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Whitman G, George E, Shatzer M, Schmid A. University of Pittsburgh School of Nursing and Medical Center, Pittsburgh, Penn.
Purpose: Describe clinical outcomes and recovery patterns in complex postoperative CS patients. Background/ Significance: Scant literature exists describing current postoperative recovery patterns for complex (ICU length of stay [LOS] > 1 day) CS patients. Methods: Prospective data collection via interviews and medical record review of 102 CS patients from one academic medical center. Results: Thirty-six patients (35.3%) were complex; they had similar characteristics as noncomplex patients except they were older (P=.001), had higher comorbidity scores (P=.001), and had previous valve surgery (P=.005) and interventional procedures (P=.001). Surgeries included CABG (50%), valve (20.6%), and CABG/valve (29.4%). Mean ICU and hospital LOS was 5.2 and 10.4 days, respectively. Discharge outcomes were home (41.7%), other facility (36.1%), and expired (22.2%). Rates of clinical outcomes were atelectasis (80.6%, average duration 2.5 days), atrial fibrillation (58.3%), pleural effusions (55.6%), pulmonary edema (50%), skin breakdown (19.4%), and pneumonia (11.1%). Activity patterns were (mean times): out of bed in chair on postoperative day (POD) 3.5, walking in room on POD 5.2, and hall walking on POD 5.8. Twenty-eight patients (77.7%) performed partial self-care and 4 (11.1%) performed total care before discharge. Mean rates for education documentation of 6 topics (procedure, diet, medications, activity, self care, symptoms) were 4.1 for patients and 2.5 for families. Conclusions: Clear understanding of the recovery trajectory of complex CS patients is essential to plan interventions that can reduce nurse-sensitive adverse clinical outcomes (eg, atelectasis, skin breakdown) and improve activity and educational outcomes. Funding: AACN/ANF Scholar grant.
A Tailored Nursing Intervention Changes the Self-Care Beliefs of Women With Heart Failure
Sethares K. College of Nursing, University of Massachusetts Dartmouth, North Dartmouth, Mass.
Purpose: This study was conducted to evaluate the timing and intensity of the effects of a tailored nursing intervention on the self-care behaviors and health beliefs of women with symptomatic heart failure (HF). Background/Significance: Research suggests that the life-altering symptoms of HF are preventable if self-care measures such as minimizing sodium intake, taking diuretics, and daily weighing are performed. Yet, studies report that less than half of persons with heart failure perform these self-care measures. In earlier studies focused on improving self-care, an evaluation of health beliefs of women with heart failure was absent. Methods: Data on health beliefs including perceived benefits, perceived barriers, and self-efficacy to perform self-care of HF, and the self-care measures of daily sodium intake, daily weighing, and medication behaviors were collected 3 to 5 days/week for 8 weeks, on 7 women according to the multiple baseline single subject research design. The intervention included 4 sessions of education and practice with performing self-care, tailored to the specific health beliefs of women with HF. Data were analyzed graphically and statistically. Results: The intervention had a significant impact on health beliefs, with an increase in perceived benefit and self-efficacy beliefs, and a decrease in perceived barrier beliefs, during the intervention phase, for all but one of the subjects. There were no significant changes in the self-care behaviors of daily sodium intake, medication-taking behaviors, or daily weighing for any of the subjects. Conclusions: The timing of change in the health beliefs varied by participant. Although this study was successful in changing health beliefs, actual self-care behaviors did not change. More research is needed to understand the linkages between health beliefs and self-care behaviors, and the dosing and type of nursing intervention needed to demonstrate a change in these behaviors in women with HF.
Family Experiences Participating in the Process of Withdrawal of Life-Sustaining Therapy
Wiegand D. University of Pennsylvania, Philadelphia, Penn.
Purpose: The purpose of this study was to describe the experience of families participating in the process of withdrawal of life-sustaining therapy (LST) from a family member with an unexpected, life-threatening illness or injury. Background/Significance: There is an increasing incidence of withdrawal of LST in ICUs. Despite this, little is known about withdrawing LST from a family’s perspective. Methods: A phenomenological study was conducted. Multiple family interviews and observations occurred throughout the withdrawal of LST. Data were collected in 3 critical care units. Theoretical purposive sampling was used to obtain families with a variety of experiences. Families were enrolled in the study until data saturation was reached. All interview transcripts and field notes were transcribed with units of meaning, clusters, and then categories inductively determined. Methodological rigor was established. Results: Nineteen families and 56 family members were included in the study. The following categories were identified: personal family issues, family issues related to having an ill/injured family member, family issues with healthcare providers, and family issues related to the hospital system. Families struggled to find meaning in the experience. Families described feeling like they were on a roller coaster. Family readiness to discuss withdrawal of LST as a possible outcome was important. Decisions to withdraw LST often involved a 2-step process with decisions to withhold LST preceding decisions to withdraw LST. Conclusions: Healthcare providers need to strive to assess family readiness and help families through this difficult process. Families found a stepwise decision-making process helpful. Family meetings and consistent health-care providers and healthcare provider messages were important to the withdrawal of LST. Funding: NIH-F31-NR07558, AACN Mentorship Grant, and Southeastern Penn Chapter of AACN.
Clinical Trial Design Considerations: A Comparison of Enteral Feeding Volume Ordered Versus Delivered
Howe K, Clochesy J, Politis J, Goldstein L, Owen H. Case Western Reserve University, Cleveland, Ohio.
Purpose: This study was conducted to compare the difference between the amount of enteral feeding volume ordered with the amount delivered. Background/Significance: While deciding the dosing method (continuous vs intermittent) for administering supplemental antioxidants in a clinical trial designed to decrease the duration of mechanical ventilatory support, data were collected comparing the volume of enteral feeding ordered for a 24-hour period compared with the total volume actually delivered. Methods: During a 9-month period, 47 critically ill medical and surgical patients receiving mechanical ventilation for more than 72 hours were prospectively followed until extubation. The total amount of enteral feeding volume delivered in a 24-hr period was recorded from the intake section of the critical care flow sheet. The 24-hour enteral feeding volume delivered was then compared with the 24-hour volume ordered. Results: Data from 343 patient days were analyzed. The mean volume of enteral feeding delivered was 303 mL less than the volume ordered. The feeding volume delivered ranged from 1840 mL less to 513 mL more than the volume ordered. On 65.3% of the days feeding volume delivered was less than the volume ordered. Of these days, on 23.9% of the days the feeding volume delivered was greater than 500 mL less than the volume ordered and on 10% of the days feeding volume delivered was greater than 960 mL less than the volume ordered. On 23.5% of the days feeding delivered was more than the volume ordered. On 10.8% of the days feeding volume delivered equaled the volume ordered. Conclusions: Every 8-hour intermittent dosing of supplemental antioxidants ensures delivery of the supplements in all subjects where on more than 65% of days subjects would have received "under-doses" of the desired antioxidant supplements. Funding: American Association of Critical-Care Nurses and Sigma Theta Tau.
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