bluuebunny/crossref_metadata_2025 huggingface dataset:
Interleukin-2 therapy: needs of the patient in a critical care setting
Authors: Raymond BA , Haney PE , Gimesky J
Published: November 2019

IL-2 is a biotherapeutic drug and a biological response modifier. This drug has not been approved by the Food and Drug Administration for general use but continues to undergo clinical trials. Candidates for this therapy are patients with advanced carcinoma that has not responded to standard modalities of treatment. Administration of IL-2 can lead to systemic toxicity, which usually appears to be dose-related. As a result, high-dose therapy requires intensive care. The critical care nurse assesses and documents side effects that occur as a result of IL-2 therapy and must be aware of both the physical and psychological needs of the patient. Through successful assessment and intervention, the nurse can gain the knowledge required to manage, both physically and psychologically, patients who are undergoing this therapy.
Use of a hemoglobin substitute in the anemic Jehovah's Witness patient
Authors: Marelli TR
Published: November 2019

Fluosol DA is an experimental means of supplementing oxygen delivery in the anemic patient. The drug's ability to improve oxygen transport appears to improve SVO2. Blood transfusion is the first choice for acute anemia secondary to hemorrhage; however, perfluorochemicals offer an alternative for the patient who cannot accept transfusion therapy. This article reports a case of severe anemia in which transfusion was refused because of the patient's religious convictions. Perfluorochemicals represented an effective medical treatment that was compatible with this patient's religious beliefs. Continued research in artificial oxygen transporters may lead to even more effective drugs for the treatment of acute anemia, possibly decreasing the need for blood transfusion for all patients.
The trauma nurse's role with families in crisis
Authors: Hopkins AG
Published: November 2019

Trauma occurs suddenly and without warning, leaving the family ill-prepared to deal with the stressful event. Because this experience is often the first of its kind for the family, they may have no experience in dealing with these situations. Depending upon which member of the family is injured, a family's entire lifestyle could be disrupted, necessitating a shift in family roles and responsibilities. Previous coping skills are generally inadequate, and feelings of helplessness and powerlessness abound. The unknown time frame for recovery from the traumatic event is an additional stressor. Loss of the traditional family structure and inadequate support systems require that the trauma nurse be able to assist families of trauma victims in this time of crisis. To effectively support the family, the nurse must understand the impact of trauma and typical family responses to crisis. The key to effective management of these families is early assessment and appropriate intervention through providing information, active listening, facilitating flexibility in visiting, and family conferences.
Listeria meningitis: a case study
Authors: Mickles LI , Mickles DP
Published: November 2019

This case illustrates that L monocytogenes should always be considered as a potential cause of clinical meningitis, especially in an immunocompromised patient. The incidence of undetected or misdiagnosed Listeria organisms (as revealed in autopsies) is high enough that extra caution should be taken to ensure that an organism is not simply disregarded as a contaminant.
Cerebral vasospasm: early detection and intervention
Authors: Armstrong SL
Published: November 2019

Many patients survive SAH with minimal neurologic deficits but are at risk for developing further neurologic insult from ischemia resulting from cerebral vasospasm. Nursing care of the patient experiencing vasospasm is challenging. The nurse who is knowledgeable about the signs and symptoms of cerebral ischemia and necessity for continually reviewing the patient's neurologic status can initiate prompt treatment to prevent further ischemic damage. Recognition of this critical problem is the first step toward combating its ominous effects.
Noninvasive hemodynamic monitoring with thoracic electrical bioimpedance
Authors: Smith MA
Published: November 2019

TEB is proving to be an exciting hemodynamic monitoring technique. It has been shown to accurately measure trends in the patient's volume and vasoactive state without the risks and discomfort of invasive monitoring. It can be applied easily and does not require specialized skill of nurses or physicians. A broad range of patient information can be displayed. However, continued education and implementation are important in helping nurses become adept at analyzing parameters that have not been measured with traditional monitoring. Further research is required to explore its possibilities and to determine which patients will benefit most from this form of monitoring.
Right ventricular myocardial infarction: detection, treatment, and nursing implications
Authors: Turner DM , Turner LA
Published: November 2019

Conventional therapy for left ventricular infarction may potentiate hemodynamic instability in a patient with right ventricular MI. The nursing role includes screening for ECG changes, intense hemodynamic monitoring, and ensuring implementation of appropriate therapy.
Cardiac arrest during pregnancy: maternal-fetal physiology and advanced cardiac life support for the obstetric patient
Authors: Mitchell L
Published: November 2019

Although cardiac arrest in pregnancy is rare, all members of the healthcare team who care for pregnant women should be aware of the maternal adaptations of pregnancy. Also, more women with preexisting medical conditions are attempting pregnancy. Perinatal nurses, especially those practicing in level III (high-risk) perinatal centers should be trained in dysrhythmia recognition and ACLS protocols. Rapid intervention sometimes can save two lives.
Challenging diagnosis: adult respiratory distress syndrome
Authors: Hamner J
Published: November 2019

