AACN News—January 1999—Practice

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Vol. 16, No. 1, JANUARY 1999


Advanced Practice Nurses Represent Unique Needs

Meeting as part of the Advanced Practice Work Group were (from left, seated) Linda Prinkey (learning connections partner), Anna Gawlinski (chair) and Judy Verger, and (from left, standing) Pat Rosier, Carin Mehan, Sara Paul, Anne Wojner, Ruth Kleinpell, Jill Jesurum, Megan Whalen, and Denise Guaglianone.

Ways to meet the increasingly complex needs of advanced practice nurses are being examined by the Advanced Practice Work Group, which met last fall in Washington, D.C.

Clinical practice, education, role delineation, and research and outcomes are among the areas on which strategies and recommendations are being focused. The work group, which is chaired by Anna Gawlinski, RN, DNSc, CCRN, CS, NP, is concentrating its efforts on potential resources including a position statement that will better define the various advanced practice nursing roles.

“With sensitivity high, we must address and help all (advanced practice nurses) to appreciate their similarities and differences,” said work group member Carin Mehan, RN, MSN, ACNP, education and research manager in minimally invasive cardiac surgery at Medtronic, Inc.

The challenge for the work group is identifying appropriate resources to assist these advanced practice nurses.

The Advanced Practice Institute,™ which was offered for the first time during the 1998 National Teaching Institute,™ is one example of ways AACN tries to ensure that the clinical education needs of advanced practice nurses are met. The second API is scheduled again in 1999 at the NTI, which is May 16 through 20 in New Orleans, La. Preconference opportunities including an acute care nurse practitioner preparatory class and a session titled “Pharmaceuticals for the Nurse Practitioner: Interaction Challenges of Prescriptive and Alternative Therapies” are planned.

Sara Paul, RN, MSN, FNP, CS, NP, a work group member who is a nurse practitioner in the congestive heart failure clinic and a clinical professor of nursing at the Medical University of South Carolina, Charleston, S.C., said that the availability of programs offering continuing education units for pharmacology content is an issue for advanced practice nurses who have prescriptive authority.

Advanced practice is taking on a whole new light in healthcare, particularly with the emergence of the nurse practitioner, noted Paul. In some cases, the role of the nurse practitioner dips into medicine.

Although dynamic discussions can result from talks around advanced practice role theory, Mehan said, there is a need to increase CEs on clinical topics.

As advanced practice nurses perform new procedures in the clinical arena, the demand for reference materials that address a particular skill increases, said Mehan. She said she would like to see an advanced practice section, added to the AACN Procedure Manual, to demonstrate common procedures performed by advanced practice nurses.

“Actually being able to see various procedures performed on CD-ROM would be an even better educational tool,” she suggested.

Both Paul and Mehan point to the Internet as a means of providing extensive opportunities for advanced practice nurses to share their expertise. Paul said she has found that Listservs, chat rooms, and e-mails are tremendously helpful tools.

Other members of the Advanced Practice Work Group are Denise Guaglianone, RN, MSN, CCRN, CS, APRN; Jill T. Jesurum, RN, MN, CCRN; Ruth M. Kleinpell-Nowel, RN, PhD, CCRN; Patricia Rosier, RN, MSN, CS; Judy Trivits Verger, RN, MSN, CCRN, NP; and Anne Wojner, RN, MSN, CCRN (board liaison). Megan Whalen, RN, MS, is the AACN staff liaison.

InfoLink

I am seeking feedback from centers that use the Basic Knowledge Assessment Tool (BKAT-5) for critical care nursing. Specifically, I am interested in where it is used (e.g., type of hospital or center), when it is administered, whether it drives the curriculum objectives, and how results are interpreted.
Contact Hildy Schell, RN, MS, CCRN, UCSF Medical Center, phone; (415) 476-0866; e-mail,
hildys@email.his.ucsf.edu.

How do you handle ACLS (acute cardiac life support) recertification in your hospital? What are the criteria for admittance into a 1-day program versus a 2-day program? Are telemetry nurses as well as ICU and emergency department nurses included in the criteria for a 1-day program?
Contact Cyndi Baxter, RN, BSN, CCRN, CEN, Central Baptist Hospital, 1740 Nicholasville Road, Lexington, KY 40503; c/o Education; phone, (606) 275-6075; email,
cbaxter@bhsi.com.

