AACN News—December 1998—Practice

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Vol. 15, No. 12, DECEMBER 1998

Neuroscience Nurses Share Their Perspectives

In September, AACN News asked our neuroscience nurse members to share their perspective on their critical care specialty. Following are some of their responses:

A Unique Position
Nurses in the neurological unit at St. David’s Medical Center are in a unique position because they provide a continuum of care for neurological patients not only on a 25-bed neuro floor but also in a 6-bed ICU, both located on the same floor.

Following are our answers to the questions posed by AACN News:

What are the most challenging aspects of the job?
• Transitioning from the organization and mind-set of an ICU setting to a floor setting every week or 2
• Developing various communication strategies with the neurological patient who is unable to speak or understand when spoken to
• Meeting the intense needs of the neuroscience patients’ family members, who are devastated by the report of an unfortunate prognostic picture or whose loved one can no longer speak, feed themselves, or move one side of their body
• Coordinating the various physical, psychosocial, and spiritual needs of neuroscience patients with the various disciplines involved in their care .

• Supporting a young wife after she has decided to discontinue life support for her 45-year-old husband who suffered a cerebral aneurysm and is now brain dead, or supporting a 76-year-old husband who has just been told that his wife of 55 years has suffered a massive stroke
• Keeping updated on hemodynamics and pulmonary artery catheters, which are used infrequently in our hospital’s neuroscience ICU

• Changing gears, feelings, and mind-set toward the patient with intracerebral bleeding, whom you have been trying to save, as you step into the role of donor management

What are the most rewarding aspects of your job?
• Being the first at the bedside to see a patient slowly improve in his or her ability to speak, move, or think, and reporting these changes to both the happy family and the medical team
• Seeing the continuity of care as a patient moves from the neuroscience ICU to the neuroscience floor
• Experiencing the pleasure of knowing that there is life after the ICU stay and knowing that what began or was done in the ICU makes a difference when a patient is transferred to the floor
• Watching and facilitating a patient who is postcraniotomy for brain tumor resection work toward achieving functional independence
• Being visited by a former neuroscience patient who remembers something simple you did for him or her that made a difference

What makes neuroscience critical care nursing different from other types of critical care nursing?
• Nursing of a patient’s mind and body, not just monitoring cardiac output or wedge pressure
• Knowing that intracranial hemodynamics make systemic hemodynamics look like a piece of cake
• Mastering assessment of the most complex organ system in the body.
• Nursing a patient who has experienced significant, complex physiological and psychological devastation
• Learning to identify subtle changes in neuroscience status, which in the end saves patients’ lives.
• Dealing with 4 ventricles instead of 2
• Having a complex discharge plan
• Continually collaborating constantly with physical, occupational, speech, and cognitive therapy—even in the ICU

• Knowing that there is life after neurological injury and neuroscience intensive care
The Nursing Staff
Intensive Neuroscience Care Area (INCA)
St. David’s Medical Center
Austin, Tex.


Diversity, Delegation Part of Role
I am a clinical manager at the Chicago Institute of Neurosurgery and Neuroscience. My job is wonderful for many reasons including the team with whom I work. Their commitment to giving our patients the best possible care is energizing.

Because we are at a satellite, which is connected to Riverside Hospital in Kankakee, Ill., I not only manage the clinical staff and activities but also assist with administrative tasks, nursing education, and patient care systems within the hospital. The ICU is only a flight of stairs away, enabling me to easily educat patients and staff, assist with patient care, or assist with problem solving.

The diversity is the best thing about this specialty practice. I am challenged to move into many different roles to ensure that quality care is delivered to a population with many intense needs. Getting it all done requires excellence prioritization and organization skills.

Shawnna Cunning, RN, MS, CCRN
Joliet, Ill.

Pushing the Limits
“But I’m not a neuroscience nurse,” was my emphatic response after being asked to teach and work in the neuroscience unit while my unit underwent construction. My response came not only from fear of change, but fear of the unknown. Neuroscience seemed too abstract, too complex, and too depressing.