ARDS patients require nursing care on all levels. Basic care such as turning and prevention of fatigue, as well as nursing care necessitated by mechanical ventilation and hemodynamic monitoring, is needed. Because nurses are the only professionals at the bedside around the clock, we are in the unique position to make a difference for ARDS patients. There is no cure yet for ARDS; therefore, appropriate supportive nursing care is of paramount importance.
Acute intermittent porphyria: a nursing case study
Authors: Resor SS , Beare PG
Published: November 2019

Nursing care for a patient with AIP can be challenging. AIP is a complex disease with various signs and symptoms and is often misdiagnosed. Recognition of the signs and symptoms of AIP could be life-saving. Ways to avoid exacerbations, as well as counseling regarding possible genetic transmission, are important aspects of the nursing care of individuals with AIP.
Stunned myocardium: theoretical mechanisms of injury
Authors: Walton J , Westrope P
Published: November 2019

Stunned myocardium may occur after an episode of prolonged or transient ischemia. This phenomenon can occur in a variety of patient groups including medical, surgical, neurologic, and cardiac patients. In the stunned myocardium, myocardial contractility is temporarily depressed, causing symptoms similar to those of cardiogenic shock. When critical care nurses are familiar with the clinical characteristics and risk factors of stunned myocardium, they can start the appropriate interventions and left ventricular function returns to normal within days with no residual hypokinesis. Critical care nurses play a key role in assisting surgeons and other noncardiac physicians in the diagnosis and care of the patient with stunned myocardium.
Using the 12-lead ECG to detect ischemia, injury, and infarction
Authors: Morton PG
Published: November 2019

The 12-lead ECG is extremely valuable in helping the critical care nurse detect the presence of myocardial ischemia, injury, and infarction. With an understanding of the 12-lead ECG, the nurse can relate the ECG findings to the patient's coronary artery disease and can anticipate the clinical consequences both for the functioning of the cardiac muscle and for the cardiac conducting system.
Case management, critical pathways, and myocardial infarction
Authors: Kegel LM
Published: November 2019

Case management is an innovative way to simultaneously modify healthcare delivery, uphold standards of care, and reduce healthcare costs. The case manager oversees the patient's condition, progress, and consumption of resources. Information is constantly analyzed and used to regulate treatment plans in accordance with the critical pathways. The goal of this regulation is to produce outcomes that serve the patient and the healthcare system. The complexity of individualized patient care can require an unlimited number of pathways if all variances are considered. If all variances are not considered, then the quality of care is hindered, rehospitalization occurs, and the goals of the critical pathways are not achieved. Therefore, effective use of case management and critical pathways involves flexible guidelines, maintains focus on outcomes, enhances efficiency, increases cost-effectiveness, and retains a high quality of patient care.
Using a critical care simulation laboratory to teach students
Authors: Morton PG
Published: November 2019

Critical care nursing is a dynamic and continuous process involving knowledge, values and attitudes, and motor skills. When combined with other teaching methods, a critical care simulation laboratory provides learners with an effective means to achieve the cognitive, affective, and psychomotor competencies necessary for the complexities of clinical practice.
Introducing the Basic Knowledge Assessment Tool for pediatric critical care nursing (PEDS-BKAT)
Authors: Runton NG , Toth JC
Published: November 2019

A 9-member educational task force and a 4-member panel of experts was used to establish the validity of the PEDS-BKAT, which was modified from version 4 of the adult BKAT for critical care nursing. A sample of 105 pediatric ICU nurses from 6 settings took the PEDS-BKAT. Test results include a mean score of 78.9 points and a reliability of 0.86 (coefficient alpha). The PEDS-BKAT can be used to assess knowledge before and after orientation, to determine learning needs for veteran staff nurses, for advanced placement of new employees with previous experience in a pediatric ICU, and in nursing research. Copies of the PEDS-BKAT are available upon request.
Research utilization and improvement in outcomes after diagnostic cardiac catheterization
Authors: Lundin L , Sargent T , Burke L
Published: November 2019

This research utilization project helped summarize the research basis of current practice related to duration of bed rest after cardiac catheterization via the femoral artery. Several physicians have changed their practice as a result of this project, and the safety of patients is being maintained. Interestingly, De Jong and Morton recently published a research analysis of interventions used to control vascular complications after cardiac catheterization. These authors concluded from the review of the literature on duration of bed rest that evidence was sufficient to support a change in practice. Because we thought that the published evidence was insufficient to be used as the sole basis for a change in practice, we continued to follow the Iowa model. Specifically, we integrated scientific principles and expert recommendations with the published research base; recommended a change in practice; and monitored patients' outcomes, which ultimately did confirm the recommendations of De Jong and Morton. We are convinced that the combination of data from our own patients and the review of the literature was helpful to assure our medical and nursing staff that this change in practice was safe. This project illustrates the benefit of using the Iowa Model for Research Based Practice to Promote Quality Care as a guide to improve patients' outcomes.
Successful use of extracorporeal membrane oxygenation to treat severe respiratory failure in a pediatric patient with a scald injury
Authors: Hilt T , Graves DF , Chernin JM , Angel CA , Herndon DN , Zwischenberger JB
Published: November 2019