I am vice president of the Croatian Nurses Association (CNA) legislation committee. The Croatian government asks the CNA to draft nursing practice law. Are any other AACN members in a similar position? In addition, the CNA is interested in establishing a Croatian Nurses Network. If you are an RN who speaks Croatian, send us your name and address. We want to invite Croatian-speaking RNs to be guests at our conferences.
Contact Davor Zec, RN, Klinicka Bolnica Osijek, Interna Klinika, Opca Intenzivna, Hutlerova 4, 31000 Osijek, Croatia; e-mail,
ivanka.zec@os.tel.hr.

Is there a need to use the nitroglycerin tubing that accompanies the intravenous product? Apparently, this drug is not absorbed into the special pvc tubing. I have been told that the drug can be titrated to effect, and so the amount absorbed into the tubing is irrelevant. I would appreciate any supporting literature or anecdotal evidence that you might have.
Contact Ruth Baltes, RN, MSN, Critical Care Educator, Long Beach Community Medical Center; rbaltes@mail.
unihealth.org.

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: Is Your Patient Depressed?

In celebration of the United Nations’ International Year of Older Persons 1999

Depression is one of the most common psychiatric disorders of older adults. Both clinicians and patients may attribute symptoms of depression to the aging process. In the older adult, these symptoms may present as somatic complaints, making them easy to overlook. Instead of complaining of depressed mood, the older adult may complain of anorexia, sleep disturbance, lack of energy, or loss of interest and enjoyment in life.

Symptoms of dementia may mask depression. The reverse is also true. The following criteria for depression are included in the American Psychiatric Association Diagnostic and Statistical Manual (DSM-IV):
• Weight and appetite changes
• Sleep disturbances
• Motor agitation or retardation
• Lack of energy and fatigue
• Irritable or depressed mood
• Lack of interest in usual activities
• Feelings of worthlessness, excessive guilt, or self-reproach
• Suicidal ideation or attempts
• Difficulty concentrating or thinking

In assessing the older adult for depression, confounding problems, use of selected prescription medications, and alcohol or substance abuse should also be considered. The following factors may complicate the diagnosis and treatment of depression in the older patient:

Reversible Causes—anemia, endocrine disorders, metabolic disturbances, nutritional deficiencies, and social isolation.

Medications—alcohol, antihistamines. antihypertensives (e.g., reserpine, methyldopa, propanolol, clonidine), antiparkinsonian agents (e.g., levodopa), antiseizure drugs, benzodiazepines (e.g., flurazepam), cardiovascular drugs (e.g., digitalis), cimetidine, corticosteroids, estrogens, and narcotics (e.g. morphine, codeine).

Atypical Presentation of Depression in the Older Adult—concentration problems, confusion, memory impairment, preoccupation with the past, increased sleep, somatization, and weight gain

Treatment may include modifying the patient’s environment such as providing sensory aids, keeping the room well lit, and placing flowers and greeting cards in patient’s view; encouraging self-care and family participation in the patient’s care; providing uninterrupted listening; and validating the patient’s feelings or fears.

In addition, the treatment may require pharmacotherapy. Following are guidelines for use of antidepressants:

• Stop all drugs that are not essential.
• Start low and go slow because of the prolonged half-life and increased sensitivity of the older adult to side effects. Start with one-half the usual recommended adult dose.
• Use enough drug, long enough. Adequate trial may take up to 6 weeks; steady state may be reached within 5 half-lives or longer.
• Sedation is not necessary to relieve depression-related insomnia. Sleep returns to normal when depression resolves.
• Tricyclic antidepressants (TCAs) remain the drugs of choice. Divide high doses over 2 or 3 times a day to minimize side effects.
• TCAs have varying degrees of sedation, orthostatic hypotension, and anticholinergic effects. All TCAs may cause arrhythmias.

References
1. Belsky JK. The Psychology of Aging: Theory, Research, & Interventions. 2nd ed. Pacific Grove, Calif: Brooks/Cole Publishing Company; 1990.
2. Mental status examination. In: Abrams WB, Beers MH, Berkow R, eds. The Merck Manual of Geriatrics. 2nd ed. Whitehouse Station, NJ: Merck & Co., Inc.; 1995:chap 90.
3. Gallo JJ, Reichel W, Andersen LM. Depression scales. In: Handbook of Geriatric Assessment. Gaithersburg, Md: Aspen Publishers, Inc; 1995:48-56.

Study Breaks Ground by Using Pigs to Explore Critical Care Issues


Huddled around a pig that is being used for research on the effects of prolonged mechanical ventilation on critically ill patients are (from left) Anna Gawlinski, Phillip Wilkerson, Jill Jesurum, and Sandra K. Hanneman.

