bluuebunny/crossref_metadata_2025 huggingface dataset:
Service Performance of State Hospitals
Authors: Avcil Seniha
Published: November 2019

Developments in health sector increased the expectations of patients. In order to meet these expectations, hospitals attach importance to their service quality. Although hospitals increase the quality of service, the perceptions of service users become more important. It was aimed to determine the quality of service and expectation of patients and their relatives who applied to four state hospitals in Istanbul by Servqual Scale.
In accordance with this purpose, the relationship between the dimensions of "physical properties", "reliability", "willingness - enthusiasm", "assurance" and "cross-empathy" quality of service and socio - demographic characteristics of participants were statistically analyzed. During sampling process, 358 participants who applied to physical therapy rehabilitation, surgery and internal medicine departments were reached via randomized sampling method.
One-way ANOVA and independent sample t-test and chi-square test were applied to analyze the differences in satisfaction level. As a result of the evaluations, it was determined that four state hospitals did not meet the expectations in terms of both the total service quality and service quality sub-dimensions of the patients and their relatives.
The Dual Adjustment Approach with an Application to the Investment Function for Turkey (1963-2017)
Authors: İsmihan Mustafa , Küçüker Mustafa Can
Published: November 2019

The dual adjustment approach enables us to consider separate dual co-movements of permanent and transitory components of time series variables and hence the possibility of dual adjustment. The common {filtered} trend concept is developed within the framework of dual adjustment approach and a simple test for the existence of such relationship is suggested for nonstationary macroeconomic variables. This paper investigates the dual adjustment with an application to the private sector fixed capital investment function by using the Turkish data over the 1963-2017 period. Our results indicated that private sector fixed capital investment and income, public sector fixed capital investment and macroeconomic instability are not cointegrated and hence they have spurious relationship. In contrast, according to the dual adjustment approach, these variables have a long run relationship. Additionally, it is shown that there are dual relationships between permanent and temporary components of private sector fixed capital investment and income. Furthermore, it is shown that there is no long run relationship between private sector fixed capital investments and public sector fixed capital investments but they are negatively related in the short run. In addition, it is concluded that macroeconomic instability is detrimental for private sector fixed capital investments only in the long run.
Teaching graduates for successful employment and career planning as the university educational priority
Authors: Ezhukova I. F.
Published: November 2019

The issues of career planning and building up, employment and graduates’ adaptation remain relevant and require new approaches to solving the problems of professional identity and formation in the modern world of labour and occupations. The graduates have difficulties in searching for a suitable job in their degree field mostly due to the lack of work experience. On the other hand, young people have great potential. They are quick to study, mobile; able to adapt to new situations and sensible in their approach to labour supplies. The task of a career advisor is to help young people to professionally identify themselves and acquaint them with modern theories of career building and employer requirements. The percent of employed graduates is established on the basis of statistical research and data processing. These are the data obtained in the course of graduates’ career monitoring. The main method of collecting data to study graduates’ employment is the method of dynamic and comparative monitoring. The subject of the research is the data obtained in the course of monitoring analysis. The purpose of the paper is to introduce the experience in developing student job-hunting skills, business career development and management in Nizhnevartovsk State University. The author introduces a modern vision of professional identity process based on psychological and sociological theories. The paper is grounded on the graduate employment studies and provides recommendations, forms and methods of interaction with students to assist successful graduate employment in their degree field
Formulation Development and In Vitro Release Studies of Tenofovir-containing Microsponges
Authors: Eslavath Ravinder Naik , Bakshi Vasudha , Jadi Rajendra Kumar
Published: November 2019

Background. Microsponges are intended to carry drugs with minimum dose, while delivering beneficial effects such as better drug stability and reduced adverse effects in recipients. The present investigation was aimed to develop and characterize microsponges containing tenofovir (TNF).
Methods. Quasi-emulsion diffusion technique was used to prepare TNF-containing microsponges. Eudragit L-100 was used as a polymer, whereas glycerol and dibutylphthalates were used as plasticizers. Drug and polymer were experimented in five formulations (F1-F5) of different ratios such as 1:1, 1:2, 1:3, 1:4, and 1:5. They were characterized for various physical parameters such as size, crystallinity, and interactions.
Results. Fourier-transform infrared spectroscopic results showed that there was no incompatibility between the drug and excipients. Drug entrapment efficacy was found between 47% and 67%, and the particle size ranges were between 4.52 μm and 8.98 μm. Cumulative drug diffusion of formulation F2 (drug:polymer ratio = 1:2) was found to be 84.15% in 180 min for an X-ray diffraction studies of pure drug and microsponges formulation clearly indicated the reduction in the crystallinity of the drug which could be the reason for the improved solubility of the drug. Scanning electron microscopy analysis results indicated that the formulations have excellent structure and almost all formulations exhibited in spherical shape.
Conclusion. Based on all the evaluation parameters, formulation F2 was concluded as the best formulation, and it is an alternative approach for conventional therapy with better patient compliance.
HUBUNGAN DUKUNGAN KELUARGA DENGAN HARGA DIRI (SELF ESTEEM) PENDERITA TUBERKULOSIS PARU DI WILAYAH EKS KAWEDANAN INDRAMAYU
Authors: Husnaniyah Dedeh
Published: November 2019

