AACN News—June 1999—Practice

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Vol. 16, No. 6, JUNE 1999

Practice Resource Network: Orient New Nurses to Critical Care Practice

Q:What resources does AACN offer to assist with orientation of new nurses to critical care?

A:The growing shortage of critical care nurses has created a new need for hospitals to hire and orient increasing numbers of inexperienced nurses. New graduates and nurses with minimal critical care experience require a comprehensive orientation or internship program to maximize their success as critical care nurses. AACN has developed a variety of resources to help
with education, orientation and competency validation.

Orientation to the Care of the Acute and Critically Ill Patient
This comprehensive, eight-set resource is designed for use by hospitals in conducting their own unit- or institution-based orientation program. It provides up to 94 contact hours. The program includes everything critical care units need to begin their orientation course.

The eight modules cover basic ECG interpretation and all the major body systems (including specifics on diagnostics, nursing and medical intervention, assessment and evaluation). Each module contains an instructor manual, with course description, learning objectives, content outline and suggested time frames; a participant manual master for reproduction and a set of high-quality transparency overheads. The course evaluation tool, Competency Assessment Tool (CAT), and final exam provide a way to document successful completion of the program.

All materials are contained in three-ring binders and an expandable file folder. To receive a copy of the entire table of contents for each module, call Fax on Demand at 800-AACN-FAX (222-6329) and request Document #6503.

A sample of the Orientation to the Care of the Acute and Critically Ill Patient is also available for preview. Call (800) 899-AACN (2226), and request Product #120799

Critical Care Procedure Performance Evaluation
These performance checklists from the AACN Procedure Manual for Critical Care cover 177 skills. Many hospitals use these checklists in their orientation and ongoing competency assessment programs. The durable card stock forms are provided in a loose-leaf binder to allow for photocopying. Call (800) 899-AACN (2226), and request Product #128200.

Pocket Reference Cards
AACN offers a variety of quick reference cards to assist nurses in finding the information they need when they need it. You can choose from a variety of topics including Hemodynamic Management, Laboratory Values, Cardiovascular Medications, Pediatric Critical Care, Peripheral Nerve Stimulation and Drug Calculation and Delegation.

CCRN Review Course Video Series
These videotape programs are available for adult, pediatric and neonatal nurses. Each video series provides an overview of cardiovascular, pulmonary, endocrine, neurologic, hematology/immunology, gastrointestinal, renal and multisystem content. Some institutions use these resources to augment their adult, pediatric or neonatal critical care courses. Tapes may be purchased individually or as a complete program. Each program includes a syllabus and is available for contact hours. Call (800) 899-AACN (2226), and request Product #301960 (adult), Product #301900 (pediatric) or Product #301800 (neonatal).

Preceptor Training Program
This program offers both an instructor’s manual and a handbook that are designed to assist nurses function in their role as preceptors. Call (800) 899-AACN (2226), and request Product #120550 (Instructor Manual) or Product #120500 (Handbook).

AACN Web Site
The AACN Web site features education and competency content in various areas including “Practice/PRN” and “InfoLink” Discussion Board.
Information about these products can also be obtained through the AACN online bookstore.

Geriatric Corner: Adverse Drug Reactions and Age

In recent years, considerable attention has been focused on the factors that influence drug therapy in elderly patients. The fact that elderly patients have an increased frequency of adverse drug reactions is well-known in literature and in pharmacology discussions.

These reactions have been attributed to both pharmacokinetic (the time course of drug absorption, distribution, metabolism,and excretion) and pharmacodynamic (the clinical aspects of physiological responses to drug actions, i.e., compensatory homeostatic responses) deficiencies in the elderly patient. Most drug reactions in older patients are extensions of the expected effects of the drug. These adverse drug reactions may be responsible for more than 10% of hospital admissions of elderly patients as well as for lengthening hospital stays.

