Critical care nurse最新文献

Introduction: Lung transplant is a critical treatment for patients with end-stage lung disease, but recovery is often complicated by physiological and psychological challenges. This case report describes a 61-year-old female bilateral orthotopic lung transplant recipient who experienced significant psychological decline during an extended intensive care unit stay and the use of animal-assisted interventions to address these challenges.

Clinical findings: The patient experienced multiple postoperative complications, including coagulopathy, venovenous extracorporeal membrane oxygenation for hypoxia, delayed chest closure, right ventricular dysfunction, acute kidney injury, adrenal insufficiency, hypogammaglobulinemia, diaphragmatic paralysis, antibody-mediated rejection, bacteremia, and severe deconditioning.

Diagnosis: The patient's psychological decline manifested through increased somnolence, reduced engagement in physical therapy, and minimal interaction with family and health care professionals.

Interventions: Weekly animal-assisted interventions were introduced to improve mood and increase motivation. These sessions involved therapy animals with the goal of enhancing the patient's psychological well-being.

Outcomes: The patient responded positively to animal-assisted interventions, showing improved mood, increased engagement, and participation in rehabilitation. The theoretical framework of acceptability was used to assess the intervention's success, with results indicating high acceptability and effectiveness.

Conclusion: Animal-assisted interventions addressed the patient's psychological challenges during prolonged intensive care unit stays following lung transplant. The intervention improved both psychological well-being and patient engagement. Theoretical framework of acceptability scores supported the acceptability of animal-assisted interventions, suggesting that these should be considered as part of an interprofessional approach to managing prolonged hospitalizations in transplant recipients.

Background: Catheter-associated urinary tract infections are a leading hospital-acquired infection and are a major cause of increased morbidity, mortality, and health care costs, with 83% of pediatric cases occurring in pediatric intensive care units. Indwelling urinary catheters are widely used in adult and pediatric patients to accurately monitor urine output and manage fluid balance.

Local problem: Staffing challenges and high nurse turnover in a 56-bed pediatric intensive care unit led to inconsistencies in practices to prevent catheter-associated urinary tract infection. Stool contamination from diapers used alongside indwelling urinary catheters increased the risk of infection.

Methods: An interprofessional team designed a comprehensive catheter-associated urinary tract infection prevention strategy through plan-do-study-act cycles. Compliance was tracked through electronic surveys during catheter-associated urinary tract infection huddles, bedside infection prevention rounds, and bundle audits, with statistical process control charts used to measure infection rates before and after implementation of interventions. Interventions consisted of introduction of an exploratory no-diapering protocol, use of an advanced indwelling urinary catheter drainage system, and consistent staff reeducation.

Results: The rate of catheter-associated urinary tract infection decreased from 3.13 to 0 per 1000 catheter days, with 527 event-free days (about 1.5 years).

Conclusion: The combination of an advanced indwelling urinary catheter drainage system, elimination of diapers, and structured staff reeducation reduced the rate of catheter-associated urinary tract infection in the pediatric intensive care unit. This approach has potential for application in both pediatric and adult critical care settings to reduce infection rates and improve patient outcomes.

Background: Early identification and treatment of clinical deterioration is crucial for improving outcomes among hospital patients. A high-acuity response team (HART) program can integrate early warning systems and proactive rounding by critical care nurses to prevent unplanned escalations in care.

Local problem: During the COVID-19 pandemic, a HART program was inconsistently implemented because of intensive care unit staffing shortages. Barriers to optimizing the HART nurse role included inconsistent practices, lack of clear role expectations, and frequent reassignment of HART nurses to compensate for staffing shortages.

Methods: Postpilot implementation of the HART program began in October 2019. Critical care nurses were designated as HART nurses, responsible for monitoring the Rothman Index, and assisted bedside nurses with high-acuity patients. Data were collected from 2019 to 2023 and were analyzed using IBM SPSS Statistics, version 29, with statistical significance defined as P ≤ .05.

Results: The HART program significantly reduced 24-hour intensive care unit readmissions by 33.9% and 72-hour readmissions by 32.7%. HART nurse consultations increased by 35.7%. There were clinically significant decreases in code blue emergencies outside the intensive care unit (22.2%) and overall (16.7%), although no statistically significant differences were found for rapid response team activations or unplanned intensive care unit transfers.

