AACN News—February 1999—Practice

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Vol. 16, No. 2, FEBRUARY 1999


Challenges Gave Meaning to the Practice of Nursing


Melissa D. Borg, RN, BSN, CCRN, formerly a captain in the U.S. Air Force, is now a nurse at Lutheran Hospital of Indiana, Fort Wayne, Ind. She received the 1998 Excellence in Clinical Practices award, which is part of AACN’s Circle of Excellence recognition program. Presented here are excerpts from the exemplar submitted by Borg in connection with her award. For information about the annual Circle of Excellence recognition awards, call (800) 899-AACN (2226), or visit the Awards area of the AACN home page at http://www.aacn.org.

By Melissa D. Borg

I was a critical care nurse for only 13 months when I was selected to be part of the intensive care unit (ICU) team during my first military deployment as a United States Air force officer.

I worked occasionally with 1 other nurse and a medical technician in a 5- to 7-bed tent unit. Medical supplies were limited and life-saving equipment was old and unfamiliar. Our patient population came from approximately 20 different countries, each with its own language and culture.

A small-framed Jordanian man arrived in the ICU at my military field hospital following an extensive small-bowel resection. Mr. H. had multiple surgical drains, dressings, and intravenous (IV) medications. I was anxious, yet energized, noting that he was awake and that his eyes were full of fear.

Before departing with his troop for combat, Mr. H. had developed severe colitis, and his condition had deteriorated during combat.

Mr. H. was anxious and combative when he returned from the operating room. After assessing his condition, I attempted to explain to him about his lines, tubes, and dressings, and to assure him that he was OK. Communication, which was limited to pointing to pictures on a board or using body and hand gestures, required patience. I spoke no Arabic and he spoke no English. Mr. H. showed no nonverbal signs of discomfort. I tried to assess his pain by watching for facial grimaces.

Hoping that familiar faces would calm him, I asked Mr. H.’s comrades to visit. Their presence settled him down enough so that he could rest. For the remainder of my shift I struggled to explain to Mr. H. about the care I was giving. His cooperation was sporadic and his patience was limited. By the time my shift ended, I was physically and emotionally exhausted.

The next day, Mr. H. was calmer. He even acknowledged me during morning report with a nod and a smile. I knew he was beginning to trust and accept me. Mr. H. had conveyed to me through interpreters the day before that he believed women should stay at home with their families, and were not to be depended upon or recognized as professionals. Nevertheless, a bond was forming between us, which I considered to be a great achievement.

Mr. H’s septic insult and surgical interventions were extensive, and the stress on his body led to respiratory difficulties. My assessment skills were crucial, especially because we did not have access to quick arterial blood gases and lab results.

I knew Mr. H. would soon require intubation and become ventilator dependent. I used any means of communication he understood to keep Mr. H. informed about his care. The physician and respiratory therapist were at the bedside as I began to plan how the intubation could best be accomplished. The available ventilator was a type that was no longer used in U.S. hospitals, but it nevertheless proved to be the lifeline for my Jordanian friend.

After Mr. H. was intubated, my days became even more demanding. His survival required one-on-one critical care and medical resources, both of which were in short supply at this hospital. I had to be creative to make the remaining equipment and supplies last without sacrificing his quality of care. Every appropriate intervention was being executed, but there was no significant change. Mr. H. was no longer responsive. The frustration of having limited equipment and resources was felt by all of the healthcare staff, but especially by me.

I encouraged Mr. H.’s friends to visit him. They all struggled to understand why Mr. H. was unresponsive, how his body became swollen to twice the size of his original frame, and why his body was covered with drains, tubes, monitors, and machines. I explained as well as I could by using the picture boards, body gestures, and interpreters, but the complexity of the situation was overwhelming to these men. I reminded these visitors and myself of the power in optimistic support for Mr. H.'s recovery.