If ECMO is to be used effectively in pediatric patients, specifically in those with burns, the candidates must be chosen with care. Unlike the situation in neonates, when ECMO is being considered for use in a pediatric patient, no clear set of inclusion or exclusion criteria exists. Evaluation of a pediatric patient for ECMO support is largely based on an assessment of the patient's condition and a center's previous experience with pediatric ECMO. The data that are available through ELSO indicate that survival decreases as the number of days a patient receives mechanical ventilation before the initiation of ECMO increases. The effect of burns on patients' outcomes is unknown. Age, duration of mechanical ventilation, and excision with allografting or homografting of the burns should all be considered before the patient is offered ECMO support. The remaining prognostic signs--duration of ECMO support, frequency of complications, and blood product requirements--are available only after the ECMO course is under way or completed. The success of our center and others in using ECMO to treat respiratory failure associated with burns shows that some patients with burns may benefit from ECMO. Unfortunately, no specific set of criteria exists that would enable ECMO centers to differentiate good candidates from poor ones and thus be able to offer ECMO support with confidence in its benefit for the patient.
The day the lights went out: one charge nurse's nightmare
Authors: Small B , Moynihan P
Published: November 2019

The synergy model can be applied to many clinical situations. As nursing leaders evolve, competencies required to effectively respond to unexpected events silently develop. Applying the Synergy Model to this exemplar helped to articulate the charge nursing's leadership in ensuring a safe practice environment. The model provides a framework to more fully describe the multiple dimensions of a charge nurse's role, and acknowledges the richness of knowledge and competence that charge nurses often contribute to complex clinical situations.
When the 'evidence' in evidence-based practice is ignored: a time for advocacy
Authors: Alspach G
Published: November 2019

There are innumerable aspects of critical care nursing where we have limited or no research basis for practice. But where evidence-based practice is available, it must be universally disseminated and applied so that all patients may benefit. Part of our responsibility as healthcare professionals is to contribute to this dissemination process so that optimal patient outcomes can be attained. Quality care should not exist on a patchwork basis across the United States. Patients have a right to expect that we afford them the best care that science presently offers. Care should rely as much as possible on research-based evidence of what helps and hinders optimal patient outcomes. When these indicators of what helps versus hinders optimal outcomes are known, patients should be able to depend on us to provide care on that basis. They should not need to rely on their zip code to receive optimal care.
Prone positioning in patients with acute respiratory distress syndrome: the Vollman Prone Positioner
Authors: Klein DG
Published: November 2019

ARDS continues to be associated with high mortality rates despite numerous advances in critical care. Improvements in oxygenation can be achieved by placing patients with ARDS prone. The Vollman Prone Positioner offers an easy, safe, and inexpensive method to turn patients prone (for more information: www.vollman.com).
Use of blood cultures in critically ill patients
Authors: Henker R
Published: November 2019

Infection, bacteremia, and sepsis are frequent complications in critically ill patients. Ideally, the infectious agent is readily identified to facilitate timely treatment to promote the patient's recovery. Use of blood cultures is one method of identifying the pathogen. Fever is the primary indicator for obtaining blood samples for culture, but other indicators may be considered, depending on the patient's medical history and condition. Use of appropriate techniques when collecting blood samples for culture will decrease contamination and improve the likelihood of identification of the infectious agent. One new technique being tested for the identification of pathogens that cause bacteremia involves genetic technology and the polymerase chain reaction. The polymerase chain reaction is used to identify the DNA of bacteria that are present in the blood. Blood cultures may not always result in identification of the pathogen because the organism may not grow once placed in culture medium. This new method that uses the polymerase chain reaction may be more sensitive than blood cultures because it requires only DNA from bacteria. Although early studies have not been conclusive in terms of the benefits of this new technology, additional research will improve methods for identification of pathogens in critically ill patients.
Carotid endarterectomy: creating the pathway to 1-day stay
Authors: Kallenbach AM , Rosenblum CJ
Published: November 2019

Use of a collaborative team approach to design a care pathway and standing orders for carotid endarterectomy patients achieved the project's goals. Variation, LOS, and resource consumption were decreased while quality of care and patients' satisfaction levels were maintained. Education of patients, patients' families, and staff members increased. Coordination between caregivers increased. The consistent concurrent database provided a feedback loop for continued change and for setting the target. Essential to the success was sponsorship from key leadership via the hospital's steering committee. The diverse membership of key associates on the CQI team helped to create an excellent revised carotid endarterectomy process and ensured full implementation. This membership of the CQI team was essential to comprehensive education and implementation. The step-by-step implementation kept the project moving forward. Creating a care pathway and changing practice require collaboration between nurses, doctors, and administrators. Creativity and systematic, thorough steps are what move a practice change from idea to inception.
Managing patients with lumbar drainage devices
Authors: Thompson HJ
Published: November 2019

