AACN clinical issues最新文献

The Institute of Medicine report published in 1999 described a healthcare system in which 44,000 to 98,000 patients die each year from preventable medical errors. The healthcare industry has been charged with identifying and ameliorating risks to patients. The advanced practice nurse is in the optimal position to influence the patient care environment and contribute to a culture of patient safety. This article will review the role of the advanced practice nurse in the care of the neuroscience patient in identifying risks unique to this at-risk population. There will be a discussion of risk factors that contribute to errors, with advanced practice nurse-driven, evidence-based solutions. A case presentation of the role of the advanced practice nurse in reducing the incidence of deep vein thrombosis in the craniotomy patients with malignant tumors will be discussed.

The brain is extraordinarily susceptible to changes in temperature. Hyperthermia has been shown to exacerbate the biochemical cascade of secondary brain injury. Inversely, hypothermia limits the damaging effects of secondary brain injury. There has been a great deal of investigation regarding the detrimental effects of hyperthermia and the neuroprotection of hypothermia in animal studies. Within the last decade, clinical trials have begun to establish how the brain reacts to both temperature extremes. In the future, studies of hypothermia will continue in the quest of the optimal timing and degree of hypothermia. Hyperthermia will be examined in depth for its detrimental effects on an injured brain. Interventions for the prevention and treatment of hyperthermia will be explored. Nurses will implement cooling strategies to induce hypothermia, applying interventions to prevent complications, and they will also diagnose hyperthermia, deciding when and if to intervene pharmacologically and therapeutically. These advanced nursing actions will be guided by knowledge and understanding of available evidence. This article presents the pathophysiology of secondary brain injury and how it is affected by both hypothermia and hyperthermia. A review of the research leading up to clinical trials is explored, as well as a discussion of the future of temperature modulation for the brain injury patient. This information will help healthcare providers understand the effect that both hypothermia and hyperthermia have on the acutely injured brain.

Patients with severe traumatic brain injury resulting in increased intracranial pressure refractory to first-tier interventions challenge the critical care team. After exhausting these initial interventions, critical care practitioners may utilize barbiturate-induced coma in an attempt to reduce the intracranial pressure. Titrating appropriate levels of barbiturate is imperative. Underdosing the drug may fail to control the intracranial pressure, whereas overdosing may lead to untoward effects such as hypotension and cardiac compromise. Monitoring for a therapeutic level of barbiturate coma includes targeting drug levels and using continuous electroencephalogram monitoring, considered the gold standard. New technology, the Bispectral Index monitor, utilizes electroencephalogram principles to monitor the level of sedation and hypnosis in the critical care environment. This technology is now being considered for targeting appropriate levels of barbiturate coma.

Evidence suggests that the mortality and morbidity of acquired brain injury could be reduced if clinicians used an aggressive intracranial pressure guided approach to care. Despite nearly 50 years of evidence that intracranial pressure monitoring benefits patient care, only about half of the patients who could benefit are monitored. Some clinicians express concerns regarding risks such as bleeding, infections, and inaccuracy of the technology. Others cite cost as the reason. This article discusses the risks and benefits of intracranial pressure monitoring and the current state of evidence of why patients should be monitored.

The goal of palliative care is to provide the alleviation or reduction of suffering and the support for the best possible quality of life for patients regardless of the stage of the disease. Palliative care can be provided in any patient care setting, including intensive care units. Death in intensive care units is a common occurrence, with literature suggesting that approximately 20% of deaths in the United States occur after a stay in the intensive care unit. Other studies suggest that approximately half of all chronically ill patients who die in a hospital receive care in the intensive care unit within 3 days of their deaths. Critical care nurses who work in neurological intensive care units are at the forefront of integrating palliative and critical care.

The brain depends on a continuous flow of blood to provide it with oxygen and glucose needed to maintain normal function and structural integrity, thus cerebral blood flow is normally tightly regulated. A decrease in cerebral blood flow to ischemic levels may be tolerated for only minutes to hours, depending on the severity of the ischemia. If cerebral blood flow ceases completely, brain cell death occurs within minutes. A variety of conditions are encountered clinically, such as stroke or traumatic brain injury, where an actual or potential alteration in cerebral blood flow puts the brain at risk for ischemia and infarction. In this article, the physiology of cerebral blood flow will be presented as a basis for understanding cerebral blood flow regulation and the rationale for clinical interventions to optimize cerebral blood flow. Techniques currently available to assess cerebral blood flow and clinical situations in which cerebral blood flow is measured will be discussed. Clinical interventions will be presented briefly.