Although ICUs are complex, the pathophysiology, treatment and ability to “put it all together” always came fairly easy for me. Now I was going to have to remember what functions each side of the brain is responsible for, the organization of complex tracts, and, of course, the cranial nerves. I wasn’t even sure if I had a penlight any more.

More than 6 years later, I am still working in the neurosciences, and I can’t imagine doing anything else. Every shift, I learn something new about this complex specialty practice. I have seen people who are near death “come back” to their families. I have seen people awaken from comas who were never expected to.

This field not only pushes my limits of learning and my emotions, it truly humbles me. I feel alive and grounded while at work, and I know that I am making a difference in the lives of others.

Do I still have a fear of the unknown when it comes to neuroscience? Sure, but these days there is a penlight shining on the unknown, and the nurse behind it is confident in her abilities and meets her challenges head on.

Allison Misti Tuppeny, RN, BSN, CCRN
Florida Hospital
Orlando, Fla.

Assessment Skills the Best Tools
When I relocated to Greenville, S.C., 7 years ago, I never imagined becoming a “neuroscience nurse.” However, the only position open at the time was in the neuroscience ICU. Although I was a CCRN� with 12 years of critical care nursing experience, the thought of caring for neuroscience patients petrified me. I knew my first day that I was in for a challenge.

Most people are intimidated by how aware neuroscience nurses must be of the most subtle changes and how devastating a clue like an unequal pupil can be. After working in the emergency room, medical-surgical area, and critical care units, I thought I was prepared for most situations. However, what I learned is that, no matter how far modern medicine has progressed, there is still much we don’t know about the brain.

As critical care nurses, we often have to put up a protective wall so that we can cope with unfortunate patient outcomes. However, it’s hard to maintain this wall when so often the outcome will significantly challenge both quality and quantity of life, simply because of the nature of a patient’s neurological disease process,.

In my 7 years as a neuroscience nurse, I have learned life’s joy and despair—the slight squeeze of a hand; the holding up of 1 finger that says, “Yes, I’m in here; please help me find my way back”; holding a mother after giving her the new that her 22-year-old Oxford-bound, law-student son is brain dead; or helping a 5-year-old boy cope with his mommy’s slow death from a glioma. These are the patients we carry with us every day. We usually keep their memory hidden deep in our hearts, but thoughts of them often emerge when you hold another family close.

There is also the joy you experience when patients return to visit and you know that, in some small way, they are here to welcome another day because of you. You realize just how much you take for granted in routine day-to-day activities when you watch your patients work so hard to regain their independence; you cherish every accomplishment, no matter how small.

The more I learn, the more I realize how much I don’t know about the brain and spinal cord. But I am convinced that, despite emerging technology, it is our brain and our assessment skills that allow us to contribute our best.

Gerri Ann Jones, RN, CCRN
Neuroscience Trauma ICU
Greenville Memorial Hospital
Greenville, S.C.

Neuroscience Nurses Ask ‘Why Not?’
Often, our fellow critical care nurses say, “I hate neuro!” We have met caregivers who were afraid of the complexities of the neurologically challenged patient. They may not recognize the potential for restoring quality of life following brain or spinal cord injury. To paraphrase and adapt a quote by the late Robert Kennedy, “Some look at the situation and ask, ‘Why?’ ” “Neuroscience ICU nurses look at their patients and ask: Why not?’”

One of the most important roles of neuroscience nursing is being an advocate for a patient who may no longer be able to communicate, or communicate only by the blink of an eye. We frequently are called upon to act as patient advocates, whether in defending the right to a dignified death or fighting the odds to pursue recovery when others have given up hope. Although we work daily to improve the outcome of our population, we are constantly reminded that the result may not be in accordance with the wishes of the individual. It is our duty to ensure that our patients’ wishes are the highest priority.

Education is key to assisting families and patients who suffer devastating brain injuries. The choice to pursue long-term supportive care often forces families to decide whether a loved one lives in a vegetative state or dies. Without the appropriate counseling and support, those involved can feel responsible for the ultimate outcome, whether positive or negative.

Minute accomplishments become major goals in an ICU, where a wedge pressure of 17mm Hg may call for infusing plasma protein fraction and starting xylometazoline hydrochloride.

