan hospitals in a midwestern city. RESULTS: Seventy percent of official policies for visitation were restrictive. In practice, 78% of nurses were nonrestrictive in their visitation practices. Variables that affected practices regarding visiting hours were the patient's need for rest, the nurse's workload, and the beneficial effects of visitation on patients. Requests from patients and their families were ranked least important. Significant differences in practices were found regarding restriction of visiting by immediate family members and of the number of visitors. Restricted hours were perceived to decrease noise (83%) and promote patients' rest (85%). Open visitation practices were perceived to beneficially affect the patient (67%) and the patient's family (88%) and to decrease anxiety (64%). Perceptions of ideal visiting hours included restrictions on the number of visitors (75%), hours (57%), visits by children (55%), and duration of visits (54%), but no restriction on visitation by immediate family members (60%). Qualitative data revealed recurrent themes in visitation practices, policies and exceptions, control of visitation by patients, and nurses' wishes. CONCLUSION: Data indicate that most nurses do not restrict visitation, regardless of whether restrictive policies are in place. Most nurses base their visitation decisions on the needs of the patient and the nurse. Needs of the family were ranked as less important in decision making about family visitation.
Comparison of methods of measuring pulmonary artery pressure
Authors: Lundstedt JL
Published: November 2019

BACKGROUND: Pulmonary artery waveforms fluctuate because of changes in intrathoracic pressure caused by respirations. Monitoring system algorithms determine digital displays of pressure measurements on the basis of recognition, analysis, and comparison of consecutive waveforms. OBJECTIVE: To compare three methods of measuring pulmonary artery pressure during mechanical ventilation and spontaneous breathing in cardiac surgery patients with stable hemodynamics. METHODS: Pulmonary artery pressure was measured during mechanical ventilation after cardiac surgery in 53 patients; 37 of the patients were studied again after extubation. Three monitoring methods were compared: graphic strip recording, the "stop cursor" (monitor screen freezing) method, and digital-display recording. Difference scores were calculated between the methods and analyzed for frequency and direction. RESULTS: All comparisons showed differences of at least +/-3 mm Hg in measurements obtained with the three methods. During mechanical ventilation, the digital and graphic measurements of systolic pressure varied most often; 57% (30/53) of the comparisons had difference scores of at least +/-3 mm Hg. The cursor and graphic measurements of diastolic pressures varied least often; 6% (3/53) of the comparisons had difference scores of at least +/-3 mm Hg. As expected, the digital method most often gave higher results than the graphic method. During spontaneous breathing, measurements of systolic pressure varied more often (38% to 53%) than did measurements of diastolic pressure (12% to 37%). Unexpectedly, for systolic pressures, the difference between digital and graphic measurements was 3 mm Hg or more 30% (11/37) of the time, and the difference between cursor and graphic measurements was 3 mm Hg or more 53% (17/32) of the time. CONCLUSIONS: Because of physiological and technical influences, measurements of systolic and diastolic pressures in the pulmonary artery made with the digital and cursor methods were not as reliable as measurements made with the graphic method. The findings support continued use of the graphic method for accurate measurements of pulmonary artery pressure.
Comfort and bleeding after percutaneous transluminal coronary angioplasty: comparison of a flexible sheath and a standard sheath
Authors: Mayer DM , Hendrickx L
Published: November 2019

BACKGROUND: Patients often have discomfort, especially back pain, after percutaneous transluminal coronary angioplasty because they must stay relatively flat while the sheath remains in the femoral vessel after the procedure. Flexible sheaths are now available, allowing the head of the bed to be raised to 60 degrees during this period of bed rest. OBJECTIVE: We assessed comfort and the frequency of bleeding in patients who had undergone percutaneous transluminal coronary angioplasty and compared the findings between patients with a flexible sheath and patients with a standard sheath. METHODS: Patients were randomly assigned either a flexible sheath or a standard sheath during percutaneous transluminal coronary angioplasty. Patients' comfort was assessed by administering a comfort questionnaire at two intervals after the procedure, and the frequency of bleeding was determined by reviewing the patients' charts. RESULTS: One hundred seven patients completed the questionnaire. The patients with a flexible sheath showed a significantly higher level of comfort than the patients with a standard sheath 5 hours after the procedure. Patients with a flexible sheath also received less pain medication than did patients with a standard sheath. The frequency of bleeding was comparable in both groups. CONCLUSIONS: Results of this study support the use of a flexible sheath to increase patients' comfort after percutaneous transluminal coronary angioplasty without increasing the frequency of bleeding.
Outpatient use of left ventricular assist devices: nursing, technical, and educational considerations
Authors: Moroney DA , Powers K
Published: November 2019