After approximately 10 days of endless medication titration, ventilator changes, dressings, drains, and physical and emotional therapy, I began to notice improvements in Mr. H. Our goals were miraculously met when Mr. H.'s progression led to extubation, alertness, orientation, and removal of all drains, machines, and IV lines. Mr. H. and I judiciously worked day after day to increase his strength and stamina. I did not give up.

Communication continued to be a challenge, but we had developed a mutual understanding. I walked with Mr. H. to the medical-surgical ward on the day his transfer was ordered. This experience was a highlight in my nursing career and I visited him regularly. One day Mr. H. told me that these visits were “good,” one of the few words he had learned in English.
Two months after Mr. H. had arrived in my ICU, he was ready to return to his home country with the other Jordanian soldiers. This was a milestone, a day most of us had never expected to arrive. Mr. H. hugged me before leaving and—in English—said, “Thank you.”

With tears in his eyes, he said through an interpreter, “You saved my life. I could never thank you enough. Now I can go home to my family.”

As I watched him walk to the plane, I knew that there was no greater satisfaction or reward I could experience. The challenges I faced with Mr. H. were the reasons I became a nurse.

Infolink

I am seeking information on orientation programs that have been used successfully in cardiac catheter labs.
Contact Melanie Roberts, Education Department, 1024 Lemay, Ft. Collins, CO; 80524; phone, (970) 495-8217; e-mail,
mgr@libra.pvh.org.

How do other pediatric ICUs handle adolescent codes? Our emergency medication dosage sheets are precalculated by weight up to 45 kg. How does your unit manage code drug administration for children over 45 kg? Do you primarily use ACLS algorithms, or are emergency medication doses calculated by weight?
Contact Michele Wilson, RN, MS, PCCNP, PICU, Clinical Nurse Specialist, Loma Linda University Children’s Hospital, 11234 Anderson, Unit 5700, Loma Linda, CA 92354; phone, (909) 824-0800, ext. 41978; fax, (909) 478-4303; e-mail,
michele_wilson@ccmail.llumc.edu.

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 http://www.aacn.org and click on InfoLink.

Geriatric Corner: How Cold Is It?

Accidental hypothermia is the unintentional decrease in body temperature to less than 34.4oC (94oF).

In the United States, an increase in the death rate among the elderly by about 75,000 in the winter is attributed to hypothermia, as well as to other winter risks such as influenza and pneumonia.

Hypothermia may be mistaken for drug or alcohol abuse, hypoglycemia, a postictal state, a new stroke, or hypothyroidism. Some patients may not be able to tell their healthcare practitioners when they are cold. Others may not have the ability to realize they are cold.

Patients with diabetes, Parkinson’s disease, or cerebrovascular diseases appear to be at higher risk. Hypothermia may be induced by alcohol, barbiturates, phenothiazines, tricyclic antidepressants, benzodiazepines, anesthetics, and narcotics. The older adult can even become hypothermic in warm climates!

Normal Aging and Temperature Regulation
Under usual environmental conditions, convection and radiation account for 65% of heat loss. Evaporation from the skin and lungs contributes another 30%.

Following are conditions that can be related to age:
• Inefficient vasoconstriction
• Decreased cardiac output
• Decreased subcutaneous tissue
• Diminished shivering
• Diminished sensory perception of temperatures
• Diminished thirst perception
• Normal or low baseline temperature

Stages of Hypothermia
Following are symptoms associated with various stages of hypothermia:

1. Early: Core body temperature of 32-35oC (90-95oF)
• No signs or symptoms presented
• No feeling of cold
• Apathy
• Weakness
• Fatigue
• Slurred speech
• Mental confusion
• Slowed gait
• Skin cool to touch
• Facial edema
• Pale or ashen skin
• Tachypnea

2. Mid: Core body temperature of 28-32oC (82-90oF)
• Mental confusion followed by loss of consciousness as temperature drops
• Slowed tendon reflexes
• Sluggish pupils
• Muscle stiffness
• Involuntary tremor
• Skin cold to touch
• Cyanosis
• Pulse, respiration, blood pressure decrease
• Spontaneous dysrhythmias as temperature drops; sinus bradycardia and atrial fibrillation most common.

