AACN clinical issues最新文献

The use of dopamine for the treatment of renal insufficiency has become a controversial issue. Dopamine exerts its effects on the kidneys through activity on the catecholamine receptors and by its diuretic and natriuretic properties. Utilization of renal dose dopamine to increase renal blood flow has been considered beneficial for preservation of renal function for over 30 years. The hypothesis proposed was that increasing urine volume must indicate improving renal function, particularly in oliguric patients. However, recent clinical trials in adult and pediatric patients have not only failed to demonstrate any benefit, but have also suggested that this therapy may actually have detrimental effects. This article reviews basic pharmacology and physiologic effects and the potential adverse effects of "renal dose dopamine." It also examines the results of clinical trials, in both pediatric and adult patients, that evaluated its usefulness for the treatment of renal insufficiency.

Changes occurring in the healthcare environment require healthcare delivery systems to provide high quality care services with increased efficiency and cost-effectiveness. Healthcare systems are encouraged to use less expensive care providers for medical management responsibilities while maintaining or increasing quality of patient care. Accompanying the changes in healthcare delivery modes is the parallel rise in patient acuity levels related to chronic illnesses of patients admitted for cardiac services such as cardiovascular surgeries. This retrospective, 2-group comparison study examined patient and economic outcomes between 2 groups of adult patients for whom postoperative cardiovascular care was directed by either cardiovascular surgeons alone or cardiovascular surgeons in collaboration with acute care nurse practitioners. Outcome measures included length of stay and cost for an episode of care. Findings revealed that when cardiovascular surgeons, in collaboration with acute care nurse practitioners, directed postoperative care, the length of stay decreased 1. 91 days and total cost decreased 5,038.91 dollars per patient.

Nosocomial infections are a major health problem for hospitalized patients and their families. Since the 1800s, hand hygiene has been recognized as the single best method to prevent the spread of pathogens and nosocomial infections. Despite this fact, many healthcare workers do not adhere to hand hygiene policies. The Centers for Disease Control and Prevention issued a guideline for hand hygiene practices in 2002. Multifaceted approaches to improve hand hygiene have been shown to increase compliance among healthcare workers and subsequently reduce infections. A performance improvement project was initiated to implement this guideline and other strategies to prevent nosocomial infection. This article summarizes the performance improvement processes and the preliminary outcomes on adherence to infection prevention policies related to hand hygiene and isolation practices. Clinically and statistically significant increases were noted for hand hygiene prior to patient care and in wearing masks when indicated. Nurses and patient care technicians had the greatest increases in compliance. Increases in hand hygiene after patient contact and wearing of gown and gloves were also noted, but results were not statistically significant. Nosocomial infection rates from antibiotic-resistant organisms decreased in the first surveillance, but rates increased during the 1-year surveillance. Consumption of alcohol-based foam disinfectant doubled from baseline. Findings are consistent with other published studies. The project will continue with further reinforcement and education over the second year.

The overall 5-year survival rate of children with cancer has now reached 77%, an increase of about 45% in the past 25 years. Newer therapies, including hematopoietic cell transplantation and cutting edge chemotherapeutics evolving in the form of molecular and biological cell targeted agents, are being researched and developed and are responsible for the change in survival rates over time. Also, despite the national trend toward hospice and palliative care, children with chronic and life threatening illnesses, continue to die in the hospital setting, often in the intensive care unit. Previous studies of children with complications of cancer and its therapy document poor outcomes among those who do require intensive care. These trends are changing, however, currently leaving a hopeful, optimistic view of the outcome in children with cancer complications admitted to the pediatric intensive care unit. It is imperative that nurses and intensive care staff understand pediatric cancer and its potential emergent consequences in order to respond to the symptoms of life threatening events.

A review of contemporary nursing research reveals a tendency to focus on select aspects of the hospital environment such as noise, light, and music. Although studies such as these shed light on discrete aspects of the hospital environment, this body of literature contributes little to an understanding of the entirety of that world as the patient in the sickbed experiences it. The purpose of the study detailed in this article was to describe the patient's experience of the acute care hospital environment. Nondirective, in-depth phenomenological interviews were conducted, then transcribed verbatim, and analyzed for themes. Against the backdrop of "I lived and that's all that matters," there were 3 predominant themes in patients' experience of the acute care environment: (1) disconnection/connection, (2) fear/less fear, and (3) confinement/freedom. In this environment, human-to-human contact increased security and power in an environment that was described as sterile, disorienting, and untrustworthy. Acute and critical care nurses and other caregivers can use the findings to create less noxious hospital environments.