Improvements in technology and in the selection, care, and treatment of patients have led to wider clinical use of mechanical circulatory support. Considerable progress has been made with the use of left ventricular assist devices. Patients are currently maintained in outpatient facilities until a donor heart becomes available; recently, left ventricular assist devices have started to be used as permanent implants. This article outlines the steps that are taken to prepare the patient, the patient's family, and the medical staff for discharge from the hospital of a patient supported with a left ventricular assist device. Extensive technical and clinical training of the primary caregiver and the patient is required to prepare for discharge from the hospital. Data are rapidly accumulating that show that left ventricular assist devices are safe and efficacious for outpatient use. Similar success is expected in clinical trials of permanent left ventricular assist devices, suggesting that many more patients will benefit from this technology in the future.
Harnessing the platelet
Authors: Futterman LG , Lemberg L
Published: November 2019

Appreciation of the critical role of platelets in cardiovascular disease came when it was shown that aspirin, by virtue of its ability to block platelet aggregation, reduced the combined incidence of MI, stroke, and vascular death by 25%. Understanding the key role played by platelets in acute thrombotic vascular events prompted the development of a new class of drugs to control platelet action. Platelet aggregation is mediated exclusively by the platelet fibrinogen receptor GP IIb/IIIa. The binding of the receptor with fibrinogen is the final common pathway leading to platelet aggregation and thrombus formation. Abciximab, the first GP IIb/IIIa platelet receptor inhibitor, effectively reduces the thrombotic complications in acute coronary vascular events. The newer GP IIb/IIIa inhibitors, the synthetic peptide antagonists, have been shown to be more specific, to be nonimmunogenic, and to cause less bleeding. It is predictable that an oral GP IIb/IIIa inhibitor will become part of the standard repertoire in patients with unstable angina. The platelet has taken center stage in the battle against arterial thrombosis. The direction of our medical attack on acute coronary events is clear: harness the platelet.
Aortic valve replacement with a pulmonary autograft: case studies of the Ross procedure
Authors: Scott C , Schactman M , Graver LM
Published: November 2019

The Ross procedure is an old surgical technique that is gaining popularity some 30 years after its introduction. The patient's own pulmonary valve is essentially used as a "spare part" to replace the diseased aortic valve. The Ross procedure has become an accepted and attractive option for patients with a life expectancy of more than 20 years and for patients in whom long-term treatment with anticoagulants is undesirable or problematic. Careful preoperative evaluation and postoperative management, as well as proficient surgical techniques, are all necessary to achieve good outcomes.
Hemodynamic monitoring: a comparison of research and practice
Authors: Grap MJ , Pettrey L , Thornby D
Published: November 2019

BACKGROUND: Measurement of hemodynamic parameters is a common practice and is well researched, but little information is available on the translation of the research into actual practice. OBJECTIVES: To determine (1) the current practice of hemodynamic measurement in relation to positioning of patients and (2) the barriers to use of research related to hemodynamic monitoring. METHODS: A stratified, random, national sample of 1000 members of the American Association of Critical-Care Nurses was surveyed by mail about hemodynamic monitoring procedures related to the positioning of patients and beds, technique used to determine the position of the bed, number of measurements of cardiac output, use of iced versus room-temperature injectate, use of printed or digital information, nurses' input into written procedures, and barriers to research utilization. RESULTS: In actual practice, 24.1% of the respondents always keep the bed flat when measuring pulmonary artery pressures, 55.0% elevate the head of the bed 30 degrees or less, 80.7% always have patients supine for measurements, and 13.3% place patients in lateral or other positions. Unit policy dictated the flat position in 25.8% of the sample; nurse managers (41.4%), staff nurses (27.5%), and staff committees (31.2%) were involved in writing the procedure. Respondents viewed research related to hemodynamic monitoring procedures as relevant and valuable. The greatest barriers to utilization were lack of staff support for implementation, insufficient time to implement research findings, and feelings among nurses that they lacked authority to implement change. CONCLUSIONS: Research findings are generally being implemented at the bedside, although not completely or consistently. Minimizing the barriers to use of research is within the scope of nurses' practice.
Requesting organ donation: an interview study of donor and nondonor families
Authors: DeJong W , Franz HG , Wolfe SM , Nathan H , Payne D , Reitsma W , Beasley C
Published: November 2019

BACKGROUND: Approximately half of the families asked to consider donation of a relative's organs decline to give consent. Understanding the difference between stated public support of organ donation and actual behavior is key to decreasing the shortage of donor organs. OBJECTIVES: To gain insight into the experiences of potential donor families and to define features of the donation-request process and other factors that are associated with consent for organ donation. METHODS: A structured telephone interview was conducted with the immediate next of kin of 164 medically suitable potential organ donors. Interviews 30 to 60 minutes long were held with members of both donor and nondonor families 4 to 6 months after the death of the study participant's relative. RESULTS: Several factors were associated with consent for organ donation: characteristics of the patient and the patient's family, beliefs and attitudes about organ donation and transplantation, whether the family knew the deceased's wishes about donation, the family's satisfaction with the hospital care that their relative received, specific aspects of the donation-request process, and the family's understanding of brain death. CONCLUSIONS: Organ donation rates could be increased by enhancing the quality of hospital care and ensuring that the request for donation is handled in a way that meets the families' informational and emotional needs.
Inflammation in plaque rupture: an active participant or an invited guest?
Authors: Futterman LG , Lemberg L
Published: November 2019