Normal Age-Related Changes
Drug Response—Aging can alter drug response. The physiological changes of aging can potentially affect pharmacokinetics, and some changes are more important than others.
Absorption—Despite the decrease in small-bowel surface area with aging, changes in drug absorption tend to be of little clinical consequence.
Distribution—A reduction in total body water and lean body mass and an increase in body fat, which is a normal age-related change, can contribute to higher concentration of drugs that are distributed in body fluids. This increased distribution and often prolonged elimination half-life of fat-soluble drugs may lead to medication problems. The clinical importance of decreased serum albumin levels and increased a1-acid glycoprotein with age is not well-established. Decreased serum albumin levels in a patient with an acute disease may lead to more problems.
Hepatic Metabolism—Age does not affect clearance of some drugs, usually those with relatively simple, one-step conjugation metabolism (e.g., Lorazepam, oxazepam). Older people are more likely to have reduced clearance of drugs with multistage metabolism (e.g., diazepam, chlordiazepoxide). Therefore, drugs with elimination that is less affected by age sometimes can be chosen.

Renal Elimination—Renal mass and renal blood flow decrease significantly with age. After age 30, creatinine clearance declines an average 8 mL/min/1.73 m2/decade, although about one-third of older people do not show any decline in creatinine clearance. Thus, the decline in glomerular filtration rate is relatively predictable, though not universal. These physiologic changes have profound effects on renal drug elimination, which is decreased in older people. Therefore, because renal function is dynamic, maintenance doses of drugs should be adjusted in patients who are acutely ill or dehydrated.
Adverse Drug Reactions—A higher frequency of adverse drug reactions in the elderly is attributed not to a patient’s chronological age, but to the fact that they consume more medications and are more likely to have baseline illness than younger patients.

Following are common types of adverse drug reactions in the elderly:
• Primary drug reactions (one drug-one side effect)
• Cimetidine psychosis
• Narcotic-induced respiratory depression

• Lidocaine psychosis
• Theophylline seizures
• Insulin reaction
• Chronic salicylism
• Secondary drug interactions (requires at least two drugs to cause interaction)
• Sulfonylurea/sulfonamide
• Cimetidine/theophylline
• Erythromycin/theophylline
• Indomethacin/propranolol
• Tricyclic antidepressant/alpha-sympatholytic
• Drug withdrawal syndromes (addictive and non-addictive withdrawal)
• Beta-blocker withdrawal
• Calcium channel-blocker withdrawal (angina, hypertension)
• “Addictive drug” withdrawal syndromes (benzodiazepines, narcotics, etc.)
• Tertiary �extrapharmocologic� effects (measurable only by epidemiologic studies)
• Falls caused by tricyclics, anxiolytics, and antipsychotics (short half-life versus long half-life agents)
• Traumatic injuries caused by drug-induced orthostatic hypotension

The Role of the Critical Care Nurse
The avoidance of adverse drug reactions is a rational goal, though it is difficult in the elderly patient. Age-related impairment of renal excretion and hepatic metabolism, and less adaptive homeostatic mechanisms of the cardiovascular, renal, respiratory, neurologic and endocrine systems make the older patient more sensitive to usual drug doses and to drug-drug interactions.

Following are some guidelines to drug therapy in the elderly patient:
• Establish a diagnosis before treating. Drug therapy should be considered for a definite period of time or a definite symptomatic or biochemical end point.
• Frequently review the patient’s drug regimen. The elderly patient with multiple diseases usually is treated with multiple drugs. Be sure to include over the counter medications.
• Minimize the number of drugs used. Review the pharmacologic actions of the drug(s) and their mode of inactivation or elimination from the body. Monitor the patient for both therapeutic and adverse effects. Use the lowest dose that is
effective in the individual patient.

When symptoms that mimic stereotypes associated with old age (forgetfulness, weakness, confusion, anorexia, anxiety) are encountered, suspect a drug reaction as a contributing factor. This is especially true if the patient is receiving a psychotropic drug, sedative-hypnotic, or drugs affecting cardiac output or the renal system.

Suggested Reading
Bressler R, Katz MD. Geriatric Pharmacology. New York, NY; McGraw-Hill, Inc.; 1993.
Gallo JJ, Reichel W, Andersen, LM. Handbook of Geriatric Assessment. Gaithersburg, Md; Aspen Publishers; 1995.
Abrams WB, Beers MH, and Berkow R, eds. The Merck Manual of Geriatrics. 2nd ed. Whitehouse Station, NJ; Merck & Co., Inc.; 1995.
Timiras PS, ed. Physiological Basis of Aging and Geriatrics. 2nd ed. Boca Raton, Fla.; CRC Press, Inc.; 1994.
Mathewson-Kuhn M. Pharmacotherapeutics: A Nursing Process Approach. 3rd ed. Philadelphia, Pa.; F.A Davis Company; 1994.