Tuberkulosis Paru merupakan penyakit menular yang disebabkan oleh Mycobacterium tuberculosis. Dampak TB Paru adalah penurunan daya tahan tubuh, kelemahan fisik, merugikan secara ekonomis dan dapat mengakibatkan isolasi sosial. Keadaan tersebut dapat mempengaruhi harga diri penderita TB Paru. Perubahan harga diri pada penderita TB Paru dapat mempengaruhi keberhasilan pengobatan, sehingga dibutuhkan adanya dukungan keluarga. Tujuan Penelitian ini adalah untuk mengidentifikasi pengaruh dukungan keluarga terhadap harga diri penderita TB Paru di Wilayah Puskesmas Eks Kawedanan Indramayu tahun 2015. Jenis penelitian ini adalah deskriptif analitik dengan rancangan penelitian cross sectional study. Pengambilan sampel dilakukan dengan tekhnik total sampling sebayak 45 responden. Hasil penelitian menunjukkan bahwa penderita TB Paru yang memiliki harga diri tinggi sebanyak 23 responden (51,1%) dan yang memiliki harga diri rendah sebanyak 22 responden (48,9%), penderita TB Paru yang mendapatkan dukungan keluarga sebanyak 26 responden (57,8 %) dan yang tidak mendapatkandukungan keluarga sebanyak 19 (42,2 %). Responden yang mendapatkan dukungan keluarga lebih banyak yang memiliki harga diri tinggi dibandingkan dengan responden yang tidak mendapatkan dukungan keluarga yaitu 69,6% dengan nilai p value = 0,047 (< 0,05). Simpulan dari penelitian ini adalah terdapat hubungandukungan keluarga denganharga diri penderita TB Paru. Hasil penelitian ini diharapkan dapat menjadi masukan bagi pemegang program TB untuk memberikan konseling terkait pentingnya dukungan keluarga bagi penderita TB Paru.
PENGARUH PIJAT STIMULASI OKSITOSIN TERHADAP INVOLUSI UTERUS PADA IBU MASA NIFAS DENGAN PERSALINAN NORMAL DI BIDAN PRAKTIK MANDIRI (BPM) WILAYAH KERJA PUSKESMAS TERISI KABUPATEN INDRAMAYU TAHUN 2016
Authors: Anggita Intan
Published: November 2019

ABSTRAK

Penelitian ini dilatar belakangi oleh meningkatnya angka kematian ibu nifas yang disebabkan oleh perdarahan salah satu cara untuk mengatasi perdarahan itu dengan cara melakukan pijat oksitosin pijatan ini dapat merangsang hormone oksitosin yang menyebabkan kontraksi uterus sehingga proses involusi berjalan normal. Tujuan penelitian ini untuk mengidentifikasi pengaruh pijat stimulasi oksitosin pada ibu nifas yang dipijat oksitosin dan yang tidak dipijat oksitosin. Penelitian ini merupakan penelitian Quasi eksperimen dengan metode post test only control group design. Sampel dalam penelitian ini diambil dengan cara consecutive sample.sampel berjumlah 45 orang yang terdiri dari 15 orang sebagai responden yang di intervensi dan 30 orang sebagai variable control. Instrument penelitian yang digunakan berupa lembar observasi untuk mengamati penurunan TFU di hari 1,2,3 dan 5 .Hasil dari penelitian ini ada pengaruh pijat stimulasi oksitosin terhadap involusi uterus pada ibu masa nifas di BPM wilayah kerja Puskesmas Terisi Kabupaten Indramayu Tahun 2016. Melalui uji statistic Chi-Square dengan nilai p
GAMBARAN PENGETAHUAN PERAWAT DALAM PENANGANAN NYERI NONFARMAKOLOGI PADA PASIEN PASCA OPERASI DI RUANG BEDAH RSUD KABUPATEN INDRAMAYU TAHUN 2017
Authors: Riyanto Riyanto , Prabowo Ridho Kunto , Rahayu Maya
Published: November 2019

Pengetahuan merupakan hal yang sangat penting bagi seorang perawat. Mengenai hal ini tentang pengetahuan perawat dalam penanganan nyeri nonfarmakologi pada pasien pasca operasi belum sepenuhnya dilaksanakan dengan baik. Sehingga penelitian ini bertujuan mengetahui gambaran pengetahuan perawat dalam penanganan nyeri nonfarmakologi pada pasien pasca operasi. Metode yang digunakan kuantitatif dengan teknik deskriptif, populasi penelitian ini perawat di ruang bedah, dengan teknik total sampling sebanyak 30 perawat. Hasil didapatkan pengetahuan perawat dalam pennaganan nyeri nonfarmakologi pada pasien pasca operasi di ruang bedah RSUD Kabupaten Indramayu sebanyak 27 responden (90.0 %) dengan pengetahuan kurang, tentang massase kulit sebanyak 17 responden (56.7 %) dengan pengetahuan kurang, kompres 23 responden (76.7 %) dengan pengetahuan kurang, hipnotis sebanyak 19 responden (63.3 %) dengan pengetahuan kurang, acupressure sebanyak 16 responden (53.0 %) dengan pengetahuan cukup, relaksasi sebanyak 21 responden (70.0 %) dengan pengetahuan kurang, dan tentang distraksi sebanyak 17 responden (56.7 %) dengan pengetahuan kurang. Pengetahuan perawat dapat ditingkatkan dengan membaca media elektronik, evidence-based practice, dan mengikuti seminar atau workshop.

