AACN clinical issues

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.

Susan C Meyer

Linda J Miers

AACN Clinical Issues Advanced Practice in Acute & Critical Care

Cardiovascular Surgeon and Acute Care Nurse Practitioner

心血管外科医生和急性护理执业护士

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.

Mary Jo Grap

Cindy L. Munro

Quality Improvement in Backrest Elevation

背部抬高中的质量改进

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.

James M Knapp

Hyperosmolar Therapy in the Treatment of Severe Head Injury in Children

儿童重度颅脑损伤治疗中的高渗疗法

Despite the seemingly daily advances in the primary, secondary, and tertiary prevention for coronary artery disease, many patients will ultimately experience progression of their disease and experience angina refractory to further active treatment. In these patients, disabling angina occurs at rest or during simple activities of daily living. When this occurs, symptom management, a predominant focus of nursing, becomes the goal of care. Several medical and surgical alternatives are available to patients with refractory angina. Enhanced external counterpulsation and transmyocardial laser revascularization are Food and Drug Administration approved therapies that can be used to attempt to restore the balance of supply and demand. Modulation of sympathetic tone via procedures such as stellate ganglion blocks has also been employed. Other methods to control the pain are techniques that alter pain perception such as spinal opioids, transcutaneous electrical nerve stimulation, and spinal cord stimulation. Too few patients with refractory angina are referred for any of these palliative therapies. Armed with knowledge regarding these therapies, nurses will be better prepared to provide anticipatory guidance to patients and their families and to support the patient's hope for relief as they cope with this devastating condition.

Julie A. Stanik-Hutt

Management Options for Angina Refractory to Maximal Medical and Surgical Interventions

难治性心绞痛的最大药物和手术干预管理方案

The nurse practitioner in pediatric critical care is a distinct advanced practice nursing role that has seen a tremendous increase in development and implementation over the past 10 years. There is a paucity of literature on this unique and valuable role. A total of 74 nurse practitioners practicing in pediatric critical care were surveyed. Part I of the survey solicited descriptive information of the nurse practitioner including background, work environment, reporting structure, and salary. The respondents also identified their role responsibilities that included direct patient management, nursing and medical education, coordination of care, research, and consultation. Part II of the questionnaire addressed skill level and need for supervision for technical procedures and leadership activities. These respondents described expert or proficient skill levels for the majority of technical procedures (ie, lumbar puncture, central line placement) and leadership activities (ie, discharge planning, participation in medical rounds). This is the first published report to delineate the role of the nurse practitioner in pediatric critical care based on responses from a national survey.

Judy T Verger

Kelly Keefe Marcoux

Maureen A Madden

Tom Bojko

Jane H Barnsteiner

Nurse Practitioners in Pediatric Critical Care

儿科重症监护中的执业护士

Journal of Nursing Care Quality (JNCQ) is a peer-reviewed journal that provides practicing nurses as well as nurses who have leadership roles in nursing care quality programs with useful information regarding the application of quality principles and concepts in the practice setting. The journal offers a forum for the scholarly discussion of “real world” implementation of quality activities.

Luann J. Capone

Nancy M. Albert

James F. Bena

Shannon M. Morrison

Characteristics of Hospitalized Cancer Patients Who Fall

住院癌症患者跌倒的特征

Christine L. Covell

Judith A. Ritchie

Nursesʼ Responses to Medication Errors

护士对药物错误的反应

Chronic venous leg ulcers account for the majority of lower extremity ulcers and represent a serious health and financial burden. Although several clinical practice guidelines and systematic reviews are available to guide treatment decisions, healing rates have not improved over the last decade. This research study illustrates some of the limitations of relying on existing databases to guide wound management as well as the importance of considering patient preferences, staff knowledge and skill, and available resources.

出版信息	出版商: Lippincott Williams and Wilkins Ltd.，出版周期: ，期刊类型: journal，开源期刊: 否
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