AACN News—November 1998—Practice

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Vol. 15, No. 11, NOVEMBER 1998

Nursing Research Grants Link to AACN Vision

Deadlines to apply for several AACN nursing research grants to fund studies that benefit patients and families or that link to AACN’s vision are approaching. Application materials may be obtained by calling (800) 899-AACN (2226).

Following is information about these grants:

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 a 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 1 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.

Abstracts Sought for 1999 State of Science Congress

Research abstracts are sought for the International State of the Science Congress, scheduled for September 15 through 19, 1999, in Washington, D.C.

The congress will include plenary sessions with invited speakers as well as presentations in 3 formats: papers, posters, and symposia. Selected will be research abstracts that address 1 of the following areas:
• Clinical nursing issues
• Nursing education
• Policy implications of nursing science
• Evidence-based practice/patient outcomes
• Healthcare delivery, quality, or services administration including innovative models of practice and professional/ethical issues

Papers must be based on completed research; however, symposia and posters may be based on completed or ongoing research.

The purpose of the congress, which is cosponsored by AACN and 16 other organizations, is to identify areas in nursing research that have had substantive growth in the 1990s; summarize previous research and project future research directions and clinical applications; serve as a forum for developing research agendas, articulating issues, and discussing needs of research training; serve as a forum for discussing current research and its dissemination and utilization; critique the scope and development of the current state of the science to provide direction for future research; and diffuse innovation to clinicians and benefit patient care.

The postmark deadline to submit abstracts is February 1, 1999. However, submissions postmarked on February 1, 1999, must be sent overnight, second-day air, or Express Mail. Faxed submissions will not be accepted.

Submission instructions and forms can be printed from the Sigma Theta Tau International home page at http://www.stti.iupui.edu. Following are the other organizations that are cosponsoring the congress: American Academy of Nursing, American Association of Colleges of Nursing, American Nurses Association Council for Nursing Research, American Nurses Foundation, American Organization of Nurse Executives, Association of Women’s Health, Obstetrics, and Neonatal Nursing, Eastern Nursing Research Society, Friends of the NINR, National Council of State Boards of Nursing, National Institute for Nursing Research, National League for Nursing, Midwest Nursing Research Society, Oncology Nursing Society, Sigma Theta Tau International, Southern Nursing Research Society, and Western Nursing Research Society.


Abstract Reviewers Needed

Volunteers are needed to review abstracts submitted for consideration for the International State of the Science Congress. If you are interested, contact Sandy Fledderjohann, research services specialist, Sigma Theta Tau International, (317) 634-8171; e-mail, sandyf@stti.iupui.edu. Provide your contact information and indicate your areas of review expertise.


Geriatric Corner

Congestive Heart Failure in the Elderly

Congestive heart failure, which is common in patients who are 65 years of age or older, has become more prevalent, especially in the last 20 years. It is now the most common diagnosis among elderly hospitalized patients.

Typical age-related changes such as increased interstitial fibrosis, prolonged myocardial relaxation, and increased collagen cross-linking, make the older patient’s cardiovascular system more vulnerable to a number of systemic illnesses.

The heart adapts to increased workload through 1 or more of the following mechanisms: increased sympathetic stimulation, myocardial hypertrophy, or the Frank-Starling mechanism. Because myocardial and vascular responsiveness to Beta-adrenergic stimulation is reduced with age and because research suggests that the myocardial hypertrophic response to a given increase in afterload is impaired, the elderly depend on the Frank-Starling mechanism.

Contributing Factors
Comprehensive geriatric assessment differs from a standard medical or nursing evaluation because it concentrates more on the elderly patient’s complex problems. An emphasis on functional status and quality-of-life concerns is needed. Other factors that may contribute to the severity of illness in an elderly patient with congestive heart failure include noncompliance with medication, use of nonsteroidal anti-inflammatory drugs, infections, hypo- or hyperthyroidism, anemia, ischemia, hypoxia, and hypo- or hyperthermia.

Physical Assessment
Careful assessment techniques can provide important clues. For example, enlargement of the left ventricle may be detected by palpation of the precordial apical impulse, with the patient in the left lateral decubitus position. A fourth heart sound may be a normal finding in the elderly; however, a third heart sound is a clear indication of volume overload. Assessment of jugular venous pressure can reveal circulatory congestion.