Give Us Your Feedback

Have you made any changes to your practice as a result of reading the “Geriatric Corner” column each month in AACN News? Was the information regarding the care of the older adult useful? Would you like to see a column similar to this one continue to appear in the AACN News? Let us know. Contact AACN Clinical Practice Specialist Justine Medina, RN, MS, CCRN, at (800) 394-5995, ext. 401; fax, (949) 448-5520; e-mail, Justine.Medina@aacn.org.

How Would You Describe Advanced Practice Nursing?

AACN’s Advanced Practice Group is seeking feedback on the following proposed description of advanced practice nursing roles. In addition to feedback on wording and content, the group would like to know if advanced practice nurses feel this type of formal description would be helpful in their practices.

Forward your comments to the Practice Resource Network (PRN) at (800) 395-5995, ext. 217, or e-mail Advanced Practice Director Megan Whalen, RN, MS, at Megan.Whalen@aacn.org.

All About Advanced Practice
An advanced practice nurse (APN) is a nurse who has received advanced education at the graduate level, or higher. Advanced practice nurses provide healthcare to patients and families and demonstrate a high level of independence.

Advanced practice nurses combine clinical practice with education, research, consultation and leadership.

According to the American Nurses Association, there are four categories of APN: nurse midwife, nurse anesthetist, clinical nurse specialist (CNS) and nurse practitioner (NP). Nurse anesthetists and nurse midwives perform very specific roles, as described by their titles, and are found mainly in the operating room and the labor and delivery area, respectively.

CNSs and NPs are employed in inpatient and outpatient settings including critical care, acute care, neonatal intensive care, long-term care, psychiatric settings, clinics, physicians offices, ambulatory surgery, schools and even patients’ homes. Many advanced practice nurses are nationally certified.

CNSs and NPs comprise the largest number of APNs in healthcare and perform a wide variety of roles. The APN is a clinical expert in a specific area of patient care. Clinical nurse specialists and nurse practitioners teach and mentor nursing staff, educate patients and families, and create teaching materials for a specific type of patient. The APN assists in the management of patients from those seeking routine healthcare to those who are acutely and chronically ill.

As an expert, the APN consults with staff nurses to increase their understanding of diseases, treatments and other aspects of patient care. In addition the APN works with physicians, respiratory therapists, occupational and physical therapists, nutritionists and others to provide care to patients and families. Advanced practice nurses develop programs, tools and procedures to improve healthcare for patients.

Research is also part of the APN role. With advanced education and training, the APN is able to conduct research to define evidence-based practices. The APN also uses current research findings to make the care provided to patients and

families better.

Nurse practitioners may be divided into areas of specialty such as Family, Adult, Pediatric, Geriatric or Acute Care. Some activities of the NP include health history and risk appraisal, interpretation of diagnostic tests, providing treatment, which may include prescribing medications. The NP participates in health promotion and preventive care within their specialized area of practice.

An increasing demand for NPs within the acute and critical care settings has led to an increase in the number of NPs practicing in the hospital setting. While primary care NPs focus on community-based care in an outpatient setting, acute care NPs focus on making clinical decisions related to complex patient care problems encountered in the acute care setting.

The clinical nurse specialist is an expert clinician in a particular specialty of nursing practice. The CNS is responsible for the identification and intervention of clinical problems and in the management of those problems to improve care for patients and families.

Foremost, CNSs provide direct patient care including assessing, diagnosing, planning, and prescribing pharmacologic and nonpharmacologic treatment of health problems.

The CNS participates in health promotion and preventive care within a specialized area of practice. In addition to direct practice, CNSs may also guide the development of evidence-based standards and practice protocols and provide clinical consultation and leadership to other health care providers. Patient, family and staff education is also a function of the CNS role.

Although CNSs are independent in their practice, they frequently work with other healthcare disciplines to coordinate the care of patients. CNSs have traditionally practiced in the acute or critical care settings within the hospital, although there has been a recent trend to move into the community-based care settings and outpatient clinics. Regardless of the practice specialty, APNs enable comprehensive coordinated care for patients, families and staff.