3. Late: Core body temperature below 28oC (82oF)
• Rapid drop in body temperature after the core body temperature falls to 34oC (93oF)
• Skin cold to touch
• Unresponsiveness increases; coma
• Fixed and dilated pupils
• Muscles rigid, areflexic
• Respiration ceases

• Oliguric
• Anuric

In a hospital setting, hypothermia may be exacerbated by the following conditions:
• Cold operating rooms
• Cold patient rooms
• Intravenous infusions at room temperature (especially when less than 18oC [65oF])
• Peripheral vasodilation from medications
• Skin exposure, thin draping materials

Interventions
• Temperature monitoring (track trends)
• Warming the environment
• Blanket, hypo- or hyperthermia blanket
• Warmed intravenous fluids
• Cardiac monitoring
• Core rewarming (late stage), cardiac bypass technique

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.

Suggested Readings
1. Geriatric emergencies. In: Abrams WB, Beers MH, Berkow R, eds. The Merck Manual of Geriatrics. 2nd ed. Whitehouse Station, NJ: Merck & Co, Inc; 1995:chap 4.
2. Hyperthermia and accidental hypothermia. In: Abrams WB, Beers MH, Berkow R, eds. The Merck Manual of Geriatrics. 2nd ed. Whitehouse Station, NJ: Merck & Co, Inc; 1995:chap 5.
3. Gallo JJ, Reichel W, Andersen, LM. Physical assessment. In: Handbook of Geriatric Assessment. Gaithersburg, Md: Aspen Publishers, Inc; 1995:chap 7.
4. Luggen AS. Core Curriculum for Gerontological Nursing. St. Louis, Mo: Mosby-Year Book/National Gerontological Nursing Association; 1996.

Disease Management Program Improves Outcomes

Deborah Moyer-Knox (seated) and Lisa Ohlwein-Mischke are part of the disease management program at Evanston Northwestern Healthcare, Evanston, Ill.

By Deborah Moyer-Knox
RN, MS, CCRN
and Lisa Ohlwein-Mischke
RN, MS

Congestive heart failure (CHF) is the most common reason Medicare-aged patients are admitted to the hospital—at almost twice the rate of the next highest diagnosis, pneumonia. The economic burden of this debilitating chronic disease demands that a mechanism be found not only to improve the quality of care for these patients but to prevent unnecessary hospitalization.

In 1995 Evanston Northwestern Healthcare (ENH), Evanston, Ill., established a disease management program in which a multidisciplinary team works to improve patient outcomes. Incorporating inpatient, outpatient, and home-care components resulted in the following improved outcomes:
• Decreased length of stay (national average = 6.2 days, ENH = 4 days)
• Reduced costs
• Decreased 30-day readmission rate (national average = 17.2%, ENH = 2.3%)
• Improved compliance with the treatment regimen

Optimal clinical management of heart failure requires the monitoring of daily weight changes and symptoms of increased congestion to prevent an exacerbation. There is extensive evidence that hospitalization rates for patients with heart failure can be substantially reduced by improved patient education, patient self-monitoring of weights, and rapid response to early signs of clinical deterioration.1-3 Noncompliance with medications, diet, and daily weighing are the primary reasons these patients are hospitalized unnecessarily. Although patients may weigh themselves daily, some neglect to or don’t know to notify the healthcare team of changes.