More information about the care of the older patient with congestive heart failure can be found in the Earn CEs area of the AACN Web site at http://www.aacn.org, where there is a CE offering for members titled “Current Trends in the Clinical Management of an Old Enemy: Congestive Heart Failure in the Elderly” by Mickey Stanley, RN, PhD., CCRN. This CE offering can also be found in the “Acute Care of the Aging Client” section of the November 1997 issue of AACN Clinical Issues.

Suggested Readings
1. Abrams WB, Beers MH, Berkow R, eds. The Merck
Manual of Geriatrics. Whitehouse Station, NY: Merck &
Co., Inc.; 1995.
2. Gallo JJ, Reichel W, Andersen LM, eds. Handbook of
Geriatric Assessment. 2nd ed. Gaithersburg, Md: Aspen
Publications, Inc.; 1995.
3. Stanley M. Current trends in the clinical management of an
old enemy: congestive heart failure in the elderly. AACN
Clinical Issues. 1997:8(4):616-626.

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.

The Future Is in Less Invasive Neurosurgical Procedures

Less invasive procedures are producing exciting results in neurosurgical care. Anne Wojner, RN, MSN, CCRN, assistant professor of clinical nursing at the University of Texas-Houston School of Nursing, shared information about stereotactic neurosurgical procedures with participants at the 1998 National Teaching Institute™ in Los Angeles. Her presentation was titled “Neuroscience Star Wars: New Frontiers for Nursing Practice.”

Stereotactic procedures use a specially designed head frame, which is mounted to the skull to assist with CT (computed tomography) or MRI (magnetic resonance imaging) localization of an intracranial lesion for treatment. Using highly advanced computer imaging, an interdisciplinary team of physicians, nurses, radiologists, and medical physicists pinpoint the target and determine the treatment plan. Treatment is then either carried out with a minimally invasive neurosurgical approach or by radiation, depending on the type of lesion involved.

Stereotactic radiosurgery (SR) was one of the treatments presented by Wojner in the presentation. Patients receiving traditional radiation therapy undergo low-dose radiation every day for several weeks. Unlike traditional radiation therapy, SR is a 1-time treatment of high-dose, ionizing radiation delivered to a preselected and stereotactically localized intracranial volume of normal or pathological tissue. Because of the high dose of radiation, a limiting factor is the size of the lesion. Lesions such as large intracranial tumors may need to be operatively reduced or debulked prior to treatment with SR.

Stereotactic radiosurgery procedures have moved to the outpatient setting. The head frame is mounted to the skull using 4 pins. The soft tissues are anesthetized prior to bolting the frame in place so the procedure is not uncomfortable. Once the head frame is in place, the patient undergoes imaging with either CT or MRI; then, the patient waits with the head frame in place over a course of several hours, so that the precise treatment approach can be mapped and entered into the computer system. Wearing the head frame for an entire day is more monotonous than it is uncomfortable, Wojner explained. The actual SR treatment itself lasts approximately
20 minutes.

Wojner also presented a stereotactic neurosurgical procedure called stereotactic pallidotomy (SP). Used to treat patients with severe, refractory Parkinson’s disease, SP involves placement of a small burr hole in the skull and insertion of an electrode into the brain. Patients start their day in a fashion similar to that described above: the head frame is bolted to the skull and the CT or MRI is taken, but the patient is taken to the operating room for treatment. Unlike most surgical procedures, patients undergoing SP are kept awake throughout the procedure so that the neurosurgical team can clinically monitor the effects of the treatment progress. A nurse with expert neuroscience assessment skills is necessary during the procedure. Because the neurosurgeon is gowned and sterile, the neuroscience nurse conducts the entire assessment, assisting with and directing progression of the treatment.

There are many applications for stereotactic neurosurgical procedures, and it’s likely that more will be developed over the coming years. The cost of SR procedures is approximately $10,000 to $15,000 less than traditional neurosurgical craniotomy procedures. Start-up costs for SR vary according to the system used, but run approximately $500,000 for conversion of an existing linear accelerator system, and between $2.5 and $3.5 million for installation of a Gamma Knife unit. Both systems produce similar results.
As more neurosurgical procedures become less invasive, the use of traditional critical care services for treatment and management of these patients is becoming obsolete. Wojner shared with participants how her neurosurgical nursing practice has moved well beyond the walls of the ICU to settings such as the operating room, CT and MRI suites, and radiation therapy treatment centers.