ABSTRACT

Knowledge is very important for a nurse. On this subject knowledge of nurse knowledge in the treatment of nonpharmacological pain in postoperative patients has not been fully implemented properly. So this study aims to determine the description of knowledge of nurses in the treatment of nonpharmacological pain in postoperative patients. The method used is quantitative with descriptive technique, this research population is nurse in surgery room, with total sampling technique counted 30 nurses. The result was obtained by nurse knowledge in non-pharmacology pain treatment in postoperative patient in surgical room of regionl public hospital regency of Indramayu with 27 respondents (90.0%) with less knowledge, about skin mass as much as 17 respondents (56.7%) with less knowledge, compress 23 respondents (76.7%) with less knowledge, hypnosis as much as 19 respondents (63.3%) with less knowledge, acupressure as many as 16 respondents (53.0%) with enough knowledge, relaxation as much as 21 respondents (70.0%) with less knowledge, and about distraction as many as 17 respondents (56.7%) with less knowledge. The nurse's knowledge can be improved by reading electronic media, evidence-based practice, and attending seminars or workshops.
Improved Coupling of Hydrodynamics and Nuclear Reactions via Spectral Deferred Corrections
Authors: Zingale M. , Katz M. P. , Bell J. B. , Minion M. L. , Nonaka A. J. , Zhang W.
Published: November 2019

Simulations in stellar astrophysics involve the coupling of hydrodynamics and nuclear reactions under a wide variety of conditions, from simmering convective flows to explosive nucleosynthesis. Numerical techniques such as operator splitting (most notably Strang splitting) are usually employed to couple the physical processes, but this can affect the accuracy of the simulation, particularly when the burning is vigorous. Furthermore, Strang splitting does not have a straightforward extension to higher-order integration in time. We present a new temporal integration strategy based on spectral deferred corrections, and describe the second- and fourth-order implementations in the open source, finite-volume, compressible hydrodynamics code Castro. One notable advantage to these schemes is that they combine standard low-order discretizations for individual physical processes in a way that achieves an arbitrarily high order of accuracy. We demonstrate the improved accuracy of the new methods on several test problems of increasing complexity.
A Comprehensive Chandra Study of the Disk Wind in the Black Hole Candidate 4U 1630-472
Authors: Trueba N. , Miller J. M. , Kaastra J. , Zoghbi A. , Fabian A. C. , Kallman T. , Proga D. , Raymond J.
Published: November 2019

The mechanisms that drive disk winds are a window into the physical processes that underlie the disk. Stellar-mass black holes are an ideal setting in which to explore these mechanisms, in part because their outbursts span a broad range in mass accretion rate. We performed a spectral analysis of the disk wind found in six Chandra/HETG observations of the black hole candidate 4U 1630−472, covering a range of luminosities over two distinct spectral states. We modeled both wind absorption and extended wind re-emission components using PION, a self-consistent photoionized absorption model. In all but one case, two photoionization zones were required in order to obtain acceptable fits. Two independent constraints on launching radii, obtained via the ionization parameter formalism and the dynamical broadening of the re-emission, helped characterize the geometry of the wind. The innermost wind components (

) tend toward small volume filling factors, high ionization, densities up to

, and outflow velocities of ∼0.003c. These small launching radii and large densities require magnetic driving, as they are inconsistent with numerical and analytical treatments of thermally driven winds. Outer wind components (

) are significantly less ionized and have filling factors near unity. Their larger launching radii, lower densities (

), and outflow velocities (∼0.0007c) are nominally consistent with thermally driven winds. The overall wind structure suggests that these components may also be part of a broader MHD outflow and perhaps better described as magneto-thermal hybrid winds.
Padrões espaciais da vegetação lenhosa associados ao processo de expansão da Floresta com Araucaria sobre Campos excluídos de manejo
Authors: Schinestsck Camila Fonseca , Müller Sandra Cristina , Pillar Valério D.
Published: November 2019

O processo de expansão florestal tem sido observado em regiões de mosaicos de campo-floresta no Sul do Brasil, especialmente em campos excluídos de fogo e pastejo. Outros fatores influenciam esse processo, porém a magnitude ainda permanece pouco compreendida. Neste estudo, avaliamos os padrões da vegetação lenhosa estabelecida num campo excluído de manejo por 34 anos, relacionando-os com variáveis de solo e espaço. Estabelecemos 110 parcelas (113 m2 cada) de forma sistemática sobre áreas mapeadas como campos em 1985, na Estação Ecológica de Aracuri, Rio Grande do Sul, Brasil. Foram amostrados todos os indivíduos lenhosos e variáveis de solo. Análises de ordenação e de partição da variância da composição de espécies nos componentes solo, espaço, e solo estruturado no espaço foram empregadas. Os padrões da vegetação foram melhor explicados pelo espaço, principalmente a distância da área fonte florestal. Comunidades mais próximas da antiga borda florestal são caracterizadas por mais espécies e indivíduos com dispersão zoocórica. Áreas mais distantes têm predomínio de arbustos campestres (Baccharis uncinella) e poucas arbóreas se estabeleceram. O solo apresentou baixa explicação (5%), porém as condições modificam-se conforme o desenvolvimento florestal avança. Concluímos que a expansão florestal em área excluída de distúrbios tem forte associação com o espaço – a distância de áreas fonte, e que os fatores edáficos pouco contribuem com a magnitude do avanço sobre o campo.
Public opinion study on the role of advertising in choice of non-prescription drugs for self-treatment
Authors: Ryvak Tetiana , Denysiuk Oksana
Published: November 2019