All nurses who care for patients with LDDs must have demonstrated initial competency with LDDs and should participate in periodic in-service training to maintain that competency. Clearly an educated critical care nurse is the most essential partner that a patient with an LDD can have for preventing complications and ensuring that the best outcomes for the patient are achieved. Nurses caring for patients with an LDD must have a clear institution-specific policy and procedure available to guide the care of these patients.
Ethanol, isopropanol, methanol, and ethylene glycol poisoning
Authors: Lobert S
Published: November 2019

Alcohol intoxication, commonly encountered in emergency department and clinic settings, is by no means a benign condition. Ethanol ingested alone or in combination with other CNS depressants (eg, isopropanol, methanol, ethylene glycol, sedatives, opioids) can be fatal. Obtaining the patient's history and careful observation for clinical signs and symptoms, along with appropriate analysis of results of laboratory tests, are the key to determining and differentiating the agent ingested. It is critical that poisoning due to ethanol and/or other related alcohols should be recognized early in order to initiate appropriate treatments and prevent fatalities. Emergency department nurses may be the first persons to collect the essential data, and it is incumbent upon them to plan and initiate appropriate care. In continuing management for these patients, critical care nurses must understand the factors contributing to the observed signs and symptoms in order to initiate and monitor ongoing care and prevent serious complications.
Managing trauma patients with abdominal compartment syndrome
Authors: Fritsch DE , Steinmann RA
Published: November 2019

ACS is due to a rapid increase in intra-abdominal pressure. Although ACS may occur in both surgical and nonsurgical patients, patients who have abdominal or pelvic trauma and/or require massive fluid replacement are at increased risk. Critical care nurses are in a unique position to recognize early signs and symptoms of increased intra-abdominal pressure to ensure timely intervention. Aggressive hemodynamic, pulmonary, and operative management is essential for the optimal outcome of patients with ACS. Without definitive treatment, multisystem organ dysfunction and death ultimately ensue.
Feeding critically ill patients: current concepts
Authors: Trujillo EB , Robinson MK , Jacobs DO
Published: November 2019

Provision of nutritional support to critically ill patients can be challenging. Critical care nurses must be aware of which patients require specific nutritional support, when to initiate nutritional support, and by which route to provide nutritional support. Consultation with a dietitian or nutritional support service can help facilitate this process. The key points in addressing these questions are (1) the nutritional status of the patient or the length of time he or she has been without significant nutrient intake, (2) whether the patient has a hypermetabolic condition that warrants the early use of nutritional support, and (3) the function of the patient's gastrointestinal tract. What to feed depends on the physiological state of the patient. Adjusting the nutrient composition of the feeding solution may prevent metabolic complications and may improve the overall outcome for the patient.
Cardiac Advanced Life Support–Surgical Guideline
Authors: Herrmann Cheryl
Published: November 2019

Cardiac arrest in the immediate postoperative recovery period in a patient who underwent cardiac surgery is typically related to reversible causes—tamponade, bleeding, ventricular arrhythmias, or heart blocks associated with conduction problems. When treated promptly, 17% to 79% of patients who experience cardiac arrest after cardiac surgery survive to discharge. The Cardiac Advanced Life Support–Surgical (CALS-S) guideline provides a standardized algorithm approach to resuscitation of patients who experience cardiac arrest after cardiac surgery. The purpose of this article is to discuss the CALS-S guideline and how to implement it.
Clinical Review and Implications of the Guideline for the Early Management of Patients With Acute Ischemic Stroke
Authors: Livesay Sarah L.
Published: November 2019

Stroke is the fourth leading cause of death and the leading cause of significant, long-term disability in the United States. Clinicians’ knowledge and use of evidence to guide the care of patients with ischemic stroke are paramount to improving patient outcomes. The recently updated “Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association” provides clinicians with evidence-based, expert consensus to guide the recognition and early management of patients with acute ischemic stroke. The guideline provides 115 recommendations for the management of patients with acute ischemic stroke, including 24 new recommendations and 51 revised recommendations divided into 14 major topic areas. This article reviews the recommendations and related literature and provides suggestions for use and implementation of the guideline within a stroke program of care.
Comprehensive Guideline for Care of Patients With Heart Failure
Authors: Buonocore Denise , Wallace Elizabeth
Published: November 2019

Heart failure (HF) is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood. More than 5.1 million people are living with HF in the United States today. This number will continue to rise with the increase in the aging population. With so many people living with HF, nurses need to be well versed on how best to care for them. The 2013 American College of Cardiology Foundation/American Heart Association guideline for the management of HF is a comprehensive guide for all clinicians caring for patients with HF. The updated guideline was developed to assist providers in decision making in the diagnosis and treatment of HF. The goals of the writing committee were to improve quality of care for patients with HF, optimize their outcomes, and improve the efficient use of various resources in the treatment of patients with HF.
Hyperglycemia After Cardiac Surgery
Authors: Stoodley Lynda , Wung Shu-Fen
Published: November 2019

Background

The Surgical Care Improvement Project #4 (SCIP#4) performance measure is used to evaluate achievement of target blood glucose control after cardiac surgery.