The clicking, whirring, and beeping of computerized and telemetric equipment filled the operating room, which was located in the basement of St. Luke’s Episcopal Hospital and Texas Heart Institute in Houston. Nurses hovered in constant attendance around the 170- and 187-pound, sedated “patients,” ensuring that expert critical care nursing practice was provided.

A steady stream of visitors came by to witness the drama that was being played out as 2 farm pigs helped principal investigator Sandra K. Hanneman, RN, PhD, FAAN, and her team discover new information about the effects of prolonged mechanical ventilation on critically ill patients.

Hanneman, associate dean for research and director of the Center for Nursing Research at the University of Texas-Houston (UT-Houston) School of Nursing and a past AACN board member, is using funding from the
National Institute of Nursing Research to test a new model for critical care research. The objectives of the study are to (1) develop an experimental model on weaning from mechanical ventilation in laboratory and patient populations, and (2) determine the effects of mechanical ventilation and weaning on biological time structures of hemodynamic, pulmonary, and metabolic functions.

“We suspect that critical illness and injury markedly disrupt biological time structures (biorhythms) of physiological function, leaving the patient without guidance from the body’s internal biological clock,” said Hanneman.

Hanneman and her team therefore wanted first to study the effects of critical care in a healthy model. The pig is an ideal model from a scientific point of view, because pigs are similar to humans with respect to cardiopulmonary, gastrointestinal, liver, and kidney function.

Fate, in the form of critical illness, took a hand in the research. Both of the pigs appeared healthy, but once on mechanical ventilation they developed a form of pneumonia that lives in farmyard dirt, to which they had been exposed before they came to the Texas Heart Institute. As a result, Hanneman and her team had to work with critically ill pigs instead of healthy ones. However, they succeeded in keeping the sedated pigs alive—1 for 5.5 days and the other for 7 days.

Previously, no one had done this in pigs for more than 24 hours.

What kept the pigs going?

“Excellent nursing care,” explained Hanneman. “The pigs received state-of-the-science care, just as if they were human ICU patients.”

The pigs—named Mikey and Opus—were cared for by a trio of expert clinicians, Jill Jesurum, RN, MN, CCRN, cardiovascular clinical nurse specialist at Swedish Medical Center Hospital in Seattle, Wash.; Raquel Guerrero, RN, senior clinician in the cardiovascular ICU at St. Luke’s Episcopal Hospital in Houston; and Anna Gawlinski, RN, DNSc, CCRN, cardiology clinical nurse specialist and acute care nurse practitioner at the University of California, Los Angeles. All are members of AACN. Baccalaureate nursing students and AACN student members B. Phillip Wilkerson, Julie Signori, Cesar De Los Rios, and Tim Phillips from UT-Houston also participated in the care of the pigs.

“This was the opportunity of a lifetime for our undergraduate students who are interested in critical care nursing,” said Anne Wojner, RN, MSN, CCRN, assistant professor at UT-Houston School of Nursing and president-elect of AACN.

The students were able to witness the integration of research and practice at the bedside, while experiencing first-hand the delivery of high-tech critical care nursing at its best.

Although the patients were large, domestic farm pigs, they were in specialty patient beds and received the benefit of the same technology that is used to care for human critically ill patients. Abbott Critical Care Systems; Diametrics Medical, Inc.; Hill-Rom; Mallinckrodt Medical, Inc.; SpaceLabs; and St. Luke’s Episcopal Hospital Department of Respiratory Care loaned equipment for the study.

The advance planning that went into trying to keep the pigs healthy while on the respirators was vital in providing data that may help significantly with critical care patients, Hanneman said. Data were gathered on the total parenteral nutrition provided to keep the pigs from losing body fat and muscle mass; body temperature, blood pressure, and blood gases; maintaining effective sedation over a long period of time; and the cost-benefit ratio of high technology.

Hanneman plans to publish several papers on a variety of these issues.

Gawlinski came to the porcine ICU from UCLA to compare continuous cardiac output and thermodilution cardiac output measurements. Because Mikey and Opus had transient hemorrhagic shock, Gawlinski was

able to obtain data in low-ejection fraction states. However, both pigs developed fever and their temperatures exceeded the functional range of the pulmonary artery catheter thermistor.

What Hanneman and her team learned from Mikey and Opus is that you can produce a critical care model of prolonged acute stress with a large animal, something that had not been done before.

“A lot of these data are going to be useful to both animal and human research communities,” she said. “The implications for nurses, anesthesiologists, nurse anesthetists, cardiac surgeons,
and intensivists who work with the problems of critically ill patients are important. You can use a large model that is similar to humans in cardiopulmonary, gastrointestinal, hepatic, and renal function, which provides a wide range of options for testing interventions such as weaning from mechanical ventilation.”