An assessment of the opinion of a certain cohort of the population on the role of drug advertising in the choice of non-prescription drugs for self-treatment was conducted. According to the questionnaire survey, it has been established that advertising affects the choice of drug for self-treatment 26.0% of the polled. Despite the fact that the majority of respondents indicate that there is no influence of drug advertising, 62.8% of them buy self-medication drug sabout which they learned from advertising. Thus, our scientific hypothesis about the presence of the direct influence of drug advertising on the commitment of patients to pharmacotherapy is confirmed. The majority of respondents (90.0%) do not consider advertising of drugs to be effective and safe, and 61.0% say that drug advertising contains contradictory and incomprehensible information. Almost all respondents (88.0%) are convinced that drug advertising is not always objective and fair. At the same time, according to 50.0% of respondents, the volume of drug advertising in Ukraine should be reduced, 22.0% of respondents believe that advertising of drugs should be prohibited.
Souffrances dans les liens parent-enfant : réflexion théorique et clinique sur les pratiques éducatives fondées sur la mentalisation auprès des enfants victimes de maltraitance
Authors: Terradas Miguel M. , Achim Julie , Domon-Archambault Vincent , Guillemette Rosalie
Published: November 2019

Une majorité d’enfants sous la protection de la jeunesse ont vécu des traumas complexes liés à la négligence, la maltraitance et diverses formes d’abus. Nous suggérons que ces jeunes présentent, tout comme leurs parents, des défauts importants quant à leur capacité de mentalisation ainsi qu’un fonctionnement psychique caractéristique des modes de pensée prémentalisants. Cet article présente une opérationnalisation de ces différents modes de pensée (modes téléologique, d’équivalence psychique et fictif). Les principes sous-jacents à un programme d’intervention basé sur la mentalisation pouvant être utilisé par les éducateurs qui travaillent auprès d’enfants hébergés dans divers milieux spécialisés de la protection de la jeunesse sont décrits. Enfin, une étude préliminaire concernant l’efficacité de ce programme est brièvement présentée.
Reclutamiento y unidades militares en las colonias romanas de la Hispania Citerior
Authors: Ortiz Córdoba José
Published: November 2019

La participación de tropas de origen hispano en el ejército romano fue frecuente a lo largo del Alto Imperio. Este trabajo tiene como objetivo el estudio de aquellos militares reclutados en las colonias romanas de la Hispania Citerior que fallecieron lejos de las mismas durante su periodo de servicio activo o bien tras recibir la honesta missio y decidir instalarse como veterani en su lugar de destino.
Monitoring and management of acute circulatory problems: the expanded role of the physiologically oriented critical care nurse
Authors: Shoemaker WC
Published: November 2019

The intensive care unit is set apart from other hospital patient care areas by (1) physiological instrumentation that permits better assessment and more effective therapy and (2) more intensive nursing. These capabilities allow nurse and physician intensivists to evaluate tissue perfusion and tissue oxygenation by the temporal patterns of oxygen delivery and oxygen consumption, as well as hemodynamics. Such evaluation provides important insight into the functional impairment of hemorrhagic, traumatic, septic, and postoperative shock. Using artificial intelligence-based systems, complex clinical algorithms--tailored to specific patient conditions--have been developed and are described. These algorithms are based on both invasive and noninvasive monitoring systems and on clinical experience with a large series of high-risk surgical patients.
Urinary bladder/pulmonary artery temperature ratio of less than 1 and shivering in cardiac surgical patients
Authors: Earp JK , Finlayson DC
Published: November 2019

BACKGROUND: Temperature gradients that normally exist between body areas may be altered as a result of heat generated by shivering. METHODS AND POPULATION: Two core thermal gradients between pulmonary artery and urinary bladder were compared with shivering in 37 coronary artery bypass graft patients. Pulmonary artery and urinary temperature were measured every 15 minutes, and shivering was evaluated electromyographically. RESULTS: Shivering developed in 28 patients (76%). With shivering the pulmonary artery/urinary bladder temperature ratio was less than 1 but in the nonshivering group was greater than 1. Correlation (r value) between pulmonary artery and urinary temperature ranged from 0.93 to 0.99. Rate pressure product was higher in the shivering group than in the nonshivering group. A pulmonary artery/urinary bladder temperature ratio of less than 1 was seen with shivering in this subset of patients. CONCLUSION: Pulmonary artery and urinary bladder temperatures are readily available clinically. The combination of a ratio of less than 1 and an increase in rate pressure product should be considered suggestive of shivering in coronary artery bypass graft patients.
Management of ventricular arrhythmias: then and now
Authors: Bennett B , Singh S
Published: November 2019