A young patient for whom we cared, attempting every possible therapy to save him from a traumatic brain injury, walked onto our unit this week to thank us for our help. He doesn’t remember the hypothermia, the ventriculostomy at continuous drain, or the rush to the operating room when he developed signs of impending herniation. He is now a first-year medical student, who wants to help others in the way that we helped him. It doesn’t get any better than that.

4200 Neuroscience ICU Staff

Duke University Medical Center
Durham, N.C.

We thank these colleagues for their outstanding contributions to this challenging field.
Anne W. Wojner, RN, MSN, CCRN
Neuroscience Critical Care Clinical Nurse Specialist & AACN President-Elect

Practice Resource Network: Frequently Asked Questions

Q We are revising our hospital visitation policy. What is the latest recommendation regarding family visitation in the ICU?

A Visitation policies for critical care continue to vary greatly from unit to unit. Historically, family visitation in critical care was limited to immediate family for short periods of time. Children were not allowed to visit because it was believed that the experience would be psychologically stressful or that they would bring infections into the units.

Many recent nursing research studies have examined visitation and family partnership in critical care, and there is now substantial evidence supporting the need to provide personal contact and close proximity between patients and their families.

Although some nurses believe that restrictive visitation helps to protect the patient from physiological harm, the evidence does not support this assumption. Research clearly supports the elimination of strict, inflexible visitation policies (highest level of recommendation, level IV).

Creating hospital policies that offer a flexible, individualized approach to visitation is strongly recommended. In addition to changing policies, helping nurses and other members of the healthcare team to understand the benefits of flexible visitation is key to the success of the transition from more restrictive practices.

AACN offers an excellent tool that hospitals can use as a resource for revising hospital policies and educating members of the healthcare team. This research-based resource, titled Family Visitation and Partnership in the Critical Care Unit, is one of 5 protocols for practice in the Creating a Healing Environment series. Provided is information regarding who should visit, how to establish policies, visitation options, preparing families for visitation, facilitating family partnership, and promoting family-centered care. The protocol also provides detailed information regarding children and animal visitation in critical care. A test at the back of each protocol can be used for continuing education credit and staff competency validation. AACN members can order this protocol (Product #170711) for $11 ($14.00 for nonmembers). The entire set of 5 protocols in this series (Product #170710) is available for $52 ($64 nonmembers).

For more information or to order Family Visitation and Partnership in the Critical Care Unit, call (800) 899-AACN (2226).

Nursing Research Grants Offered

Several nursing research grants are available through AACN. Application materials may be obtained by calling (800) 899-AACN (2226).

Following are grants for which application deadlines are approaching:

Mallinckrodt Inc.-AACN Mentorship Grant
Cosponsored by Mallinckrodt Inc., this grant is designed to facilitate research mentoring between a novice and an experienced researcher.

Up to $10,000 is awarded to the novice researcher, who may apply the funds toward research for an academic degree. The novice researcher must be an RN and current AACN member. The mentor cannot be designated as a mentor on an AACN grant for 2 consecutive years and may not be conducting the research as part of an academic degree.

Grant proposals must be received by February 1, 1999.

AACN Critical Care Research Grant
Up to $15,000 is awarded for research by a nurse investigator who is actively involved in acute and critical care nursing practice.

The principal investigator must be an RN with current AACN membership. The proposed study may not be used to meet requirements for an academic degree.

Proposals must be received by February 1, 1999.

AACN Clinical Inquiry Grants
Up to $250 each is awarded for clinical research projects that will directly benefit patients and families. Funds will be awarded for projects that address one or more of AACN’s research priorities and link with AACN’s vision.
To be eligible, the principal investigator must be an RN, a current AACN member, employed in a clinical setting, and directly involved in patient care.

Applications must be received by January 1, 1999.

Physio-Control-AACN Small Projects Grants Program
Three grants of up to $500 are awarded to qualified individuals to carry out projects that focus on aspects of acute myocardial infarction or resuscitation such as the use of defibrillation, synchronized cardioversion, invasive pacing, or interpretive 12-lead electrocardiogram. This award is sponsored by Physio-Control.