Sepsis is a common source of morbidity and mortality among critically ill patients, and targeting measures to promote early recognition and treatment of sepsis is at the forefront of many critical care initiatives. Starting formally in 1992, with the publication of the definitions of sepsis, continuous monitoring of several common physiologic parameters, including electrocardiogram, blood pressure, and oxygen saturation, have been advocated as important in the early identification and treatment of patients with sepsis. The descriptive study detailed in this article was conducted to assess the perceptions and clinical continuous physiologic monitoring practices of experienced critical care clinicians with regard to their use of common physiologic monitoring parameters in the care of patients with sepsis. A convenience sample of 100 physicians and 517 nurses completed a 20-item survey assessing perceptions and clinical monitoring practices related to the care of patients with sepsis. Results indicated that the basic parameters of electrocardiogram, invasive blood pressure, pulmonary arterial catheter monitoring, and oxygen saturation all have value in the recognition and treatment of patients with sepsis. The majority of clinicians used these parameters routinely and felt they were necessary for patient care. These results indicate that clinical practice is in concordance with current practice recommendations.

The positioning of critically ill patients is an independent nursing decision, often has multiple rationales, and may significantly affect morbidity and mortality. Recent evidence suggests that backrest elevation in critically ill patients may reduce ventilator-associated pneumonia. However, use of recommended levels of backrest elevation is infrequent in the critical care environment. In addition, published guidelines for backrest elevation to reduce pneumonia conflict with those for protecting skin integrity. This article reviews the benefits and complications of backrest elevation, data related to current positioning practices, and recommendations for backrest elevation. A quality improvement process to guide evidence-based care related to backrest positioning is also described.

Over the last 50 years, healthcare has undergone countless changes. Some of the important changes in recent years have been budget cuts, decreased resident work hours, and increased patient acuity. The need for additional clinical expertise at the bedside has resulted in nurse practitioners becoming an integral part of the healthcare delivery team. To date, little has been published regarding the role of the nurse practitioners in intensive care units. This article outlines how one pediatric hospital has successfully utilized nurse practitioners in the intensive care unit.

Munchausen syndrome by proxy is difficult to diagnose unless healthcare providers are astute to its clinical features and management. A case is presented to educate nurses and advanced practice nurses, of the nursing, medical, legal, and social complexities associated with Munchausen syndrome by proxy. This article also provides a brief review of the definition of Munchausen syndrome by proxy, its epidemiology, common features of the perpetrator, implications for healthcare personnel, and the legal and international ramifications of Munchausen syndrome by proxy.

Traumatic brain injury is the result of a primary, acute injury and is complicated by the development of secondary injury due to hypotension and hypoxia. Cerebral edema due to brain injury compromises the delivery of essential nutrients and alters normal intracranial pressure. The Monroe-Kellie Doctrine defines the principles of intracranial pressure homeostasis. Treatment for intracranial hypertension is aimed at reducing the volume of 1 of the 3 intracranial compartments, brain tissue, blood, and cerebrospinal fluid. Hyperosmolar therapy is one treatment intervention in the care of patients with severe head injury resulting in cerebral edema and intracranial hypertension. The effect of hyperosmolar solutions on brain tissue was first studied nearly 90 years ago. Since that time, mannitol has become the most widely used hyperosmolar solution to treat elevated intracranial pressure. Increasingly, hypertonic saline solutions are being used as an adjunct to mannitol in basic science research and clinical studies. Hyperosmolar solutions are effective in reducing elevated intracranial pressure through 2 distinct mechanisms: plasma expansion with a resultant decrease in blood hematocrit, reduced blood viscosity, and decreased cerebral blood volume; and the creation of an osmotic gradient that draws cerebral edema fluid from brain tissue into the circulation. The pediatric section of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies adapted previously published guidelines for the treatment of adult brain injury into guidelines for the treatment of children with traumatic brain injury. These guidelines offer recommendations for the management of children with severe head injury, including the use of mannitol and hypertonic saline to treat intracranial hypertension. Acute and critical care pediatric advanced practice nurses caring for children with severe head injury should be familiar with management guidelines and the use of hyperosmolar solutions. The purpose of this article is to assist the advanced practice nurse in understanding the role of hyperosmolar therapy in the treatment of pediatric traumatic brain injury and review current guidelines for the use of mannitol and hypertonic saline.