“Now I can see patients from start to finish, using all the critical care skills that I’ve used for years in the ICU in a different way. It’s a very satisfying way to practice!”

Practice Resource Network: Frequently Asked Questions

Q What resources are available for progressive care and telemetry nurses regarding continuous cardiac monitoring practice and policies?

A AACN and ECRI surveyed hospitals regarding cardiac monitoring. The resulting document, titled "Continuum of Care Monitoring—It’s Time Has Come," was published in January 1998. The survey revealed that 68% of the hospitals responding currently provide continuum of care monitoring. Continuous cardiac monitoring was attributed to the reduction or elimination of patient transfers between care areas (66.8% reported this benefit). The survey addressed staffing issues, central station location, dedicated monitor watchers, and training requirements, as well as other related subjects. This resource (product #1105) is free. To order, call (800) 899-AACN (2226).

AACN has also produced a research-based Protocol for Practice titled "Bedside Cardiac Monitoring" (product #170640). This resource contains easy-to-use information regarding cardiac monitoring including setup, lead placement, troubleshooting, and ST segment monitoring. This resource can be purchased by AACN members for $11 ($14 for nonmembers). To order, call (800) 899-AACN (2226).

If you have a question or are seeking resources, contact the Practice Resource Network (formerly PRAISe) at (800) 809-2273, ext. 217, or visit the Practice Resource Network area of the AACN home page.


Do you use preceptors in your hospital? Do you use the AACN publication? From Staff Nurse to Preceptor? If so, would you be willing to share your experiences and/or participate in a survey about preceptorships?
Contact Marsha Moore, 43509 Plantation Terr., Ashburn, VA 22014; phone, (703) 729-4472.

Our hospital wants to establish a measurable, preadmission educational process in connection with its new cardiac surgery program. Are you providing this type of service or any other preadmission process?
Contact Renee Diana, RN, MBA, CCRN, St. Barnabas Medical Center, East Win-Suite 102, OID Short Hills Rd., Livingston, NH 07039.

I am setting up an Amiodarone clinic to monitor for possible side effects. Information on specific labs or tests and their frequency would be helpful. I am also seeking ideas for patient education.
Contact Cinda Dizney, RN, BSN, CCRN, Brevard Cardiology Group, 80 Fortenberry Rd., Merritt Island, FL 32952; phone, (407) 452-3811, ext. 42; fax, (407) 454-4026.

Do You Have a Question?

Send your InfoLink questions to: AACN News, 101 Columbia, Aliso Viejo, CA 92656-1491; fax, (949) 362-2049; e-mail, aacnnews@aacn.org; or call (800) 809-2273, ext. 502, or (949) 362-2000, ext. 502 (outside the United States). Please include as much of the following information as possible: your name, mailing address, phone number, fax number, and e-mail address. InfoLink questions are published based on available space. You also can post InfoLink questions online. Go to www.aacn.org and click on InfoLink.

Patient Teaches the True Meaning of Nursing Care

By Lisa A. Richards

As soon as I saw Michael, I knew he was not your ordinary 47-year-old patient. He was extremely agitated, biting on his endotracheal tube (ETT) and thrashing in the bed. He constantly reached for tubes.
Assigned as his primary nurse, I worried about my inexperience. I realized that I needed to learn all I could about him if I was to help him.
Michael had a painful and disabling lower extremity claudication, which led him to an aortobifemoral bypass graft. It was hoped that this would allow him to regain some mobility.
Michael kept me very busy. In addition to replacing the tubes that he pulled out on a daily basis, I was faced with one devastating problem after another.
Michael’s complications included a myocardial infarction (MI), which was compounded by periods of agitation. This agitation caused him to go into a hypertensive crisis with blood pressures of 300/150, flash pulmonary edema requiring diuretics, and 100% FIO2 to maintain a saturation level greater than 85%. His cardiac status was compromised when his rhythm went from rapid atrial fibrillation to ventricular tachycardia and then to severe bradycardia.