Compliance monitoring through an automated telemanagement program reinforces education, identifies early warning signs, and reduces the likelihood of hospitalization. A telephone can be a simple, useful tool for enhancing compliance. Telephone technology was used in the medical field in the diagnosis of respiratory problems as early as 1879.4 Effective telephone care can yield correct and timely diagnosis and treatment, promote compliance with the treatment regimen, and enhance patient and healthcare provider satisfaction.5 The staff of the CHF program at ENH reasoned that daily symptom and weight monitoring would improve compliance, which in turn would keep patients out of the hospital. Modern telephone methods are used to effectively apply this approach to a broad number of patients.
The CHF Tel-Assurance program is a computerized phone system designed for CHF patients to call in their daily weights and answer questions related to heart failure. (See Table.) Patients receive instructions about the automated voice system in the hospital, during home care visits, or in the outpatient clinic by a CHF Tel-Assurance trained nurse. The nurse enters each patient’s demographic data, comorbidities, ideal body weight with minimum and maximum ranges, serum creatinine level, medications, physician phone number, and fax. Patients call daily to a local number by noon to record their status. Each day, a computerized database allows clinical variances to be identified. Variances include 3 categories:

• Patients who did not call daily
• Patients with changes in symptoms
• Weight changes outside prescribed parameters
When necessary, a nurse will call the patient to assess the situation, provide education, and adjust medications to prevent hospital admissions.
As advanced practice roles evolve, nurses may take a more active role in medication adjustments. Frequently, patients dine out and do not order low-sodium choices or exceed the 2,000 mg
sodium limit. Patients report that if they receive a call the next day requiring an adjustment of their medications, they then learn to connect their actions with the consequences.
Within the system, patients can obtain their updated medication regimen, next clinical appointment, and general information regarding exercise and a low sodium diet. Patients have the option to leave a message for a nurse who will return their call that same day. This disease management approach was measured with compliance tracking and a patient satisfaction survey. After 18 months, telemanaged participants’ compliance rate averaged 89.5% (n = 40). Most studies have shown compliance rates for taking daily medications to be approximately 50%.6 CHF hospitalization rates were 0.6 times per patient/year, compared to the national benchmark of 1.7 times per patient/year. The patient satisfaction surveys indicate a high level of satisfaction with the CHF Tel-Assurance program and the quality of care patients received.

The number of patients with CHF is consistently rising as patients live longer and modern technology (i.e., surgical techniques and timely interventions) improve survival. However, the readmission rate for CHF patients is high, because patients are not adequately monitored in the outpatient setting. By preventing unnecessary hospitalizations, the CHF Tel-Assurance program has improved patients’ quality of life and substantially reduced the
cost of care.

References
1. Rich MW, Beckham V, Wittenberg C, et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med. 1995;333:1190-1195.
2. Fonarow GC, Stevenson LW, Walden JA, et al. Impact of a comprehensive management program on the hospital readmission and functional status of patients with advanced heart failure. J Am Coll Cardiol. 1997;30:725-732.
3. Hanumanthu S, Butler J, Chomsky D, et al. Effect of a heart failure program on hospitalization frequency and exercise tolerance. Circulation. 1997;96:2842-2848.
4. Grument G. Telephone therapy: a review and case report. Am J Orthopsychiatry. 1979;49:574-584.
5. Guy DH. Telephone care for elders: physical, psychosocial, and legal aspects. J Gerentol Nurs. 1995;21:27-34.
6. Sackett DL, Haynes RB. Compliance With Therapeutic Regimens. Baltimore, Med: Johns Hopkins; 1976;1651, 1664-65.

Telemanagement Daily Symptom and Weight Survey Questions

1. Have you felt more short of breath in the last day?

2. Have you felt fatigued or tired in the last day?

3. Have you noticed more swelling in the last day?

4. Did you wake up from sleep short of breath last night?

5. Has your appetite been worse in the last day?

Practice Resource Network: Frequently Asked Questions

Q Where can I locate resources to help me care for critically ill infants and children?