The principal investigator must be an active or affiliate member of AACN and not currently conducting another study funded by an AACN research grant.

Examples of eligible projects include the development of patient education programs, continuous quality improvement projects, outcomes evaluation projects, and small clinical research studies.

Applications must be received by January 15, 1999.

Hewlett-Packard Grant Awarded to Philadelphia Researcher

Jacqueline Sullivan (center) was presented the Hewlett-Packard-AACN Critical Care Nursing Research Grant by Marianne Messina (left) during the Leadership Connections conference in October. Announcing the grant award was AACN President Mary McKinley (right).

Jacqueline Sullivan, RN, PhD, CCRN, CNRN, of Philadelphia, Pa., is the recipient of the 1999 Hewlett-Packard/AACN Critical Care Nursing Research Grant.

The $32,000 grant, the largest offered through AACN, was announced by AACN President Mary McKinley, RN, MSN, CCRN, during the 1998 Leadership Connections conference in Arlington, Va. Making the presentation was Marianne Messina, RN, MSN, learning products specialist in the patient monitoring division of Hewlett-Packard, which supports the annual grant. In addition to the $32,000 grant award, the recipient receives a Hewlett-Packard Vectra personal computer, Hewlett-Packard LaserJet printer, and associated utility software.

Sullivan is a clinical researcher in the Department of Nursing/Research & Evaluation at Thomas Jefferson University Hospital in Philadelphia. The grant will be used for a study on predicting outcome with multimodality monitoring after severe head injury. The research will be conducted at Thomas Jefferson University Hospital. Co-investigators are David G. Brock, MD; Jamie Strause, RN; Karen A. Horner, RN, MSN, CCRN; and Richard Moberg.

The deadline to apply for the 1999 Hewlett-Packard/AACN Critical Care Nursing Research Grant is July 1, 1999. RNs who are members of AACN are eligible to apply. The money may be used to fund research that is associated with an academic degree.

To obtain an application, call (800) 899-AACN.

Trauma Case Drives Home Value of Critical Care Nursing

Susan Yeager, RN, MS, CCRN, is a trauma nurse clinician at Riverside Methodist Hospital, Dublin, Ohio. She received the 1998 Excellence in Caring Practices award, which is part of AACN’s Circle of Excellence recognition program. Presented here are excerpts from the exemplar submitted by Yeager in connection with her award. For more information about the annual Circle of Excellence awards program, call (800) 899-AACN (2226).

By Susan Yeager

As I heard the call, “level one trauma in 10 minutes,” my adrenaline surged and I raced down 4 flights of stairs to the trauma room. Although I had been a critical care nurse for 8 years, I had been a trauma nurse clinician for only 4 months, and my heart still pounded when a trauma alert was called.

I prepared myself and the room for the 23-year-old motorcycle collision victim, setting up the rapid infuser and intubation and thoracostomy supplies. The squad brought him in and we worked to stabilize him. By the time he reached the ICU, tubes and wires were protruding from everywhere.

By the time I returned to the emergency department the family was waiting. I took a couple of quick breaths before entering the room and gently explained what had happened and the nature of Rob’s injuries. In lay terms, I told Rob’s family that he had sustained a left frontal epidural bleed with mass edema, a left hemopneumothorax with a flail segment and pulmonary contusion, a right clavicle fracture, a splenic laceration, and multiple cuts and abrasions. I explained about the medical devices being used including the ventilator, ventriculostomy, thoracostomy, and pulmonary artery catheter.

His family members cried. I listened and answered their questions as honestly and gently as I could. Although they were still upset when I escorted them to the unit to see Rob, they were better prepared for the sights and sounds of the unit.
When I left my shift, Rob was critically stable. His parents were camped in the waiting room, not wanting to leave.

When I returned the next morning, I learned that Rob’s intracranial pressure readings had steadily climbed. The decision was made to place Rob in an induced coma. An EEG machine and additional pumps for inotropes were added to the equipment in his room. The ICU nurse and I worked as a team to recheck Rob and to obtain the needed medications and supplies. During a tertiary exam, I discovered a distal radius fracture of the right wrist, which orthopedics quickly splinted.