Hanneman said that more feasibility work is planned for the original question regarding the best time to wean the pigs from
the ventilators.

“In our next study, we will pretreat the pigs with antibiotics,” she said.

Deadlines Near for 2 Research Grants

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 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.

Neuroscience Nursing Means Embracing the Challenge

AACN News recently asked our neuroscience nurse members to share their perspective on their critical care specialty. Some responses appeared in the December issue. Following is another response:

By Elizabeth Chelette, RN, BSN, and
Mariann Haselman, RN, BSN, CNRN
Neuroscience ICU
Medical College of Virginia Hospital/Virginia
Commonwealth University
Richmond, Va.

Neuroscience nursing is a journey that can be challenging and tragic, yet incredibly rewarding. It offers a tremendous opportunity to serve others.

Neuroscience nurses give hope to the hopeless and friendship to the forsaken. They infuse a touch of unconditional love into another’s fractured reality by doing for them what they cannot do for themselves.

Our time in neuroscience nursing will not be remembered in years, but in moments in time. Included will be the privilege of calling a 16 year old’s mother to tell her her son has awakened from a coma and is asking for her. It will also include crying with a mother over the devastation of a gunshot wound to the head of her only son and supporting her decision to donate his organs so that others could live. Another moment in time will be writing notes to a patient’s family member 3 months, 6 months, or even 1 year later to let them know they and their loved one are not forgotten, and then receiving a response that says, “Your note came when I thought no one else cared. Thank you for taking time out of your schedule to think of me.”

Neuroscience nursing serves many patients who are facing death. Although death is a part of life, no one facing it ever finds it routine. This is where critical care nurses can help patients bear the unbearable and make a difference, not only in the lives of our patients but in the lives of those they leave behind.

Neuroscience nursing, whether it is long term or short term, will challenge you, stretch you, teach you, bring you tears and laughter, broaden your vision, and strengthen your faith. It will change your life. It offers the opportunity to meet and bond with patients for a brief time at a completely different level of experience. Being part of patients’ lives brings you more joy, because you are able to serve, infuse
hope, and help make their lives a little easier.

Little Things’ Can Make a Big Difference

Jane Skornia, RN, CCRN, is a nurse at St. John’s Mercy Hospital, Washington, Mo. 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 Skornia in connection with her award. For more information about the annual Circle of Excellence awards program, call (800) 899-AACN (2226).

By Jane Skornia

Cheryl and her husband, Brad, were on their way to a favorite restaurant with her in-laws when another driver crossed the centerline and hit their minivan almost head on. Brad’s mother died instantaneously from severe head injuries.

Brad’s younger brother was accompanied by his father, who was not injured, to another hospital.

Cheryl and Brad were admitted to my hospital. Brad, who was suffering from extensive arm lacerations and abrasions, was admitted to the medical floor. Cheryl, who had sustained an internal head injury, several rib fractures on her left side, and a lacerated spleen, was admitted to our ICU. I knew that each of these life-threatening injuries could cause complications.

A computed tomography scan indicated a small splenic laceration that appeared to have encapsulated itself, but continuous monitoring for any change in mental status, heart rate, blood pressure, urinary output, pain, and complete blood count (CBC) for signs of bleeding was imperative. If the spleen bled, Cheryl would require immediate surgery. I made sure Cheryl had 2 large bore intravenous sites and kept packed red blood cells on hand.

I constantly updated Cheryl and her parents on her condition. The first 3 CBCs showed a slow but steady decline in the hemoglobin and hematocrit. The fourth CBC not only stabilized, but also showed a slight increase. Everyone breathed a cautious sigh of relief.

Although the splenic laceration caused Cheryl slight discomfort, the rib fractures were painful. I knew this pain would not only hinder Cheryl’s use of the incentive spirometer but also inhibit coughing and deep breathing. Until Cheryl’s neurological condition improved, I knew that atelectasis would develop quickly and bring a whole new set of problems if effective pulmonary toileting was not accomplished. I intravenously administered meperidine hydrochloride (Demerol) for her pain, in increments sufficient to obtain comfort but to not cause a decrease in consciousness. By the end of my 12-hour shift, Cheryl could inspire 2 liters on the incentive spirometer; 2.5 liters was her target level. Except for slightly decreased breath sounds in the left lower lobe (LLL), her lungs remained clear.