Numerous reports have established the association of inflammation with acute coronary events. Data have been presented that suggest that elevated levels of CRP indicate heightened risk of future MI and stroke. Thus CRP measurement is both predictive and prognostic of cardiovascular and cerebrovascular events. Is inflammation merely a marker, an invited guest so to speak, or is inflammation an active participant that influences the process of plaque rupture and thrombus formation? The beneficial effects of aspirin in reducing the risks of a first MI and stroke are directly related to high plasma concentrations of CRP, whereas small, nonsignificant reductions in risk occurred among patients with low or normal CRP levels. Thus inflammation is not only an uninvited guest but is actually an aggressive participant in the destabilization of the atheromatous endothelial plaque.
Time of removal of femoral sheaths after interventional procedures: comparison of hemoglobin and hematocrit values
Authors: Bowden SM , Matsco M , Worrey JA
Published: November 2019

BACKGROUND: Few investigators have examined the time of removal of femoral sheaths after interventional procedures and its effect on patients' hematocrit and hemoglobin levels. OBJECTIVE: To determine if hematocrit and hemoglobin values differed significantly according to the length of time femoral sheaths remained in place after interventional procedures. METHODS: After a review of the literature, data were collected on a convenience sample consisting of 2 groups. Patients in group 1 (n = 30) had femoral sheaths removed within 3.5 to 9.0 hours (mean, 5.5 hours) after an interventional procedure. Patients in group 2 (n = 30) had the sheaths removed within 17 to 36 hours (mean, 22 hours) after an interventional procedure. Blood samples were obtained from all patients before the interventional procedure (baseline values) and again 1 day after the procedure. Patients in group 1 had sheaths removed before the second blood sample was obtained; patients in group 2 did not. Data were analyzed by using an equal-variance t test to determine if hematocrit and hemoglobin values differed significantly between the 2 groups. RESULTS: Hematocrit and hemoglobin values the day after interventional procedure differed significantly in the two groups. CONCLUSION: Earlier removal of femoral sheaths may have a beneficial physiological effect. The results indicate that prompt removal of femoral sheaths after interventional procedures improves patients' outcomes.
A survey of endotracheal suctioning with instillation of normal saline
Authors: Schwenker D , Ferrin M , Gift AG
Published: November 2019

BACKGROUND: Instillation of normal saline before suctioning is a common nursing intervention although little research supports the practice. OBJECTIVES: To determine when and how often saline is used during suctioning and to assess the knowledge of nurses and respiratory therapists of the advantages and dangers of using saline during endotracheal suctioning. METHODS: A survey of nurses and respiratory therapists working in adult ICUs was conducted in a large university teaching hospital. RESULTS: Of the 187 respondents, 96 (51%) rarely instill saline before suctioning, whereas 61 (33%) frequently use saline. Fifty-five percent use saline to enhance retrieval of secretions, and 45% use it to stimulate a cough. Nurses and respiratory therapists differ in their use and understanding of saline instillation. Most nurses (64%) rarely use saline before suctioning, whereas most respiratory therapists (71%) frequently use saline. Respiratory therapists (57%) were more aware than were nurses (37%) of the benefit of using normal saline to stimulate a cough. Nurses indicated more adverse effects of instillation of normal saline, specifically oxygen desaturation and increased risk of pulmonary infections, than did respiratory therapists. CONCLUSION: The results of the survey helped determine target areas for educational programs for nurses and respiratory therapists. A protocol is being developed for use by all who do suctioning.
Intra-aortic balloon pump: nursing implications for patients with an iliac artery approach
Authors: Molnar HM
Published: November 2019

Long-term use of an intra-aortic balloon pump is often necessary for patients with severe left ventricular dysfunction who are awaiting cardiac transplantation. Complications caused by prolonged bed rest and immobility can occur when the traditional femoral approach is used for insertion of the balloon catheter. Insertion of the intra-aortic balloon catheter through the iliac artery is an alternative technique that allows patients to sit, stand, and walk while receiving counterpulsation. This approach is now being used to prevent the complications of immobility in patients awaiting cardiac transplantation. In this article, the special considerations, potential complications, and nursing interventions unique to the iliac artery approach are delineated.
The ECG in cardiac stress testing: a valuable, but unappreciated source of clues
Authors: Futterman LG , Lemberg L
Published: November 2019