OBJECTIVE: To review the changing environment of antiarrhythmic therapy. DATA SOURCES: The majority of articles chosen were written by experts in the field of arrhythmia management. The references include a pilot study, abstracts, original articles and results of study groups. An equal number of sources used in this article were obtained from fellow healthcare professionals and MEDLINE searches. STUDY SELECTION: Large, controlled clinical trials in which patient populations had structural heart disease, prior myocardial infarction and/or frequent ventricular premature beats. All were treated with either antiarrhythmic therapy or devices. DATA SYNTHESIS: Past research in the field of arrhythmia management has indicated that ventricular premature beat suppression is the key to increasing patient survival. After reviewing the results of such pivotal trials as the Cardiac Arrhythmia Suppression Trial, however, the question of whether to initiate therapy remains. CONCLUSIONS: Several trials investigating the efficacy of antiarrhythmic drugs in decreasing sudden death have yielded disappointing results. These trials have been beneficial, however, in classifying arrhythmias and assessing patient risk. The outcomes of these trials, combined with advances in the treatment of heart disease, provide us with a framework for antiarrhythmic therapy. Additional controlled clinical trials are necessary if we are to learn the best means of increasing survival in ventricular arrhythmia patients.
Terminal weaning from mechanical ventilation: ethical and practical considerations for patient management
Authors: Campbell ML , Carlson RW
Published: November 2019

Decisions to withdraw life-sustaining therapy are being made more often as patients and healthcare providers increase their awareness of patient rights. The process of withdrawal of mechanical ventilation must be conducted in a humane fashion. An understanding of the ethical, legal and practical considerations for patient management during this type of intervention will enhance the ability of the healthcare provider to participate.
Unstable angina associated with critical proximal left anterior descending coronary artery stenosis
Authors: Stiesmeyer JK
Published: November 2019

A critical proximal left anterior descending coronary artery stenosis associated with unstable angina places a patient at extreme risk for extensive anterolateral myocardial damage with potentially irreversible hemodynamic demise. Characteristics of this pathology are a clinical profile of new-onset unstable angina, normal or minimally elevated cardiac enzymes, and 12-lead electrocardiographic indicators specific for anterolateral ischemia usually seen in periods when the patient is pain-free. Knowledge of this profile, administration and evaluation of pharmacologic therapies and a unique bedside monitoring strategy with hourly surveillance of the precordial leads are key measures necessary to stabilize and preserve the integrity of myocardial tissue until aggressive, invasive revascularization therapies are instituted.
Case study: heart transplantation--increased incidence of acute rejection in female recipients
Authors: Thornlow DK
Published: November 2019

Although the precise link between the increased incidence of allograft rejection in female heart transplant recipients remains uncertain, various gender-specific characteristics may predispose women to earlier rejection episodes. Critical care practitioners must be cognizant of the underlying immunologic factors that indicate higher risk in these recipients. Until the ideal treatment for cardiac rejection is discovered, identifying pertinent immunologic factors, attending to subtle symptoms, obtaining serial endomyocardial biopsies and initiating prompt, additional aggressive immunosuppressive protocols remain paramount in rendering quality patient care. Research must continue to elicit more specific tissue-typing antigens and more selective immunosuppressive agents that will ultimately result in prolonged survival of all heart transplant recipients.
TIPS: a new alternative for the variceal bleeder
Authors: Adams L , Soulen MC
Published: November 2019

BACKGROUND: Standard medical therapies for variceal bleeding secondary to portal hypertension (vasopressin, esophagogastric balloon tamponade and sclerotherapy) are associated with high rates of recurrent bleeding. Surgical shunting has a mortality rate of 15% to 50%. The transjugular intrahepatic portosystemic shunt offers a novel, minimally invasive procedure for nonsurgical portal decompression. METHOD: Following catheterization of the hepatic vein from a jugular vein approach, a needle is directed fluoroscopically from the hepatic vein into a branch of the portal vein along an intrahepatic tract. The intrahepatic tract is then dilated and held open with a stainless steel stent delivered on a balloon catheter. This creates a portosystemic shunt entirely within the liver. RESULTS: The collective experience of more than 300 cases from several centers has been reported. The technical success rate for the transjugular intrahepatic portosystemic shunt is 92% to 96%. Thirty-day mortality rates range from 0% to 14%, with less than 3% attributed to procedural complications. Primary shunt patency is about 90%, with a secondary patency rate of 100%. Rates of encephalopathy and rebleeding are 9% to 14%. Ascites resolves in 80% to 90% of patients. CONCLUSION: The transjugular intrahepatic portosystemic shunt appears to be a safe and effective procedure for management of variceal bleeding and holds promise for becoming the treatment of choice for portal hypertension.
Evaluation and revision of a vasopressin/nitroglycerin protocol for use in variceal bleeding
Authors: Burns SM , Martin M , Merrill P , Luer J , Stone DD
Published: November 2019