Objectives

The purpose of this study was to identify patient characteristics and outcomes in patients undergoing cardiac surgery who met the SCIP#4 performance measure versus those who did not.

Methods

A retrospective case-control design was used.

Results

Preoperative hemoglobin A1C (HbA1C) level and history of diabetes were 2 major risk factors for failing to meet the SCIP#4 measure. A trend toward a longer length of stay was observed, mortality was 3 times more prevalent, and renal failure was 4 times more frequent in patients who did not meet the SCIP#4 quality measure.

Conclusions

Not meeting the SCIP#4 measure is associated with adverse outcomes. History of diabetes and preoperative HbAIC level should be considered when evaluating strategies for managing postsurgical hyperglycemia.
Abdominal Pain
Authors: Brown Helen F. , Kelso Lynn
Published: November 2019

Acute abdominal pain represents the cardinal symptom of a large number of intra-abdominal pathologies. Because of multiple organ systems, varied pathology from life threatening to benign, and differences in presentation related to sex and age, identifying a final diagnosis is a challenge. The clinician’s goal for patients with acute abdominal pain is to rapidly identify whether the underlying cause requires an urgent or immediate surgical intervention. By developing a systematic approach to evaluating patients with abdominal pain, clinicians can generate a differential diagnosis to ensure appropriate treatment and improved patient outcomes. The purpose of this article is to provide clinicians with a framework for evaluating the complaint of acute abdominal pain and recognizing patients who require expedited evaluation.
A Case for the Use of Validated Physiological Mortality Metrics to Guide Early Family Intervention in Intensive Care Unit Patients
Authors: Searl Molly F.
Published: November 2019

In the current health care climate a large portion of health care dollars are spent in the final months of life, so ensuring that care provided is in line with the wishes of patients and their families is more critical than ever. On the one hand, surviving families often report that they wish they had been given prognostic information earlier and that, in retrospect, they would have made different treatment decisions if they had been given prognostic information. On the other hand, providers often are reluctant to discuss prognosis for various reasons, not the least of which is the inherently uncertain nature of prognostication. To address this issue, this article reviews pertinent literature about provider reticence, family preference, and the move toward palliative care and includes a discussion of the various validated mortality-prediction models available. A case is made to use those validated metrics to guide early discussions of palliative or end-of-life care for patients who are critically ill. A suggested checklist to facilitate inclusion of prognosis discussions in family meetings is included as well as a case study to illustrate the problem, current practice, and a model for improvement.
Role of the Clinical Nurse Specialist in the Journey to Magnet Recognition
Authors: Hanson M. Dave
Published: November 2019

Clinical nurse specialists (CNSs) work with and through other nurses as well as interprofessional team members to advance nursing practice, improve outcomes, and provide clinical expertise to effect system-wide changes to improve programs of care. They practice across the continuum and through 3 spheres of influence, encompassing the patient, nurse, and system. Clinical nurse specialists possess expertise in developing and refining structures, strategies, and processes to optimize outcomes at both the unit (micro) level and the organization or system (macro) level. This unique vantage point positions CNSs as ideal individuals to assume several key roles when a health care organization makes the decision to embark on the Magnet journey and to maintain Magnet recognition. The competence and competencies of CNSs and a health care organization’s desire to achieve and/or maintain Magnet recognition represent a synergistic match.
Resolving Communication Challenges in the Intensive Care Unit
Authors: Grant Marian
Published: November 2019

Communication in the intensive care unit (ICU) is challenging because of complexity, high patient acuity, uncertainty, and ethical issues. Unfortunately, conflict is common, as several studies and reviews confirm. Three types of communication challenges are found in this setting: those within the ICU team, those between the ICU team and the patient or family, and those within the patient’s family. Although specific evidence-based interventions are available for each type of communication challenge, all hinge on clinicians being culturally competent, respectful, and good communicators/listeners. Critical care advanced practice nurses promote a positive team environment, increase patient satisfaction, and model good communication for other clinicians. All advanced practice nurses, however, also need to be adept at having difficult conversations, handling conflict, and providing basic palliative care, including emotional support.
Intravenous Antibiotics Used in the Treatment of Methicillin-Resistant Staphylococcus Aureus
Authors: Scordo Kristine Anne
Published: November 2019