The ECG exercise stress test is a very potent aid to the clinical diagnosis of CAD. Thorough knowledge of the ECG abnormalities and clinical features related to the stress test are required for an accurate diagnosis. The ECG exercise stress test is not a substitute for clinical acumen. Proper evaluation of the stress test is a clinical art of the skilled clinician. ECG exercise stress testing can be done efficiently and effectively by trained emergency department physicians. As a result, the diagnosis of CAD can be greatly accelerated.
Weaning from mechanical ventilation: patterns in young children recovering from acute hypoxemic respiratory failure
Authors: Curley MA , Fackler JC
Published: November 2019

OBJECTIVE: The purpose of the study was to describe the patterns of weaning from mechanical ventilation in young children recovering from acute hypoxemic respiratory failure. METHODS: Decision-making rules on progressive weaning were developed and applied to existing data on 82 patients 2 weeks to 6 years old in the Pediatric Acute Respiratory Distress Syndrome Data Set. RESULTS: Three patterns of weaning progress were detected: sprint, consistent, and inconsistent. Length of ventilation and weaning progressively increased from the sprint, to the consistent, to the inconsistent subset. Patients in the inconsistent subset were most likely to have a systemic (sepsis or shock) trigger of acute respiratory distress syndrome and to be rated as having at least moderate disability at discharge. Hypothesis-generating univariate and then multivariate logistic regression analyses indicated that patients who experienced more days of mechanical ventilation before the start of weaning and who had a higher oxygenation index during the weaning process were most likely to have an inconsistent pattern of weaning. CONCLUSION: Patterns of weaning are discernible in a population of young children and indicate a subset at risk for inconsistent weaning. Knowing the patterns of weaning may help clinicians anticipate, perhaps plot, and then modulate a patient's weaning trajectory.
Can measurement of mixed venous oxygen saturation replace measurement of cardiac output in patients with advanced heart failure?
Authors: Gawlinski A
Published: November 2019

BACKGROUND: Nursing care of patients with advanced heart failure with low ejection fraction requires strict management of IV fluids. Measurement of mixed venous oxygen saturation offers advantages over measurement of cardiac output because no administration of fluid is required and data are obtained continuously. OBJECTIVES: To determine the relationship between mixed venous oxygen saturation and cardiac output in patients with advanced heart failure who have low ejection fraction and to determine if use of vasoactive medications alters the relationship between mixed venous oxygen saturation and cardiac output. METHODS: Simultaneously obtained measurements of mixed venous oxygen saturation and cardiac output were compared in 42 patients with advanced heart failure with ejection fractions of 30% or less (mean, 19.5%). RESULTS: Correlation between mixed venous oxygen saturation and cardiac output was r = 0.54 (P < .001). For subjects not receiving vasoactive medications (n = 28), r = 0.52 (P = .004); for those receiving vasoactive medications (n = 14), r = 0.57 (P = .03). CONCLUSIONS: Similar correlations in the groups receiving and not receiving vasoactive medications suggest that even with pharmacological support, changes in mixed venous oxygen saturation may not be reflected by concomitant changes in cardiac output. Measurement of mixed venous oxygen saturation should not replace measurement of cardiac output for clinical decision making in patients with advanced heart failure with low ejection fraction.
Accuracy of measurements of hemoglobin and potassium in blood samples from peripheral catheters
Authors: Fincher RK , Strong JS , Jackson JL
Published: November 2019

OBJECTIVE: To compare measurements of hemoglobin and potassium in blood samples obtained from peripheral venous catheters with measurements in samples obtained via venipuncture. SUBJECTS: 53 adult volunteer patients admitted to a medical ward. METHODS: For each patient, a 10-mL blood sample was obtained from a 20-gauge or larger peripheral venous catheter after a 3-mL volume of fluid was discarded. Immediately afterward, additional samples were obtained by venipuncture, and all samples were sent to the laboratory for measurement of hemoglobin and potassium levels. Separate venipuncture samples were obtained from both extremities in another 10 subjects to assess intratechnique variation. Results were analyzed by using limits-of-agreement analysis. RESULTS: Blood samples were successfully obtained from a peripheral catheter in 32 (60%) of the 53 patients. The success rate was 78% with 18-gauge catheters and 42% with 20-gauge catheters (P = .021). The 95% agreement interval in the set of differences between values for samples obtained via catheter and samples obtained via venipuncture was +/- 0.37 mmol/L for potassium and +/- 7.6 g/L for hemoglobin. The 95% agreement interval for the venipuncture control group was +/- 0.21 mmol/L for potassium and +/- 7.3 g/L for hemoglobin. The preset acceptable interval for potassium measurements was +/- 0.3 mmol/L, and that for hemoglobin measurements was +/- 10 g/L. CONCLUSIONS: Obtaining blood samples from peripheral catheters is an acceptable alternative to venipuncture for hemoglobin measurements but not for potassium measurements. Larger gauge catheters are better than small-gauge catheters for obtaining blood samples.
Acquired organ system derangements and hospital mortality: are all organ systems created equally?
Authors: Kollef MH , Sherman G
Published: November 2019