There is a critical mismatch between available organs for transplant and acutely or critically ill patients with end-stage organ disease. Patients who may benefit from organ transplantation far outnumber available organs. The causes for this imbalance are multiple. One cause is family refusal to donate. A second cause is nonrecognition or delay in determination of brain death. A third cause is donor loss due to profound cardiopulmonary and metabolic instability consequent to brain-stem herniation and brain death. Family refusal may be addressed by education, public awareness, as well as close attention to social, cultural and ethical issues, and optimal communication with donor families. Brain death may be consequent to traumatic brain injury, ischemic versus hemorrhagic stroke, as well as massive cerebral anoxia/ischemic following cardiac arrest. Nonrecognition or delay in brain death determination may be addressed by clinician education and frequent clinical assessment to detect early stages of brain-stem herniation refractory to aggressive measures for control of intracranial pressure. Donor loss due to profound cardiopulmonary and metabolic instability may be addressed by aggressive, mechanism-based treatment for clinical instability based on affected body system, as well as measures to support metabolic activity at the cellular and tissue level in the brain-dead organ donor. This article explores cerebral physiology related to impending brain death and catastrophic intracranial pressure elevations. In addition, physiologic consequences of brain death are correlated with affected body systems and mechanism-based therapies to support organ function pending transplantation. Ethical/legal issues are explored as related to patient autonomy and optimal family outcomes. Effective family communication, astute clinical assessment, and optimal clinical management of the organ donor are illustrated using a case study approach, highlighting the role of the advanced practice nurse in donor management.

Stroke, a neurologic event due to altered cerebral circulation, is the third leading cause of death in the United States. Risk factors for stroke include hypertension, family history, and diabetes mellitus. The subtypes of stroke are ischemia, infarction, and hemorrhage. Ischemia and infarction are the result of atherosclerotic development of thrombi and emboli. Decreased and/or absent cerebral circulation causes neuronal cellular injury and death. Intracerebral hemorrhage occurs from rupture of cerebral vessels often as the result of hypertension. Patient assessment and diagnosis include the use of computed tomography scans, magnetic resonance imaging, and the National Institute of Health Stroke Scale, and treatment depends on the etiology of the stroke. Thrombolytic therapy is the mainstay of treatment for thrombotic and embolic events. Current recommendations for future stroke care include the development of designated stroke centers. Directions for research in stroke treatment includes examining neuroprotective therapies.

Use of technology in the management of the severely brain-injured patient has increased over the past decade and can be confusing and overwhelming to the critical care nurse clinicians who are new to the field of neurology. This article will describe normal physiology and cerebral dynamics and potential abnormal physiology encountered after brain injury. The technology reviewed will include intracranial pressure monitoring, cerebral blood flow monitoring and autoregulation, cerebral oxygen consumption and tissue oxygen monitoring, metabolism, sedation, and temperature monitoring. Integration of appropriate technology into patient management will be discussed using a case study to explore the utility of information at the bedside. Recognizing the difficult task of trying to control secondary injury in our patients is the first step to better outcomes. Implementing the use of technology to mitigate the situation must be done with careful consideration and a team approach to achieve the greatest benefit for the patient.

Aneurysmal subarachnoid hemorrhage is an increasing problem in the United States, affecting approximately 30,000 people every year. Despite advances in the neurosurgical field, approximately 50% of patients die within the first month after hemorrhage. Traditionally, craniotomy with aneurysmal clipping has been employed to manage these patients, but endovascular embolization is moving to the forefront of treatment, particularly for high grade (IV to V) aneurysms. Patient selection is often based on age, aneurysm size, location, characteristics and presentation, and patient hemodynamics. Postprocedure management relies on skilled observers to determine those potential complications that may occur, including vasospasm, rupture, bleeding, or vessel occlusion. Advanced practice nurses have an obligation to be aware not only of the procedure and its management, but also of the potential complications and ongoing care of the patients and families as well.