After finishing rounds with the attending trauma surgeons and residents, I went to talk to Rob’s family. Early morning updates became a regular routine throughout Rob’s month-and-a-half stay. During these times, I learned about Rob’s wedding plans and his life as an engineer, body builder, son, and friend.

As expected, Rob’s course was rocky. His head injury worsened, his intracranial pressure climbing in spite of the pentobarbital. As a result, the morning updates were filled initially with “if’s,” “maybe’s,” and a lot of tears.

We struggled to help Rob recover from his emergent splenectomy and RDS (respiratory distress syndrome). When we finally were able to extubate Rob, we were faced with the challenge of head injury rehabilitation and the effect it had on Rob, his family, and his nursing staff. This effort was further affected by a lack of bed availability in the trauma step-down unit, so Rob was placed in a medical step-down area. This meant teaching head injury stages of healing and appropriate interventions not only to the family but also to the staff of the step-down unit.

Through the coordinated efforts of physical therapy, occupational therapy, speech therapy, physical medicine and rehabilitation, social service, nursing staff, and family, Rob soon was ready for discharge to the rehabilitation department. I coordinated the follow-up care for all the services, called my report to rehab, and said goodbye to Rob and his family.

I didn’t see Rob again for a month. Then one day he strolled into the trauma clinic with a gleam in his eye and his father at his side. Rob smiled and flexed his reforming muscles. He was swimming almost 1 mile a day and had just been released to an outpatient rehab status.

Rob probably would never return to his engineering position and had broken off his engagement, but his father’s face shone with pride. His eyes filled with tears as he thanked me for helping to return his son home.
The trauma clinic can seem far removed from my critical care roots, but it is times like this that make critical care nursing so worthwhile.

Geriatric Corner: In Search of Sleep!

Sleep is a major topic of discussion at least twice a year—when we change to or from daylight savings time. Just ask any patient or nurse (who works on the night shift). Approximately 50% of the 19 million Americans who are 65 years or older experience some sort of sleep disorder, and in the inpatient setting, complaints regarding sleep are estimated to be as high as 90%.

Contrary to common perception, the need for sleep does not decrease significantly with age. Older adults may sleep the same number of hours as when they were younger; however, that sleep time may be distributed throughout the 24-hour day. Complaints or change in assessment for the hospitalized older person may be from disrupted sleep (see suggested reading for more information on sleep architecture).

This is where our role as nurses could be the right medicine for an older patient by making time for patients to sleep throughout the day and night.

Symptoms of Sleep Deprivation
Physiological Psychological
Nystagmus: ptosis Mood disruption
Hand tremors Disorientation
Clumsiness of fine movements of the fingers Sluggishness
Decreased reflexes Irritability
Slowed response times Decreased motivation
Brief loss of equilibrium Emotional lability
Dysarthria Agitation
Decreases in word memory and addition Decreased impulse control
Decreases in reasoning, judgment, and association Increased suspicion and sensitivity
Increased anxiety Fatigue; malaise
Decreases in auditory and visual vigilance Sleepiness
Decrements in hypoxic and hypercapnic ventilatory responses Decreased integration and interpersonal effectiveness
Cardiac arrythmias Hyperactivity
Loss of strength of neck flexion Delusions; hallucinations
Paranoid and psychotic behavior

Importance of Sleep in the ICU—Role of Healing
Not only does higher cellular division occur during sleep, but it takes a cell less than half the time to divide during sleep as compared to wakefulness.
During the day, catecholamines and cortisol are at their highest levels and are known to inhibit protein synthesis.
Wakefulness enhances catabolism.
Sleep disruption to the point of deprivation has been shown to induce the onset of a catabolic state.

Role in the Immune System
The immune system has a decreased ability to resist and fight infection with sleep deprivation.

Sleep deprivation affects interferon production by lymphocytes (known to play a role in the antiviral defense process).