BACKGROUND: Acquired organ system derangements are common among patients who require intensive care, but the relative importance of different derangements as determinants of patients' outcomes is unclear. OBJECTIVES: To determine organ system derangements that occur in patients who require intensive care and the relative importance of different derangements to hospital mortality. METHODS: A prospective cohort study design was used to evaluate the occurrence of organ system derangements and hospital mortality in 617 adults admitted to the medical and surgical intensive care units of a university-affiliated teaching hospital. RESULTS: Eighty-three patients (13.5%) died while hospitalized. Patients who died had significantly more derangements than did patients who survived (3.3 +/- 1.2 vs 0.9 +/- 0.9; P < .001). The crude hospital mortality rate varied with the specific organ system involved (pulmonary, 23.6%; gastrointestinal, 25.0%; hepatic, 42.4%; hematological, 47.9%; cardiac, 54.0%; renal, 54.8%; neurological, 65.9%). Derangements of neurological function (adjusted odds ratio, 3.20; 95% CI, 2.0-5.3; P = .019) and cardiac function (adjusted odds ratio, 3.96; 95% CI, 2.63-5.99; P < .001) were independently associated with hospital mortality. Additionally, derangements occurred later during the stay in the intensive care unit in patients who died in the hospital than in patients who survived, especially for derangements of pulmonary, neurological, and renal function. CONCLUSION: Among critically ill patients, neurological and cardiac dysfunction are the acquired organ system derangements most closely associated with hospital mortality. These data suggest that hospital mortality depends on both the specific types of derangements that occur and the total number of such derangements. Interventions to prevent cardiac and neurological dysfunction have the greatest potential for improving outcomes for patients in the intensive care unit.
Effects of relaxing music on cardiac autonomic balance and anxiety after acute myocardial infarction
Authors: White JM
Published: November 2019

BACKGROUND: Acute myocardial infarction places additional demands on an already compromised myocardium. Relaxing music can induce a relaxation response, thereby reversing the deleterious effects of the stress response. OBJECTIVES: To compare the effects of relaxing music; quiet, uninterrupted rest; and "treatment as usual" on anxiety levels and physiological indicators of cardiac autonomic function. METHODS: A 3-group repeated measures experimental design was used. Forty-five patients, 15 per group, with acute myocardial infarction were assigned randomly to 20 minutes of (1) music in a quiet, restful environment (experimental group); (2) quiet, restful environment without music (attention); or (3) treatment as usual (control). Anxiety levels and physiological indicators were measured. RESULTS: Immediately after the intervention, reductions in heart rate, respiratory rate, and myocardial oxygen demand were significantly greater in the experimental group than in the control group. The reductions in heart rate and respiratory rate remained significantly greater 1 hour later. Changes in heart rate, respiratory rate, and myocardial oxygen demand in the attention group did not differ significantly from changes in the other 2 groups. The 3 groups did not differ with respect to systolic blood pressure. Increases in high-frequency heart rate variability were significantly greater in the experimental and attention groups than in the control group immediately after the intervention. State anxiety was reduced in the experimental group only; the reduction was significant immediately and 1 hour after the intervention. CONCLUSIONS: Patients recovering from acute myocardial infarction may benefit from music therapy in a quiet, restful environment.
Mechanical circulatory support as a bridge to cardiac transplantation: toward the 21st century
Authors: Scherr K , Jensen L , Koshal A
Published: November 2019

Mechanical circulatory support is used to sustain the lives of patients awaiting cardiac transplantation who would otherwise die before a donor organ became available. Currently available ventricular assist devices used for mechanical circulatory support, risk factors and complications associated with use of these devices, and selection of candidates for treatment with mechanical support as a bridge to cardiac transplantation are reviewed. The importance of early insertion of the devices before end-organ dysfunction occurs is examined.
Intensive care nurses' experiences with end-of-life care
Authors: Kirchhoff KT , Spuhler V , Walker L , Hutton A , Cole BV , Clemmer T
Published: November 2019

BACKGROUND: With much attention being focused on how patients die and whether or not they are provided appropriate care, the care of dying patients in intensive care units must be described and improved. OBJECTIVES: To describe end-of-life care in intensive care units as perceived by critical care nurses who have taken care of dying patients. METHODS: A semistructured interview guide was developed and revised after pretesting in a focus group of faculty clinicians with extensive, recent experience in intensive care. Four focus groups were held with randomly selected nurses from 4 intensive care units in 2 hospitals; participants had 2 years or more of experience and were working half-time or more. Tapes from each focus group were transcribed and reviewed by the investigators before the subsequent group met. Category labels were developed, and topics and themes were determined. RESULTS: "Good" end-of-life care in the intensive care unit was described as ensuring that the patient is as pain-free as possible and that the patient's comfort and dignity are maintained. Involvement of the patient's family is crucial. A clear, accurate prognosis and continuity of care also are important. Switching from curative care to comfort care is awkward. CONCLUSIONS: Disagreement among patients' family members or among caregivers, uncertainty about prognosis, and communication problems further complicate end-of-life care in intensive care units. Changes in the physical environment, education about end-of-life care, staff support, and better communication would improve care of dying patients and their families.
Impact of a nurse-managed heart failure clinic: a pilot study
Authors: Paul S
Published: November 2019