Methicillin-resistant Staphylococcus aureus (MRSA) continues to cause significant morbidity and mortality. Despite advances in medical care, the prevalence of both community-acquired and hospital-acquired MRSA has progressively increased. Community-acquired MRSA typically occurs in patients without recent illness or hospitalization, presents as acute skin and soft tissue infections, and is usually not multidrug resistant. Hospital-acquired MRSA, however, presents in patients recently hospitalized or treated in long-term care settings and in those who have had medical procedures and is usually associated with multidrug-resistant strains. Both types of infections, if not properly treated, have the potential to become invasive. This article discusses current intravenous antibiotics that are available for the empiric treatment of MRSA infections along with a newer phenomenon known as the “seesaw effect.”
Feeding Protocols for Neonates With Hypoplastic Left Heart Syndrome
Authors: Jenkins Erin
Published: November 2019

Optimizing nutrition in neonates with hypoplastic left heart syndrome is essential, given the high rate of growth failure in this population. Infants with hypoplastic left heart syndrome are predisposed to nutritional deficiency as a result of their increased metabolic demand; however, early enteral feeding also increases the risk of serious gastrointestinal morbidity and mortality caused by poor intestinal perfusion. Consequently, providers have difficulty deciding when and how to safely feed these patients. A review of the literature found that implementation of a structured enteral feeding protocol may decrease the risk of gastrointestinal complications while also minimizing dependence on parenteral nutrition and decreasing length of hospital stay. As these studies were limited, further research is warranted to establish a best practice feeding protocol to decrease risk and optimize nutrition in this fragile population.
Challenges in Hospital-Associated Infection Management
Authors: Stacy Kathleen M.
Published: November 2019

Maintaining a successful unit-based continuous quality improvement program for managing hospital-associated infections is a huge challenge and an overwhelming task. It requires strong organizational support and unit leadership, human and fiscal resources, time, and a dedicated and motivated nursing staff. A great deal of effort goes into implementing, monitoring, reporting, and evaluating quality improvement initiatives and can lead to significant frustration on the part of the leadership team and nursing staff when quality improvement efforts fail to produce the desired results. Each initiative presents its own unique set of challenges; however, common issues influence all initiatives. These common issues include organization and unit culture, current clinical practice guidelines being used to drive the initiatives, performance discrepancies on the part of nursing staff, availability of resources including equipment and supplies, monitoring of the data, and conflicting quality improvement priorities.
Antibiotic Dosing in Critically Ill Patients Undergoing Renal Replacement Therapy
Authors: Susla Gregory M.
Published: November 2019

Continuous renal replacement therapy is frequently used to manage acute renal failure in critically ill patients. Antibiotic drugs used to treat infections in critically ill patients need to be dosed on the basis of the method of renal replacement therapy to be used, degree of residual renal function, and the sensitivity of the organism to be treated. Antibiotic dosing regimens must then be continuously monitored and adjusted according to modifications made to the renal replacement circuit and the patient’s underlying condition.
Home Monitoring for Cardiovascular Implantable Electronic Devices
Authors: Leahy Robin A. , Davenport Elizabeth E.
Published: November 2019

Recent technological advances in the management of patients with cardiovascular implantable electronic devices (CIEDs) have expanded clinicians’ ability to remotely monitor patients with CIEDs. Remote monitoring, in addition to periodic in-person device evaluation, provides many advantages to patients and clinicians. Aside from the therapeutic and diagnostic benefits of pacemakers, implantable cardioverter-defibrillators, cardiac resynchronization therapy devices, and implantable loop recorders, improvement in clinical outcomes, clinical efficiencies, and patient experience can be realized with the adoption of remote CIED monitoring. These advantages create significant value to both patients and CIED follow-up centers.
Cardiac Implantable Electronic Device Implantation
Authors: Harding Melissa E.
Published: November 2019

Implantation of cardiac implantable electronic devices (CIEDs), including pacemakers, implantable cardioverter-defibrillators, and biventricular pacemakers/cardioverter-defibrillators, is becoming increasingly common with new implants now exceeding 1.5 million per year globally. As a result, health care providers in all disciplines are caring for an increasing number of patients with CIEDs. Although the risk of complications associated with implantation of CIEDs is relatively low, the sequela can be catastrophic. Management requires an understanding of an individual patient’s indication for CIED implant, the steps of implant procedures, device function, and natural history of each complication.
Acute Kidney Injury
Authors: Martin Rhonda K.
Published: November 2019