BACKGROUND: Continuous infusion of IV vasopressin have been widely used to lower portal pressure and reduce bleeding from esophageal varices. Recently, the combination of vasopressin and nitroglycerin has been noted to be superior to vasopressin alone. This is due to the ability of nitroglycerin to reduce the detrimental effects of vasopressin while preserving its beneficial effects. In September 1989 the authors initiated a protocol in the medical intensive care unit of a large university teaching center that directed caregivers in the simultaneous use of vasopressin and nitroglycerin for use in variceal bleeding. OBJECTIVE: To determine whether the protocol was being used correctly and whether the addition of nitroglycerin produced the desired cardiovascular effects. METHOD: Nineteen patients (25 separate episodes) assigned to the vasopressin/nitroglycerin protocol were monitored retrospectively over a 20-month period for a total of 1068 hours of vasopressin/nitroglycerin infusion. Twenty-four patients received nitroglycerin at 10 to 50 micrograms per minute, 13 at 50 to 100 micrograms per minute and 6 at 100 to 400 micrograms per minute. RESULTS: Nitroglycerin dosage was not advanced appropriately in 78% of episodes despite evidence of bradycardia, hypertension and peripheral vasoconstriction. CONCLUSIONS: Revision of the protocol, giving additional guidance to clinicians on assessment and nitroglycerin advancement, was necessary and was accomplished.
Indirect blood pressure measurement: a need to reassess
Authors: Anderson FD , Cunningham SG , Maloney JP
Published: November 2019

BACKGROUND: Indirect blood pressure measurement is the assessment tool used most frequently in epidemiological studies and hypertension management in the population at large. OBJECTIVE: To review indirect blood pressure measurement within the context of nursing practice. RESULTS: Nurses are not following recommended American Heart Association measurement guidelines. CONCLUSION: A national program of certification in indirect blood pressure measurement, similar to that of basic and advanced cardiac life support, is needed. An initial approach to evaluating present practice is also suggested.
Consenting to DNR: critical care nurses' interactions with patients and family members
Authors: Jezewski MA , Scherer Y , Miller C , Battista E
Published: November 2019

OBJECTIVE: To investigate the process of consenting to do-not-resuscitate status from the perspective of critical care nurses who have been involved with patients and/or family members during their decision. METHOD: A network sample of 22 critical care nurses, with at least 1 year's experience in a critical care unit and self-reported multiple experiences with the do-not-resuscitate consent process, participated in the study. Semistructured, formal interviews were used to collect data. All interviews were tape recorded and transcribed verbatim. The grounded theory method was used to collect and analyze data. RESULTS: The analysis revealed a core category: consenting to do-not-resuscitate status. Integrated into the process were intervening conditions that further explained the process: the meaning of "do not resuscitate," the importance of time/timing in the process, the nurse's role and conflict issues that arose during the process of consenting to do-not-resuscitate status. CONCLUSIONS: The theoretical model developed in this study provides a framework to describe the role of critical care nurses in the do-not-resuscitate process. In addition, a description of the categories provides information for nurses, especially novice nurses, to consider when caring for patients and families who are in the process of making decisions concerning resuscitation.
Case studies in terminal weaning from mechanical ventilation
Authors: Campbell ML
Published: November 2019

Terminal weaning, withdrawal of mechanical ventilation when the patient is not expected to survive the process, must not be burdensome to the patient or significant others. The healthcare team must individualize the weaning process, considering the physiologic comfort of the patient and the psychoemotional comfort of both the patient and family. The following case studies illustrate variations in a method for terminal weaning that are patient-specific and are based on the experience of a supportive care team.
Management of delirium associated with use of the intra-aortic balloon pump
Authors: Sanders KM , Stern TA
Published: November 2019

Five patients who developed an agitated delirium in association with use of an intra-aortic balloon pump are presented. The differential diagnosis of delirium in critically ill cardiac patients is reviewed and effective pharmacologic treatment strategies (involving rapid and aggressive management with intravenous haloperidol) are discussed.
Syndrome X: fact or fancy?
Authors: Futterman LG , Lemberg L
Published: November 2019

Syndrome X continues to be a puzzle to the profession. A consensus as to the definition, etiology, pathology, prognosis and treatment has still to be developed.
Dimensions of procedural pain and its analgesic management in critically ill surgical patients
Authors: Puntillo KA
Published: November 2019

BACKGROUND AND PURPOSE: Many critically ill patients undergo endotracheal suctioning and chest tube removal procedures, yet little documentation of associated pain exists. Therefore, a study was conducted to (1) compare the magnitude and dimensions of pain associated with endotracheal suctioning and chest tube removal in intubated and nonintubated patients and (2) correlate preprocedural analgesic administration and pain magnitude. METHODS: Multiple dimensions of pain (ie, intensity, extent, sensation, and affect) were measured after postoperative cardiovascular surgery patients underwent endotracheal suctioning (N = 45) or chest tube removal (N = 35). Preprocedural analgesics and intubation status during pain assessments were noted. RESULTS: Patients reported lower pain intensity with endotracheal suctioning (mean, 4.9 on a 0-10 numerical rating scale) than with chest tube removal (mean, 6.6). Pain extent, sensation, and affect scores were relatively low for endotracheal suctioning and chest tube removal. Similar words such as "tender," "sharp," and "heavy" were used to describe both procedures; however, more patients described their response to chest tube removal as "fearful." Intubated patients had different pain experiences than extubated patients. Patients received little analgesic premedication, and correlations were low and nonsignificant between amount of medication received and pain magnitude. CONCLUSIONS: Patients were able to communicate extensive information about procedural pain, even when intubated. Endotracheal suctioning and chest tube removal were both painful; yet, there was little preparatory analgesic management of the pain. Research is needed to investigate a variety of pharmacological and nonpharmacological interventions for pain related to endotracheal suctioning and chest tube removal.
MRI protocol for critically ill patients
Authors: Rotello LC , Radin EJ , Jastremski MS , Craner D , Milewski A
Published: November 2019