Cheryl had lost consciousness at the accident scene. A CT of her head revealed a large frontal, soft tissue hematoma. Initially, she was combative and confused. Her neurological function had to be assessed every hour for indications of increased cerebral pressure.

Our hospital does not have a neuroscience surgeon on staff or intracranial pressure (ICP) monitoring. Patients with severe head injuries are transferred immediately by helicopter to a large medical center 45 minutes away. Those with stable head injuries are admitted to our ICU, but are transported to the medical center if they show any sign of deterioration.

Acute skills are needed to detect even the slightest change in a patient’s neurological condition, thus ensuring quick transfer if necessary. Fortunately, with each check, Cheryl became more lucid.

I have worked in critical care for 20 years. Our 11-bed ICU is a general unit, so I have cared for a variety of patients with a variety of diagnoses. I have learned to be prepared for the unexpected. I knew that there is more to critical care than monitoring an invasive line, titrating vasopressive drugs, or suctioning an endotracheal tube. These are necessary tasks, but at the heart of these activities is a human being with a life and a family, who deserve respect, truth, and compassion. It is the “little things” that may take the extra time you often don’t have but that mean so much. This is what I tried to give Cheryl and her family.

By the time Cheryl started to ask appropriate questions about what had happened, her parents were with her and were allowed to stay at her bedside along with Brad, who had been discharged.

I hugged Brad and told him how sorry I was about the death of his mother. I told him just to ask if there was anything I could do to make things easier.

I arranged for a telephone to be place in Cheryl’s room so that Brad could call the other hospital any time to talk to his father and check on his brother’s condition.

Cheryl’s parents were camping when they were notified of the accident. Her mother was exhausted and in need of a bath. I located an empty room where she could shower so that she wouldn’t have to leave the hospital.

Brad’s wound dressings had to be changed twice daily, but he had brought them with him and he did not want to leave his wife’s bedside. I gathered the necessary equipment, changed the dressing, and assured him that the other nurses would take care of him the following day.

Visitors were allowed including a priest, who helped to guide the family through grief.

At the end of my shift, I went to Cheryl’s room. This time Brad hugged me and thanked me for all I had done. This gesture made it all worthwhile.

The next day, Cheryl was transferred out of the ICU, and 2 days later her mother came to tell us that Cheryl was going home. Cheryl’s mother had a box of candy and a thank you card for all of us. She had a hug for me. “A special thank you for a special person,” she said.

Practice Resource Network:Frequently Asked Questions

Q:What resources are available to help nurses care for patients with pulmonary artery catheters and, in particular, zeroing transducers?

A:AACN has developed research-based protocols on hemodynamic monitoring, which includes the latest knowledge on how to provide care for patients who require arterial pressure monitoring, pulmonary artery pressure monitoring, cardiac output monitoring, and Svo2 monitoring.

These resources, funded by a grant from Abbott Critical Care Systems, Mountain View, Calif., contain easy-to-use information regarding the technology, its accuracy and precision, related occupational hazards, ethical considerations, competency issues, and practice recommendations with rationales. These 4 protocols are a good way to evaluate whether your hospital’s policy and procedures are up to date and evidence based.

The hemodynamic monitoring protocols can be purchased as a set or individually:
Complete Series: Item #170700
Arterial Pressure Monitoring: Item #170701
Pulmonary Artery Pressure Monitoring: Item #170702
Svo2 Monitoring: Item #170703
Cardiac Output Monitoring: Item #170704

To order or for more information on these or other protocol series, call (800) 899-AACN (2226), or visit the online Bookstore area of the AACN home page (http://www.aacn.org).

In addition, the “Ask the Experts” column published in the December 1997 issue of Critical Care Nurse discussed the correct reference site for an arterial catheter in the heart, which is identified externally by the phlebostatic axis (CCN. 17(6):96-97, 101-102). The controversy regarding proper reference location for arterial catheters has been hotly debated for years. This column describes the controversy and supports the use of the phlebostatic axis as the correct reference point. 

Vox Populi: Continuous IV Inotropic/Vasoactive Medication

In your facility, which continuous IV inotropic/vasoactive medications are administered in unmonitored medical/surgical units? Select all that apply, but do no include medications administered only during resuscitation.

 

Low-dose/renal dose Dopamine (<5 mcg/kg/min) 25%
Dopamine (>5mcg/kg/min) 3.6%
Dobutamine 4.3%
Amrinone or Milrinone 0%
Nitroglycerine 3.6%
Nitroprusside 1.4%
Other 3.6%
None 20%
Source: Volunteers in Participatory Sampling—a demographically representative sample of AACN members; 1998.
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