BACKGROUND: One approach to optimize clinical and economic management of congestive heart failure is the use of multidisciplinary outpatient clinics in which advanced practice nurses coordinate care. One such clinic was developed in 1995 at a southeastern university hospital to enhance management of patients with chronic congestive heart failure. OBJECTIVES: To evaluate the effects of a multidisciplinary outpatient heart failure clinic on the clinical and economic management of patients with congestive heart failure. METHODS: Data on hospital readmissions, emergency department visits, length of stay, charges, and reimbursement from the 6 months before 15 patients joined a heart failure clinic were compared with data from the 6 months after the patients joined the clinic. RESULTS: The patients had a total of 38 hospital admissions (151 hospital days) in the 6 months before joining the clinic and 19 admissions (72 hospital days) in the 6 months afterward. The mean length of stay decreased from 4.3 days in the 6 months before joining to 3.8 days in the 6 months afterward, and the number of emergency department visits also decreased, although neither decrease was statistically significant. Mean inpatient hospital charges decreased from $10,624 per patient admission to $5893. Reimbursements were $7751 (73% collection rate) and $5138 (87% collection rate), respectively. CONCLUSIONS: Patients seemed to benefit from participation in the heart failure clinic. If a healthcare provider is available to manage early signs and symptoms of worsening heart failure, hospital readmissions may be decreased and patients' outcomes may be improved.
Eye care for patients receiving neuromuscular blocking agents or propofol during mechanical ventilation
Authors: Lenart SB , Garrity JA
Published: November 2019

BACKGROUND: The presence of a corneal reflex and the ability to maintain eye closure are instrumental in protecting the cornea. Use of neuromuscular blocking agents or propofol can result in impaired eyelid closure and loss of corneal reflex, leading to corneal exposure. The cornea is then at risk for drying, infection, and scarring, which may lead to permanent visual loss. OBJECTIVES: To determine whether applying artificial tear ointment to the eyes of paralyzed or heavily sedated patients receiving mechanical ventilation decreases the prevalence of exposure keratitis more than does passive closure of the eyelid. METHODS: A prospective, randomized control trial was done. The sample was 50 patients in the intensive care unit receiving either neuromuscular blocking agents or propofol during mechanical ventilation. In each patient, artificial tear ointment was applied to one eye; passive closure of the eyelid was used for the other eye (control eye). RESULTS: Nine patients had evidence of exposure keratitis in the untreated eye, and 2 had corneal abrasions in both the treated and the control eyes. The remaining 39 patients did not have corneal abrasions in either eye. Use of the artificial tear ointment was more effective in preventing corneal exposure than was passive eyelid closure (P = .004). CONCLUSIONS: Eye care with a lubricating ointment on a regular, set schedule can effectively reduce the prevalence of corneal abrasions in patients who are either paralyzed or heavily sedated and thus can help prevent serious complications such as corneal ulceration, infection, and visual loss.
Treatment of trauma-associated hypothermia in children: evidence-based practice
Authors: Bernardo LM , Henker R , O'Connor J
Published: November 2019

BACKGROUND: Hypothermia is a serious immediate consequence of traumatic injury in children. Although numerous studies have addressed the treatment of hypothermia in adults after trauma or surgery, few have examined this issue in injured children. OBJECTIVES: To evaluate the research literature on when and how to treat hypothermia during emergency care of children with trauma and to apply these findings to clinical nursing practice. METHODS: Electronic literature searches conducted periodically for 3 years yielded more than 50 publications on hypothermia and its treatment in trauma and surgical patients. Publications were grouped by cause of hypothermia and by warming methods. Single case reports and publications related to submersion injuries were excluded. RESULTS: Three clinical trials of patients with head injuries included adolescents aged 15 years and older. One study compared peripheral and core warming methods used during operative management of infants and young children. Only one study evaluated core warming in children with trauma. DISCUSSION: The treatments examined in the few research-based studies on the treatment of hypothermia during emergency care of children with trauma were given low recommendations. Although the warming methods were successful in selected surgical and adult patients, the methods cannot be recommended for treating children with trauma because of the lack of evidence-based findings. CONCLUSIONS: Caution should be used when extrapolating published data on the treatment of hypothermia in injured adults to injured children. Ongoing clinical trials should evaluate in children with trauma those warming methods that have been used successfully in surgical patients.
Hibernating myocardium
Authors: Brown TA
Published: November 2019