BACKGROUND Ventilators compatible with magnetic resonance imaging machines are not universally available. However, the lack of such equipment should not preclude magnetic resonance imaging. We have developed a method by which a critically ill patient requiring mechanical ventilation can safely undergo such imaging without compatible equipment. METHOD By using extended ventilator tubing and calculating volume lost due to tubing compliance, safe and reliable mechanical ventilation can be achieved from a distance without impairing scan quality. RESULTS We devised a method to calculate volume lost due to mechanical compliance of the tubing with ventilator circuits employing 20, 30, and 50 feet of tubing. We added the estimated loss of volume to the set tidal volume of 700 mL to give a delivered volume of 700 mL. Twenty breaths were evaluated for each length of tubing. The evaluation of the 20- and 30-foot lengths of tubing demonstrated 10- and 52-mL discrepancies, respectively, between predicted and measured volumes. The 50-foot length showed a 121-mL discrepancy between predicted and measured volumes. CONCLUSIONS Our method appears to be clinically accurate for predicting volume lost due to tubing compliance for lengths of ventilator tubing less than or equal to 30 feet. We have found this technique to be a safe and effective way to ensure patient safety and scan quality in patients requiring mechanical ventilation during magnetic resonance imaging.
Effect of oxygen insufflation during endotracheal suctioning on arterial pressure and oxygenation in coronary artery bypass graft patients
Authors: Dam V , Wild MC , Baun MM
Published: November 2019

BACKGROUND Numerous studies have demonstrated the need for increased inspired oxygen with endotracheal suctioning to prevent hypoxemia; however, increased arterial pressure has been reported as a consequence of lung hyperinflation/inflation used to deliver hyperoxygenation. OBJECTIVES To compare insufflation during endotracheal suctioning with a standard procedure of hyperoxygenation using a ventilator on arterial pressure, pulmonary artery pressure, heart rate, arterial oxygen saturation, and blood gases in intubated, mechanically ventilated coronary artery bypass graft patients. METHODS A within-subjects, repeated-measures design was used to measure arterial pressure (systolic, diastolic, and mean), pulmonary artery pressure (systolic, diastolic, and mean), airway pressure, heart rate and rhythm, arterial oxygen tension, arterial carbon dioxide tension, pH, and arterial oxygen saturation during an oxygen insufflation protocol and a hyperoxygenation protocol via the ventilator. RESULTS Using analysis of variance for repeated measures, statistically significant time effects were found for all variables. Statistically significant differences between protocols over time were found for arterial pressure, arterial oxygen tension, and arterial oxygen saturation. CONCLUSIONS Oxygen insufflation resulted in less increase in arterial pressure than did the hyperoxygenation protocol. The hyperoxygenation protocol resulted in hyperoxia. Based on this study, oxygen insufflation is a safe alternative for providing oxygen during endotracheal suctioning.
Ulnar peripheral nerve stimulation by train-of-four technique in adult nonmedicated patients
Authors: Davidson JE , Verderber A , Lake V , Weinger M , Partridge B , Munden B , Taylor J
Published: November 2019

BACKGROUND: Peripheral nerve stimulation is necessary to quantify the level of neuromuscular blockade and prevent prolonged paralysis related to drug accumulation. Some nurses and physicians are hesitant to administer nerve stimulation because of concerns about inflicting pain on the patient. OBJECTIVE: To describe the feeling associated with train-of-four ulnar nerve stimulation, and to quantify discomfort, monitor heart rate response, and define the amount of current necessary to stimulate thumb adduction. METHODS: Healthy, nonmedicated volunteer subjects (N = 39) were asked to describe train-of-four ulnar nerve monitoring at 3 current strengths. Heart rate was monitored throughout the testing procedure. The milliamperes delivered at each current strength and the occurrence of thumb adduction were recorded. RESULTS: Subjects described nerve stimulation generally as an unusual prickly sensation. On a discomfort scale of 1 to 10, the mean discomfort score when stimulated with the current setting at 4 (15.5-23.6 mA) was 3.63. Level 4 stimulation produced thumb adduction in 54% of subjects. No heart rate change occurred in response to nerve stimulation. CONCLUSION: Nerve stimulation by train-of-four method was moderately uncomfortable but not painful. Heart rate response could not be relied on as a measurement of discomfort. Protocols for stimulation should include testing at level 4 and increasing as necessary to cause thumb adduction.
Comparison of SVO2, SpO2, and clinical parameters with arterial blood gases during ventilatory weaning after cardiac surgery
Authors: Noll ML , Byers JF
Published: November 2019

Correlations of mixed venous and arterial oxygen saturation, heart rate, respiratory rate, and mean arterial pressure with arterial blood gas variables were computed for 57 sets of data obtained from 30 postoperative coronary artery bypass graft patients who were being weaned from mechanical ventilation. Arterial oxygen saturation and respiratory rate correlated significantly, although moderately, with blood gases.
The effect of Trendelenburg and modified trendelenburg positions on cardiac output, blood pressure, and oxygenation: a preliminary study
Authors: Ostrow CL , Hupp E , Topjian D
Published: November 2019