Research Grants and Awards Part of Circle of Excellence

Nursing research grants and awards are part of the AACN Circle of Excellence recognition program. The deadlines for these awards vary. Following are brief descriptions of the grants and awards that are available:

AACN Distinguished Research Lecturer Award
This award honors a nationally known researcher who will present the annual Distinguished Research Lecture at the 2001 NTI. The lecturer receives an honorarium of $1000 and $1000 toward NTI expenses. Nov. 1, 1999, is the deadline for next year’s award.

AACN Research Abstract Award
This award recognizes research abstracts that display outstanding scientific merit and particular relevance to critical care nursing.

Up to three research abstract awards and one research utilization abstract award will be selected. The presenters receive $1000 toward NTI expenses. Recipients will be selected from among the research and research utilization abstracts submitted for the 2000 NTI. September 1, 1999, is the deadline to submit abstracts.

Research Grants
• Sigma Theta Tau-AACN Critical Care Grant—deadline October 1, 1999

• AACN Clinical Inquiry Grants—deadlines July 1, 1999, and January 1, 2000.

• Medtronic/Physio Control-AACN Small Projects Grants—deadline January 15, 2000

• Mallinckrodt-AACN Mentorship Grant—deadline February 1, 2000

• AACN Clinical Practice Grants—deadline October 1, 1999

• Hewlett-Packard-AACN Critical Care Nursing Research Grant—deadline July 1, 1999

• American Nurses Foundation-AACN Research Grant—Deadline May 1, 2000

• AACN Data-Driven Clinical Practice Grant—deadlines October 1, 1999, and March 1, 2000

• AACN Critical Care Research Grant—deadline February 1, 2000

For more information about these Circle of Excellence grants and awards, call the National Office at (800) 899-AACN (2226) or visit the AACN Web site at http://www.aacn.org.

National Research Conference Set for September, 1999

The National Nursing Research Conference, titled “Better Health Through Nursing Research,” is scheduled for September 15 through 18, 1999, in Washington, D.C.

Cosponsored by 19 nursing organizations including AACN, the State of the Science Congress will include more than 140 papers, more than 60 posters, and exhibits by some of the top research funders.

A special “Nightingala” pre-event, hosted by the Friends of the National Institute of Nursing Research, is also planned.

The purpose of the congress is to identify areas in nursing research with substantive growth in the 1990s, to summarize previous research and to project future research directions and clinical applications. The conference serves as a forum for developing research agendas, articulating issues and discussing needs of research training as well as for discussing current research and its dissemination and utilization.

Additional information on the congress is available online at http://www.nursingworld.org/aan/nnrc.htm. The conference registration form is available on this site.

Apply for a Research Grant

July 1, 1999, is the deadline for two nursing research grants that are available through AACN. Following is information about each grant.

Hewlett-Packard-AACN Critical Care Nursing Research Grant
Sponsored by Hewlett-Packard Company, this grant awards $30,000 for studies that are preferably related to the technological requirements of patient management in acute and critical care.

In addition, $2000 in travel expenses, an HP Vectra personal computer, HP printer, and associated utility software is presented to the recipient of the grant. Eligible applicants must be AACN members and have an active RN license. The grant may be used to fund research that is associated with an academic degree.

Applications must be received by July 1, 1999. To obtain an application, call (800) 934-7372 or visit the Hewlett-Packard Web site at http://www.hp.com/go/healthcare. Access grant information by clicking on the grant title found on the blue scroll bar on the Hewlett-Packard home page. If you have additional questions, contact the Research Department at AACN, (800) 809-2273, ext.335.

AACN Clinical Inquiry Grants
These grants provide up to $250 to support projects that will directly benefit patients and their families.

Funds will be awarded for projects that address one or more AACN research priority and that link to AACN's vision of a healthcare system driven by the needs of patients and their families. To be eligible, the principal investigator must be an RN, an AACN member, employed in a clinical setting, and directly involved in patient care.

Applications must be received by July 1, 1999. To obtain an application, call (800) 899-AACN (2226).

For additional information about nursing research grants that are available from AACN, call (800) 899-AACN (2226).

Vox Populi: Staffing and Patient Classification

What is the primary patient classification system used at your hospital?


GRASP 6.2%
Medicus 23.9%
TISS 0.9%
Meditech 9.7%
APACHE 14.2%
CCT 0%
Developed own 17.7%
A combination of systems 0.9%
Do not use 25.7%
Other 0.9%

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

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