Michael was so unstable that he remained paralyzed. He was sedated so his lungs could be ventilated. Care became increasingly complex. The trigger of an IV pump alarm would catapult Michael into another episode. Over a short time, his muscles began to atrophy, and hope for his recovery diminished.
As Michael’s agitation episodes became more frequent, maximum ventilator settings had to be sustained for days at a time. As a result, his lungs became fibrous and inelastic.
Disagreement soon ensued among the physicians regarding the best treatment plan. None of the specialists had answers for his agitation and deterioration.
Throughout these 2 months I began to learn of the challenges that faced Michael before his surgery. He had suffered a traumatic childhood injury that required insertion of a metal plate in his forehead, resulting in uncontrollable migraines. A dysfunctional family life led to failed marriages and distant family relationships, even with his only son. Back pain from the childhood trauma prevented him from doing his job as a truck driver. Unemployed and lacking money for food or medications, Michael’s sisters were the only family he had left, though they were distant physically as well as emotionally.

In addition, Michael was an alcoholic. He suffered bouts of depression and had made numerous suicide attempts. I realized that Michael’s family would not be able to agree on decisions on his behalf. Michael’s sisters disagreed on prognosis; his brother was in denial about the seriousness of this illness; and his son was too young to make decisions.
The family became frustrated and demanded answers. I was frustrated because I had no answers. His nursing care was extremely demanding. I collaborated with the teams of physicians and worked to maintain a low-stimulus environment. Narcotics, paralytics, and antihypertensives were used to treat his unstable condition.
Suddenly, Michael’s episodes stopped for 10 days and his condition appeared to be improving. He remained ventilated on normal settings while we strived for extubation.
Being able to discontinue the paralytics and sedation allowed me to get to know Michael better. For 2 months, I cared for an agitated stranger. Now we were friends. He even smiled at the “bad” jokes I told him.

The agitation and cardiovascular instability returned—as abruptly as they had stopped. His condition worsened after each episode, requiring resuscitation and full life support. Very high doses of narcotics and antihypertensives were soon needed, and paralytics were ineffective.
I advised Michael’s sisters, who were becoming increasingly distressed, that after 4 months it was time to begin making decisions about his life and poor prognosis. I could not bare to watch this fragile human being suffer anymore. There was nowhere to turn but our hospital ethics committee.
Michael had become so unstable that—at least a dozen times—I thought he would die. On the day the committee met, he looked especially bad, and I thought that he would die even as we met on his behalf. It was the hardest day of my life.
Before the committee meeting, which his sisters also attended, I pleaded for an answer, hoping deep down that dignity and peace would be the choice. The committee decision was as follows: life support for a limited time and, based on progress, a transfer to a special pulmonary unit within our hospital.

I said goodbye to Michael for the last time. I told him my last joke and, just before the punch line, he squeezed my hand as if to say goodbye and thank you.
I continued to follow Michael from a distance and each day his condition worsened until finally he passed away after a lengthy resuscitation attempt. I felt angry when I remembered how he had suffered. I had seen Michael struggle to breathe so many times and fought hard to bring him comfort. I had seen pain and anguish in a family that faced an unthinkable burden. I remember the look of “air hunger” when he awoke from paralytics. I remember times when Michael had a blood pressure of 20/10, when I prayed that he would just let go. Although I wanted peace for him, I also wanted a cure and a chance for him to have a real life.
In these moments of remembrance and regret, I began to realize what it is that we really do. It’s not only about fighting for a patient’s comfort. It’s about all the extra things we do to try to make our patients forget, if only for a minute, where they are. It’s about caring without being judgmental. It’s about doing the right thing for the patient.

I can never repay Michael for the hard lessons he taught me. Without him, I never would have realized my own strengths or the true meaning of patient care. I had thought that mergers and politics prevented nurses from making a difference and that “red tape” affected their ability to care for patients, but I was so wrong.
The strength we have as nurses is the power of a voice. Nursing is an earned privilege, which comes with enormous responsibility: preserving life. It also means preserving quality of life and helping families to understand their choices. Through Michael, I found a higher level of knowing how to care. His life has given my life more meaning.

AACN Clinical Reference for Critical Care Nursing

The fourth edition of the AACN Clinical Reference for Critical Care Nursing, featuring updated practice information, is now available. This improved reference provides cutting-edge treatment information including new chapters on alternative therapies, postresuscitation care, and management of obstetrical emergencies. In addition, each chapter includes clinical pathways in boxes and tables. Clinical physiology, physical and laboratory assessment, diagnostic procedures, pathophysiology, therapeutic goals, patient outcomes, and interventions are all covered in this fourth edition.

Product: #128250
Price: $75 ($85 for nonmembers)
plus shipping and handling

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

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