BACKGROUND: Although we have insufficient knowledge about the effects of Trendelenburg positions on various hemodynamic parameters, these positions are frequently used to influence cardiac output and blood pressure in critically ill patients. OBJECTIVES: To determine the effect of Trendelenburg and modified Trendelenburg positions on five dependent variables: cardiac output, cardiac index, mean arterial pressure, systemic vascular resistance, and oxygenation in critically ill patients. METHODS: In this preliminary study subjects were 23 cardiac surgery patients (mean age, 55; SD, 8.09) who had a pulmonary artery catheter for cardiac output determination and who were clinically stable, normovolemic and normotensive. Baseline measurements of the dependent variables were taken in the supine position. Patients were then placed in 10 degrees Trendelenburg or 30 degrees modified Trendelenburg position. The dependent variables were measured after 10 minutes in each position. A 2-period, 2-treatment crossover design with a preliminary baseline measurement was used. RESULTS: Five subjects were unable to tolerate Trendelenburg position because of nausea or pain in the sternal incision. In the 18 who were able to tolerate both position changes, no statistically significant changes were found in the five dependent variables. Changes in systemic vascular resistance over time approached statistical significance and warrant further study. CONCLUSIONS: This preliminary study does not provide support for Trendelenburg positions as a means to influence hemodynamic parameters such as cardiac output and blood pressure in normovolemic and normotensive patients.
Use of extracorporeal photochemotherapy in heart transplant recipients during acute rejection: a case study
Authors: Macey WH , DeNardo B , Rook AH , Singh A , Bromley P
Published: November 2019

Despite the growing availability of improved immunosuppressive agents, acute and chronic rejection episodes remain a major complication in heart transplant recipients. The rejection of allografts is a normal part of the body's response to foreign antigens. The key to controlling this response is to administer a regimen of multiple immunosuppressive drugs. Evidence indicates that by adding extracorporeal photochemotherapy to a standard immunomodulatory regimen, the rejection process can be reversed without significantly increasing patient risk. In this case study we examine extracorporeal photochemotherapy and the care of patients receiving this therapy.
Comparing arterial and end-tidal carbon dioxide values in hyperventilated neurosurgical patients
Authors: Christensen MA , Bloom J , Sutton KR
Published: November 2019

BACKGROUND: Hyperventilation is a frequently used method for inducing hypercarbia in neurosurgical patients. This practice requires careful carbon dioxide monitoring that might be replaced by a less expensive and less invasive alternative to arterial blood gas monitoring. OBJECTIVE: To determine the accuracy of end-tidal carbon dioxide monitoring in hyperventilated neurosurgical patients. METHODS: Nineteen adult patients requiring hyperventilation for the reduction of intracranial pressure following head injury or neurosurgery were enrolled from the surgical intensive care unit of a level I trauma center. A correlation design was used to compare arterial carbon dioxide tensions and end-tidal carbon dioxide measurements during specific periods; secondary analysis with bias and precision estimates was performed. Also, changes in arterial carbon dioxide tensions were compared with simultaneous changes in end-tidal carbon dioxide values. RESULTS: End-tidal carbon dioxide values showed a moderately acceptable correlation with arterial blood gas measurements. However, changes in end-tidal carbon dioxide values failed to correlate with simultaneous changes in arterial carbon dioxide tension measures. Bias and precision measures confirmed these findings. CONCLUSION: In this patient sample, changes in end-tidal carbon dioxide values did not accurately reflect changes in arterial carbon dioxide tension levels in the intensive care setting. Further technological advances in noninvasive carbon dioxide monitoring may lead to a significant cost savings over traditional arterial blood gas analysis.
Ultrasonographic diagnosis of catheter-induced combined subclavian and internal jugular vein thrombosis
Authors: Abulafia O , Sherer DM , DeEulis TG
Published: November 2019

Catheter-induced subclavian and internal jugular vein thrombosis in a patient with unresectable ovarian carcinoma was diagnosed by sonography following subtle clinical symptomatology. Ultrasonographic diagnosis of central vein thrombosis offers applicable, noninvasive bedside diagnosis. The case we describe suggests that a low threshold should be maintained for application of this technique in the diagnosis of this potentially life-threatening complication, especially with the current widespread application of invasive monitoring.
Volume control: a reliable option in the management of 'refractory' congestive heart failure
Authors: Valle BK , Valle GA , Lemberg L
Published: November 2019

CAVH can be effective in severe hypervolemic states, which are generally major hemodynamic abnormalities associated with refractory congestive heart failure, and not infrequently may have a poor renal response to diuretics and vasodilators. Reduced vascular volume with CAVH is accompanied by lower preload and afterload and thus decreased heart size. As a result, cardiac efficiency and contractility improve and oxygen demand is reduced. The temporal progression of congestive heart failure from a mild to a severe state need not be a sign of progressive pathology of heart muscle but rather a result of feedback circuits in which failure begets failure and leads to progressive cardiac enlargement, progressive hypervolemia, and peripheral edema. An appreciation of this concept permits a more optimistic approach to the management of congestive heart failure. Thus, the effective use of CAVH in reducing vascular volume and peripheral edema may reverse "refractory" congestive heart failure and prolong life.