Acute kidney injury (AKI) is a common disease in the acutely ill patient population, as a singular diagnosis or a complication of sepsis, causing significant mortality and morbidity. Progress in diagnosis, treatment, and research in AKI has been limited by the lack of a universally accepted clinical definition. The clinical definition of AKI onset and progression, early diagnostic indicators, and understanding the unique pathophysiology of AKI are requisite to early treatment and management and ultimately positive patient outcomes. This article reviews the advances in defining and staging AKI on the basis of international consensus statements. An update on the most recent concepts affecting renal pathophysiology in AKI is also presented. Current clinical tools used in diagnosing and monitoring AKI, including the development of renal biomarkers, are discussed.
Best Practices in Creating a Culture of Certification
Authors: Fleischman Rhonda K. , Meyer Laura , Watson Christine
Published: November 2019

Certification is the criterion standard of professional practice, distinguishing excellence in nursing care, mastery of knowledge, skills, and abilities beyond the scope of professional licensure. It is the validation of an individual nurse’s qualifications for practice in a defined area. Becoming certified is a personal and professional commitment that demonstrates the value that the individual nurse places on higher standards of practice and lifelong learning. The American Association of Critical-Care Nurses (AACN) Beacon Award for Excellence, Magnet Recognition Program, and Malcolm Baldrige National Quality Award all recognize certification as a key component of nursing excellence in specialty practice. Both the general public and nurse professionals increasingly recognize the need for practice on the basis of evidence to provide safe, quality patient care. In today’s rapidly changing and complex health care delivery system, certification is becoming the standard by which bedside practice and the impact of nursing care on patient outcomes are measured. This article will provide a review of current best practices in creating a culture of certification, including the journey of 3 hospitals selected as the 2010 Best Practice Roundtable presentations at the AACN National Teaching Institute.
Life-Threatening Injuries in Older Adults
Authors: Scheetz Linda J.
Published: November 2019

Unintentional injuries are among the leading causes of death and disability in older adults. Although older adults account for approximately 12% of the US population, in 2008, they accounted for 15% of all traffic fatalities, 14% of all vehicle occupant fatalities, and 18% of all pedestrian fatalities. Severely injured older adults have far worse outcomes than younger adults. Despite this difference, many survive with aggressive resuscitation and goal-directed therapy. This article describes the impact of life-threatening injuries in the older adult population, specifically injuries sustained in motor vehicle collisions, and how these injuries relate to anatomic and physiologic changes of aging, the metabolic response to injury, the role of preexisting diseases and medications taken to treat these diseases, and complications.
The Importance of Assessing Symptoms and Symptom Clusters in Critical Care Units
Authors: Sousa Karen H. , McDermott Carrie M. , Weiss Jason
Published: November 2019

In the highly technological environment of critical care, a comprehensive symptom assessment from the patient’s perspective is routine. There is a paucity of research related to symptom management in the critical care environment. The lack of understanding of the symptom experience for critical care patients could represent missed opportunities to manage symptoms and minimize suffering. This article discusses the importance of assessing symptoms and symptom clusters in critical care patients and challenges surrounding the assessment of symptom clusters. By understanding symptom clusters, critical care nurses can develop more comprehensive assessments, as well as more tailored intervention strategies.
Placement of an Esophageal Temperature Probe by Nurses
Authors: Makic Mary Beth Flynn , Lovett Karen , Azam M. Fareedul
Published: November 2019

Background

Current guidelines support therapeutic hypothermia after cardiac arrest. An esophageal temperature probe (ETP) provides a core temperature assessment; however, accurate placement is necessary.

Objectives

To demonstrate accurate placement of an ETP and evaluate the effectiveness of high-fidelity simulation with anatomic imaging.

Methods

Registered nurses (RNs) were educated using 3-dimensional, high-fidelity simulation with VH Dissector technology (Touch of Life Technologies, Aurora, Colorado) to demonstrate ETP placement. The RNs provided survey responses on the effectiveness of simulation before and after using the simulator.

Results

Thirty-two RNs participated and did not demonstrate difficulties with the skill; however, 53.1% required more than 1 attempt for accurate placement in the distal esophagus. Survey results found that participants had increased confidence and high satisfaction with simulation and 3-dimensional imaging (P < .001).

Conclusions

Literature is lacking to guide ETP placement. In this study, RNs overestimated the depth for ETP insertion. Accurate temperature readings are highly dependent on accurate anatomical location placement. Providing skill competency training that incorporated anatomical imaging technology enhanced RNs’ awareness for effective skill acquisition.
Evaluating a New Rapid Response Team
Authors: Scherr Kimberly , Wilson Donna M. , Wagner Joan , Haughian Maureen
Published: November 2019

Evidence is needed to validate rapid response teams (RRTs), including those led by nurse practitioners (NPs). A descriptive-comparative mixed-methods study was undertaken to evaluate a newly implemented NP-led RRT at 2 Canadian hospitals. On the basis of data gathered on 255 patients who received an RRT call compared with the patient data for the previous year, no significant differences in the number of cardiorespiratory arrests, unplanned intensive care unit admissions, and hospital mortality were found. In addition, no significant differences in patient outcomes were identified between the NP-led and intensivist physician-led RRT calls. A paper survey revealed that ward nurses had confidence in the knowledge and skills of the NP-led RRT and believed that patient outcomes were improved as a result of their RRT call. These findings indicate that NP-led RRTs are a safe and effective alternative to intensivist-led teams, but more research is needed to demonstrate that RRTs improve hospital care quality and patient outcomes.
Temporary Ventricular Assist Devices in the Intensive Care Unit as a Bridge to Decision
Authors: Myers Timothy J.
Published: November 2019