According to estimates, up to 50% of patients with coronary artery disease and impaired left ventricular function have areas of viable myocardium. This dysfunctional, yet viable myocardial tissue, which can improve functionally after myocardial oxygen supply is reestablished, has been called hibernating myocardium. The possible pathophysiological mechanism that leads to hibernating myocardium is controversial: is the phenomenon due to persistent ischemia or is it the result of repetitive episodes of ischemia and reperfusion, such as myocardial stunning? Regardless of the mechanism, the presence of viable myocardial tissue indicates that structural and biochemical cellular changes occur, and the recovery of left ventricular function after revascularization depends on the severity and extent of these changes. Whether these changes reflect a long-lasting state of cellular dedifferentiation, an adaptive process that is reversible, or eventually lead to cellular degeneration has not been determined. Perhaps early detection of hibernating myocardial tissue via noninvasive imaging techniques used to assess contractile response, integrity of the cellular membrane, myocardial metabolism, and myocardial blood flow and subsequent early coronary revascularization may prevent infarction and deterioration in left ventricular function. Knowledge that reversible changes and areas of viable myocardium can occur in patients with left ventricular dysfunction will assist healthcare providers in the care and management of patients with hibernating myocardium.
A comparison of 2 methods of measuring rectal temperatures with digital thermometers
Authors: Nuckton TJ , Goldreich D , Wendt FC , Nuckton JG , Claman DM
Published: November 2019

BACKGROUND: Digital rectal thermometers typically have 2 distinct modes of operation: dwell or monitor, in which body temperature is displayed continuously, and predictive, in which body temperature is mathematically estimated on the basis of the curve of temperature rise that occurs after the thermometer is inserted. Although the dwell mode is generally considered more accurate, the predictive mode allows more rapid measurement. Direct comparisons of these 2 methods are lacking. OBJECTIVE: To determine if measurements of rectal temperatures obtained with the predictive mode differ significantly from those obtained with the dwell mode. METHODS: For each of 10 subjects, both dwell and predictive modes were used to measure early morning rectal temperature. For comparison of the 2 modes during states of temperature flux, 8 subjects had rectal temperatures measured after swimming in cold water. Initial predictive values were measured directly after each subject exited from the water. Initial dwell values were estimated by linear extrapolation of measured 3- and 6-minute dwell values. Paired-sample statistical methods were used to compare data. RESULTS: Measurements of early-morning temperatures obtained with the predictive mode did not differ significantly from those obtained with the dwell mode (P = .64). Predictive values also did not differ significantly from extrapolated dwell values for measurements obtained during mild temperature flux after immersion in cold water (P = .33). CONCLUSION: The predictive and dwell modes of digital rectal thermometers yield similar measurements of temperature during steady-state conditions and during states of mild temperature flux.
Beta-blockers: a new therapy in congestive heart failure
Authors: Meghani SH , Becker D
Published: November 2019

BACKGROUND: Until recently, use of beta-blockers was contraindicated in treatment of patients with congestive heart failure. However, empirical evidence suggests that adding beta-blockers to the standard therapy can slow the progression of heart failure and reduce mortality, including sudden cardiac death. PURPOSE: To analyze the results of major, prospective, randomized controlled trials on the effects of beta-blockers in congestive heart failure and to provide recommendations for clinical practice and patients' education. METHODS: MEDLINE (1989-2001) and biomedical databases (1995-2001) were searched for literature on the use of beta-blockers in patients with congestive heart failure. Information on major randomized controlled trials of at least 6 months' duration with mortality as a major end point were reviewed. RESULTS: Both selective and nonselective beta-blockers significantly reduce mortality due to all causes; decrease need for hospitalization due to cardiovascular causes; and improve patients' New York Heart Association functional classification, hemodynamic status, left ventricular ejection fraction, and signs and symptoms of congestive heartfailure. However, clinical use of beta-blockers remains limited. CONCLUSION: Strong empirical evidence supports adding beta-blockers to the standard therapy for congestive heart failure. Future efforts should be directed toward establishing the safety and efficacy of beta-blockers in patients with severe heartfailure.
Critical Care Nurses’ Assessment of Patients’ Anxiety: Reliance on Physiological and Behavioral Parameters
Authors: Frazier Susan K. , Moser Debra K. , Riegel Barbara , McKinley Sharon , Blakely Wendy , Kim Kyungeh An , Garvin Bonnie J.
Published: November 2019

• Background Anxiety activates the sympathetic nervous system and hypothalamic-pituitary-adrenal axis and may increase morbidity and mortality in vulnerable critical care patients. Despite the adverse effects of anxiety, little is known about critical care nurses’ practices for assessing anxiety.