Conclusion: The HART nurse program effectively integrates early warning systems and rapid response teams, significantly reducing intensive care unit readmissions and improving patient care. Clear role expectations and dedicated staffing are needed, and continuous stakeholder engagement and resource allocation are essential for sustaining the program's success.

Background: Bronchiolitis obliterans/bronchiolitis obliterans syndrome is an irreversible, obstructive lung disease characterized by the narrowing of bronchioles by lung fibrosis, inflammation, and scarring.

Objective: To provide acute care, transplant, and critical care nurses a summary of the disease process, causes, and treatment options for bronchiolitis obliterans in pediatric patients to promote early recognition of signs in at-risk patients.

Methods: This descriptive literature review was limited to articles published in 2013 or later. Searches of the PubMed and CINAHL databases using the terms bronchiolitis obliterans and pediatric yielded 432 articles. Of these articles, 22 were used for this review. The Johns Hopkins Nursing Evidence-Based Practice appraisal tool was used to assess levels of evidence and methodologic quality of the articles.

Results: Patients in 3 main groups are at risk for bronchiolitis obliterans: those who have had respiratory infection, those who have received lung transplant, and those who have received stem cell transplant.

Discussion: A diagnosis of bronchiolitis obliterans requires lung biopsy and histopathology. For patients who are unable to undergo biopsy or whose biopsy results are inconclusive, bronchiolitis obliterans syndrome can be clinically identified with spirometry (forced expiratory volume in first second of expiration and forced expiratory flow at 25% to 75% of forced vital capacity) and high-resolution computed tomography. Systemic corticosteroids are often the first-line treatment; second-line strategies are under investigation.

Conclusion: Knowledge of risk factors, signs, and current treatments for bronchiolitis obliterans/bronchiolitis obliterans syndrome can help acute care and critical care nurses decelerate progression of the disease.

Introduction: Given the serious illness burden of patients in medical intensive care units, palliative care is a key element of their care. This case discussion highlights the role of the palliative care specialty registered nurse in an embedded palliative care model in medical intensive care units.

Clinical findings: A 44-year-old female patient with decompensated cirrhosis was transferred to the study hospital for liver transplant evaluation. Her hospital stay involved multiple complications.

Diagnosis: The patient was determined to have palliative care needs. Multiple areas of intervention were identified.

Interventions: A model including a palliative care specialty registered nurse was initiated in the medical intensive care unit.

Outcomes: The palliative care specialty registered nurse had 2 roles: (1) optimizing patient care by partnering with medical intensive care unit colleagues to develop a plan of care aligned with patient and family values and preferences and (2) supporting and enhancing critical care nursing excellence by helping bedside nurses advocate for the patient's palliative care needs. Nurses were also empowered with communication skills to engage with patients, family members, and primary team colleagues.

Conclusion: The palliative care specialty registered nurse model can be used in various intensive care unit settings. However, the complex care needs of critically ill patients, the unique nature and structural variations across critical care settings, and the resources required to implement this model are potential challenges.

Introduction: Limited research on preventing and managing skin failure events such as deep tissue injuries and Kennedy terminal ulcers is available. These skin failure events often appear among patients experiencing multiple organ failure with hypoperfusion to the skin despite evidence-based nursing interventions to enhance skin integrity.

Clinical findings: A 68-year-old White man presented at a trauma hospital after several recent falls at home. He immediately required hospitalization. Several medical complications, including a deep tissue pressure injury, evolved. The pressure injury remained clinically stable throughout his hospitalization.

Diagnosis: The patient received a diagnosis of deep tissue pressure injury.

Interventions: Aggressive medical management, implementation of a turning schedule on a low-air-loss surface, foam dressings, and offloading boots were used to prevent skin damage and preserve skin integrity.

Outcomes: The patient's condition declined and he developed a deep tissue pressure injury on the sacrum that did not advance or become infected. The family agreed to comfort measures and he soon died.

Conclusion: Skin failure events such as deep tissue pressure injuries and Kennedy terminal ulcers often occur among critically ill patients, older patients, those approaching end of life, and other patients with prolonged pressure upon body surfaces. The Centers for Medicare & Medicaid Services holds hospitals financially accountable for sequelae of events associated with hospital-acquired full-thickness pressure injuries. Additional research to categorize skin failure events as secondary to hypoperfusion and not medical mismanagement can optimize patient safety and positively impact the finances and credibility of medical organizations.