Morbidity and mortality in patients with cardiogenic shock remain high despite the recent advances in therapy. New temporary ventricular assist devices (VADs) that are rapidly applied to normalize cardiac output in patients with severe heart failure are being used more frequently. Bridge to decision describes the temporary use of a VAD to stabilize critically ill patients until complete diagnostic tests are performed and decisions about more definitive therapy are made. The CentriMag, Tandem-Heart, and Impella VADs offer versatility for use in many patients and in multiple hospital settings. These VADs provide continuous blood flow, altering the usual assessment of arterial blood pressure. Patients are usually immobilized during support to prevent dislodgement of cannulas. Anticoagulation therapy is commonly required, and bleeding is a frequent complication. Infection prevention measures must be used to avoid septic complications. In the past 10 years, clinical experience with these devices has expanded, but they remain underused.
Physiology of Continuous-Flow Pumps
Authors: Christensen Dawn M.
Published: November 2019

The use of mechanical pumps for circulatory support started in the mid-1950s. The evolution of these devices has led to the present-day use of continuous-flow pumps to take over the function of a patient’s failing heart. The physiology associated with rotary blood pump use is quite different from normal cardiovascular physiology. Clinicians caring for patients who are supported by rotary blood pumps must have an understanding of the differences in physiology, monitoring methods, and unique complications associated with the use of these pumps.
Target Temperature Within 3 Hours
Authors: Gessner Patty , Dugan Guy , Janusek Linda
Published: November 2019

Therapeutic hypothermia has been shown to improve neurological outcomes for patients who survive cardiac arrest. Timely cooling can be achieved by rapid initiation of a comprehensive targeted temperature protocol, which includes shivering assessment and management. The purpose of the study was to evaluate an updated therapeutic hypothermia protocol for patients who survive cardiac arrest. The first 6 patients who met inclusion criteria were placed on the updated protocol. These cases were compared with historical cases. Upon discharge or death, cases were analyzed for time to reach the target temperature, the use of paralytic agents, and discharge disposition. Patients placed on the updated protocol cooled 2 hours faster than did the patients from the historical cases (median = 179 vs 285 minutes). The use of paralytic agents appeared to safely accelerate the time to goal temperature. Four of the 6 patients were discharged home or to rehabilitation compared with only 1 patient from the historical cases. Implementing this evidence-based protocol for therapeutic hypothermia led to faster cooling.
Pilot Study Evaluates Nutrition for Patients Receiving Mechanical Circulatory Support in the Intensive Care Unit
Authors: Nellett Michelle , Gregory Mary P. , Lefaiver Cheryl A.
Published: November 2019

Establishing a nutrition protocol with an accompanying algorithm allows a multidisciplinary team to make decisions to maintain or improve nutrition-related outcomes during the intensive care unit (ICU) stay. This descriptive pilot study included subjects (N = 11) recruited from a convenient sample of patients admitted for surgical implantation of a mechanical circulatory support device. Nutritional and strength measures were compared across 3 time intervals: preoperatively, postoperative day 3, and within 48 hours of transfer from ICU. The mean age of the sample was 60 ± 8 years. Overall, subjects maintained preoperative nutritional status demonstrated by a nonsignificant change in the nutritional and strength measures from the preoperative period compared to transfer from ICU. The nutrition protocol with algorithm provided a step-by-step approach to ensure a consistent nutritional plan of care. It also standardized nutritional care while ensuring safe practice.
Unresolved Issues in the Management of Aneurysmal Subarachnoid Hemorrhage
Authors: Bautista Cynthia
Published: November 2019

A cerebral aneurysm is an outpouching of a weakened arterial wall, usually at a bifurcation of one of the larger vessels of the Circle of Willis. When the outpouching ruptures, arterial pressure forces blood into the subarachnoid space. The annual incidence of aneurysmal subarachnoid hemorrhage is 8 to 10 per 100 000 in the United States. The outcome varies for this patient population. New management strategies have emerged; some practices are evidence based, whereas others are based on anecdotal experiences. This variation has resulted in a number of unresolved issues in caring for patients with an aneurysmal subarachnoid hemorrhage. This article discusses some of these unresolved issues, including the use of medications such as nimodipine, antifibrinolytics, statins, and magnesium; coiling or clipping for aneurysm securement; and the prevention and treatment of potential complications. Critical care nurses must conduct detailed assessments and provide complex care to optimize patient outcomes.