• Objective To determine the importance that critical care nurses place on evaluating anxiety and to describe clinical indicators used to assess anxiety.

• Methods Twenty-five hundred members of the American Association of Critical-Care Nurses received the Critical Care Nurse Anxiety Identification and Management Survey and were asked to rate the importance of anxiety assessment, to rate the importance of 61 anxiety indicators, and to select and rank the 5 most important anxiety indicators.

• Results Seven hundred eighty-three completed surveys (31.6%) were returned by female (92.0%), white (88.6%) staff nurses (74.2%) who practiced critical care nursing 32.5 hours (SD, 12.3 hours) weekly. Nearly three quarters (71.3%) of respondents thought that anxiety assessment is very important. Only 2 indicators, agitation and patients’ verbalization of anxiety, were rated as very important to anxiety assessment. Thirty-nine indicators rated as important primarily included measurable physiological changes and observable behaviors. The top 5 anxiety indicators were agitation, increased blood pressure, increased heart rate, patients’ verbalization of anxiety, and restlessness.

• Conclusion Important indicators of anxiety included observable behaviors and measurable physiological changes. Reliance on these criteria may produce an inaccurate and incomplete anxiety evaluation in vulnerable patients and lead to poorer outcomes. A comprehensive, systematic anxiety assessment tool for valid and reproducible evaluation of patients’ anxiety is needed.
Pepsin as a Marker for Pulmonary Aspiration
Authors: Metheny Norma A. , Chang Yie-Hwa , Ye Jing Song , Edwards Sharon J. , Defer Julie , Dahms Thomas E. , Stewart Barbara J. , Stone Kathleen S. , Clouse Ray E.
Published: November 2019

• Background Although assessment for aspiration of small volumes of gastric contents in tube-fed patients receiving mechanical ventilation is important, available methods for this purpose are not wholly satisfactory. A potential method is immunoassay of tracheal secretions for the gastric enzyme pepsin.

• Objectives To determine the frequency with which pepsin in suctioned tracheal secretions from acutely ill, tube-fed patients receiving mechanical ventilation could be detected via an immunoassay.

• Methods A convenience sample of 136 specimens of suctioned tracheal secretions was collected from 30 acutely ill, tube-fed adults receiving mechanical ventilation. Multiple samples were obtained from 26 of the 30 patients (range, 2–11 per subject). An immunoassay with rooster polyclonal antibodies to purified human pepsin was used to detect pepsin in the secretions.

• Results Fourteen specimens tested positive for pepsin. Secretions from 5 patients accounted for the 14 pepsin-positive results. A significant relationship was found between the position of the head of the bed and the presence of pepsin in tracheal secretions (P< .001). Of the 14 pepsin-positive specimens, 13 (92.9%) were obtained from subjects in a flat position.

• Conclusions A pepsin immunoassay can be used to detect pepsin in human tracheal secretions. If pepsin in tracheal secretions is considered an indicator of aspiration of gastric contents, aspiration occurred in 5 of the 30 subjects. A flat position is strongly associated with the presence of pepsin in tracheal secretions.
Resource Utilization Related to Atrial Fibrillation After Coronary Artery Bypass Grafting
Authors: Hravnak Marilyn , Hoffman Leslie A. , Saul Melissa I. , Zullo Thomas G. , Whitman Gayle R.
Published: November 2019

• Background Studies of resource utilization by patients with new-onset atrial fibrillation after coronary artery bypass grafting have addressed only length of stay and bed charges.

• Objective To compare resource utilization between patients with new-onset atrial fibrillation and patients without atrial fibrillation after isolated coronary artery bypass grafting.

• Methods Retrospective review of clinical and administrative electronic databases for 720 subjects who underwent isolated coronary artery bypass grafting with cardiopulmonary bypass in 25 months at one medical center. The prevalence of atrial fibrillation was determined, and resource utilization in various hospital cost centers was compared between subjects with and without atrial fibrillation.

• Results The prevalence of new-onset atrial fibrillation was 33.1%. Compared with subjects without atrial fibrillation, subjects with atrial fibrillation had a longer stay (5.8 ± 2.4 vs 4.4 ± 1.2 days, P< .001), more days receiving mechanical ventilation (P=.002) and oxygen therapy (P< .001), and higher rates of readmission to the intensive care unit (4.6% vs 0.2%, P< .001). Subjects with atrial fibrillation also had more laboratory tests (P< .001) and more days receiving cardiac drugs, heparin, diuretics, and electrolytes. Subjects with atrial fibrillation had higher total postoperative charges ($57261 ± $17 101 vs $50 905 ± $10 062, P = .001), a mean difference of $6356. The mean differences were greatest for bed charges ($1642), laboratory charges ($1215), pharmacy ($989), and respiratory care ($582).

• Conclusions The economic impact of atrial fibrillation after coronary artery bypass grafting has been underestimated.