A Nurses who care for critically ill children face the special challenge of dealing with critical illness while meeting the developmental needs of these patients, who range from tiny neonates to adult-sized adolescents. AACN offers a wide variety of resources in various formats to help you meet this challenge.
Following is information about some of these resources:
Books—The AACN Core Curriculum for Pediatric Critical Care Nursing (Product #128870), which can help you prepare for the pediatric CCRN� exam, is useful as a ready-reference.
Pocket card—The Pediatric Critical Care Pocket Reference (Product #400825), which you can carry with you to the bedside, presents information in easy-to-use tables.
Audiotapes—AACN’s Pediatric Building Blocks audiotape series (National Nursing Network Product #136-97) is a comprehensive collection of presentations by some of the best known speakers in pediatric critical care. The 1998 NTI preconference titled “New Directions in the Management of Pediatric Respiratory Failure” (National Nursing Network Product #PCE13-50-98) provides state-of-the-art information including nitric oxide, ECMO, liquid ventilation, and new ventilation strategies. (For these products, call the National Nursing Network at 800-373-2952.)

Videotapes—The Neonatal Critical Care Core Review video series (Product #301800) and Pediatric Core Review multisystem video series (Product #301900) can be used for orientation, continuing education, and in preparation for the CCRN exam.
Educational programs—AACN’s annual National Teaching Institute™ offers a dedicated pediatric and neonatal educational track. (The 1999 NTI is May 16 through 20 in New Orleans, La.)
Continuing education articles online—From the AACN home page (www.aacn.org), click on the Earn CEs area, then on content. Under the Pediatric/Neonatal area are CE articles that contain valuable practice information.
Certification resources—The Sample CCRN Exam for both pediatric (Product #200205) and neonatal (Product #200105) nurses is available in booklet format. It is also available with a CD-ROM (Pediatric Product #200210, Neonatal Product # 200110).
Internet—Look for pediatric content in various areas of the AACN home page (www.aacn.org). Perform a search using the words “pediatric” or “neonatal” to locate all the related content or look for dedicated pediatric sections in the Practice, InfoLink Discussion, or Earn CEs areas.

Interactive software—“AACN Clinical Simulations: Pediatric and Neonatal Critical Care” is a CD-ROM that is available from Lippincott Williams & Wilkins. For more information, contact Lippincott Williams & Wilkins at (800) 527-5597.
Telephone and e-mail—Consult the Practice Research Network about your pediatric critical care practice-related questions. Call (800) 394-5995, ext. 217, or e-mail practice@aacn.org.
Networking—Participate in discussions with other clinicians regarding clinical issues via the Infolink Discussion area of the AACN home page (www.aacn.org). Volunteer to participate in the Pediatric or Neonatal advisory teams. (See page 1 for information about these and other national-level volunteer opportunities.)

More information about AACN products and services is available by calling (800) 899-AACN (2226) or by visiting the AACN home page at www.aacn.org.

Grants Support Nursing Research

Deadlines are approaching to apply for the following nursing research grants:

AACN Data-Driven Clinical Practice Grant
Awards of up to $1000 each are given for studies that focus on stimulating the use of patient-focused data and/or previously generated research findings to develop, implement, and evaluate changes in acute or critical care nursing practice.
Principal investigators, who must be RNs and current members of AACN, may not be currently conducting a study funded by another AACN research grant. Proposed studies may be used to meet requirements for an academic degree.
Applications must be received by March 1, 1999. To obtain a grant application, call (800) 899-AACN (2226).

AACN Research Grant
Sponsored by AACN, this $3500 award is administered by the American Nurses Foundation (ANF) and given annually to support research relevant to critical care nursing practice.
The principal investigator must be an RN who has obtained a baccalaureate or higher degree in nursing. This program is designed for beginning nurse researchers or experienced nurse researchers who are entering a new field of study. The proposed study may be used to meet the requirements of an academic degree.
Applications are available from ANF at (202) 651-7298. Proposals must be received at ANF by May 1, 1999.

Vox Populi: Continuous IV Inotropic/Vasoactive Medication

According to your hospital policy, how often does the patient and/or IV site need to be assessed by an RN when continuous IV inotropic/vasoactive medications are being administered?

Every hour and prn 31.4%

Every 2 hours and prn 14.4%

Every 4 hours and prn 13.6%

Once per shift and prn 13.6%

Depends on the patient, type of IV, or other factors 27.1%

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