So, in caring for your next patient, conduct a sleep assessment and include sleep as an important part of your plan. Following are some suggestions:
• Close doors to patient rooms.
• Close doors to the general unit.
• Reduce the volume on alarms during sleep periods; turn down the lights.
• Turn off equipment not in use (wall suction, televisions, etc).
• Avoid unnecessary talking in patient care areas.
• Consider providing ear plugs.

For more information about the International Year of Older Persons or age-related care issues, contact AACN Clinical Practice Specialist Justine Medina, RN, MS, CCRN, at (800) 809-2273, ext. 401; fax, (949) 362-2020; e-mail, Justine.Medina@aacn.org.

Suggesting Reading
1. Edwards GB, Schuring LM. Sleep protocol: a
research-based practice change. Critical Care
Nurse. 1993;13(4):84-88.
2. Geary SM. Intensive care unit psychosis revisited:
understanding and managing delirium in the
critical care setting. Critical Care Nursing
Quarterly. 1994;17:51-63.
3. Richards KC, Benham G, DeClerk L. AACN
Practice protocols: promoting sleep in acute and
critical care. In: Chulay M, Molter NC, eds.
Creating a Healing Environment Series; 1998.
Available from AACN by calling
(800) 899-AACN (2226)

Practice Resources Expanded Online

Check out the latest upgrades to the AACN Web site (http://www.aacn.org), where the Practice & Research area has been completely rebuilt. The changes respond to feedback from members who asked for additional clinical resources that would be easily accessible from their computers. Following are some of the areas featured:

InfoLink Discussion Board
This area allows you to post and respond to questions. It has been reorganized into a series of topics and subtopics to help you find information more easily. The newest navigation tools, “sort by date” and “sort by author,” help you find your question and check for responses. You do not need a password to enter this area. Just click on “Infolink.”

Clinical Practice Resources
This new area provides a comprehensive list of AACN resources, grouped by specific topic areas. It is your gateway to the AACN Web-based resources you need without having to search through multiple pages.
Clinical Practice Links

Hotlinks are hot! One of the benefits of the Internet is that it places a wealth of information at your fingertips. AACN’s practice links area provides a comprehensive collection of quality resources including government agencies, academic institutions, professional associations, and other helpful Web sites.

Ask the Experts
Each month, Critical Care Nurse provides an excellent column that presents a detailed response from a topic expert to a clinical, practical, or legal question from a reader. Selected questions from this column are now posted under a new “Ask the Experts” area and filed by topic in the “Clinical Practice Resources” section. Check out your area of interest!

Frequently Asked Questions (FAQs)
The practice team at AACN receives many requests for clinical information. This area is dedicated to answering the most common questions and providing direction to helpful resources. You can also check out “Frequently Asked Questions” in AACN News each month. The entire collection of FAQs are on the Web site.

Fact Sheets and Position Statements
In response to current events and frequently asked questions, AACN produces informational documents (fact sheets) and formal statements (position statements) regarding AACN’s position related to a particular issue. These documents are also available on AACN’s Fax on Demand at (800) AACN-FAX (2226-329). For a directory of all Fax on Demand documents, request #1000.

Acute Care Nurse Practitioner Clinical Curriculum and Certification Review

This unique 2-in-1 resource is both a comprehensive clinical overview and a certification review guide. This reference addresses the diagnosis and treatment of common disorders in acute and critical care for all organ systems. The content is supported by easy-to-read tables and figures, which will help to maximize understanding.

Product #128880
Price: $55.25 ($65 nonmembers)
plus shipping and handling

To order, call (800) 899-AACN (2226).

Polling Corner: Vox Populi

Continuous IV Inotropic/Vasoactive Medication

In your institution, which units provide care to patients receiving continuous IV inotropic/vasoactive medications? Select all that apply, but do no include units that only administer these drugs during resuscitation.

ICU and/or CCU 96.4%
Emergency department 77.1%
Postanesthesia recovery area 68.6%
Diagnostic/interventional radiology area 35%
Intermediate or step-down unit 50%
Telemetry unit 50%
Medical/surgical units (with monitors) 15.7%
Medical/surgical units (without monitors) 8.6%

Source: Volunteers in Participatory Sampling—a demographically representative sample of AACN members; 1998.

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