AACN News—March 1999—Practice

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Vol. 16, No. 3, MARCH 1999


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I am developing a protocol for pulmonary artery catheter removal by staff RNs. Would you be willing to share a protocol or guideline used at your facility? I am also interested in finding out what other institutions are doing to train and validate competency.
Contact Anne Mitchell at (619) 532-9072; fax, (619) 532-9091;
e-mail, Magiku@simplyweb.net.

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). You also can post InfoLink questions online. Go to http://www.aacn.org and click on “InfoLink.”

Geriatric Corner: To Turn or Not to Turn?

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

As many as 3 million people suffer each year from pressure sores or decubitus ulcers, which are produced by excessive and prolonged pressure to a limited surface area. The annual cost of caring for these patients exceeds $5 billion.

Less than 20% of decubitus ulcers develop in nursing homes or home care settings; more than 60% develop in acute care settings.

Normal Age-Related Skin Changes
The skin consists of three main layers—epidermis, dermis, and hypodermis. As people age, the epidermis becomes thin and flattened, particularly over bony prominences, forearms, lower legs, and the dorsal surfaces of hands and feet.

Because of this thinning, veins appear more prominent.

The dermis is the thick connective tissue layer consisting of collagen, elastic, and reticulin fibers that provides support to the skin. The dermis, which is highly vascular, contains sensory nerve endings, hair follicles, eccrine glands, apocrine (sweat) glands, and sebaceous (oil) glands. In addition, the dermis partially controls temperature regulation through blood vessel and apocrine gland activity. As people age, less collagen is formed and there is a decreased amount of elastic fiber, resulting in a more wrinkled appearance. The overall degeneration of the connective tissue, coupled with a decrease in total body water, contributes to decreased skin turgor.

The deepest layer is the hypodermis, or subcutaneous layer, where fat is manufactured and stored. This layer also insulates and cushions the body.

In addition to facilitating skin breakdown, these age-related changes may do the following:
a. Mask signs of ischemia (e.g., erythema and warmth from engorged red blood corpuscles in the capillaries may not be evident because of reduced blood flow)
b. Delay wound healing due to slower epithelization
c. Diminish pain sensation felt at a pressure area
d. Favor skin breakdown due to decreased elasticity
e. Diminish cell-mediated immunity

Pathophysiology and Risk Factors
Pressure ulcers occur as a result of the following four major factors:
1. Excessive and prolonged pressure over a limited surface area
a. Pressure results in decreased transcutaneous oxygen tension, vessel leakage, lack of nutrients, and accumulation of toxic metabolites with subsequent necrosis of muscle, subcutaneous tissue, dermis, and epidermis.
b. Area of ischemia is cone shaped, with the wide base in the deeper tissues.
c. Almost all pressure ulcers develop at 5 classic sites (sacrum, ischium, greater trochanter, tuberosity of calcaneus, and lateral malleolus).
2. Shearing force
a. This term refers to the sliding of adjacent surfaces with distortion of subcutaneous vessels and resulting tissue ischemia and necrosis.
b. It typically occurs when the head of the bed is raised and the body slides downward, causing a compressive force on the posterior sacral tissues.
3. Friction
a. This usually occurs when an individual is pulled across the bed linen.
b. Friction removes the protective stratum corneum and can result in development of intra-epidermal blisters.

4. Moisture
a. This macerates tissue and predisposes the skin to break down.
b. It is generally secondary to fecal and urinary incontinence and perspiration.

Contributing Factors
1. Age-related changes
2. Poor nutritional status (may be secondary to other factors such as immobility, financial hardship, isolation, poor dentition, or confusion)
3. Stroke, fractures, bed or wheelchair confinement, impaired consciousness, weight loss, and hypotension, all independently associated with pressure sore formation

Prevention Is Always the Best Nursing
• Decrease pressure by repositioning and by using pressure-relieving mattresses.
• Minimize shearing force by avoiding prolonged, head-elevated position in bed.
• Decrease friction by using drawsheets to position patients, and try to position patients to decrease the degree of sliding down in bed.
• Minimize moisture.
• Assess and evaluate nutritional status.
• Encourage activity and mobility.
• Assess patients early and often for risk factors and institute preventative measures for high-risk patients. Many institutions use screening tools such as the Braden scale and Norton scale.

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 Resources
1. Gallo JJ, Reichel W, Andersen LM. Physical assessment. Handbook of Geriatric Assessment. Gaithersburg, Md: Aspen Publishers, Inc; 1995:chap 7.
2. National Gerontological Nursing Association; Luggen AS, ed. Core Curriculum for Gerontological Nursing. St Louis, Mo: Mosby-Year Book; 1996.
3. Clinical Practice Guideline Number 3: Pressure Ulcers in Adults: Prediction and Prevention. Rockville, Md: US Dept of Health and Human Services, Agency for Health Care Policy and Research, Public Health Service; May 1992. AHCPR publication 92-0047.
4. Clinical Practice Guideline Number 15: Treatment of Pressure Ulcers. Rockville, Md: US Dept of Health and Human Services, Agency for Health Care Policy and Research, Public Health Service; December 1994. AHCPR publication 95-0652.
5. Braden BJ, Bergstrom N. Clinical utility of the Braden scale for predicting pressure sore risk. Decubitus. 1989;2(3):44-55.
6. Norton D. Calculating the risk: reflections on the Norton scale. Decubitus. 1989;2(3):24-31.

Grant Supports Research

May 1, 1999, is the deadline to submit applications for the $3500 AACN Research Grant, which is awarded annually to support research relevant to critical care nursing practice.

The grant, which is sponsored by AACN, is administered by the American Nurses Foundation (ANF).

This program is designed for beginning nurse researchers or experienced nurse researchers who are entering a new field of study. The principal investigator must be an RN who has obtained a baccalaureate or higher degree in nursing.

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.

SCCM Course Offered With 1999 NTI/API in May

A special course on May 15 and 16, 1999, in conjunction with the National Teaching Institute™ and Advanced Practice Institute™ in New Orleans, La., will feature the Fundamental Critical Care Support Course created by the Society of Critical Care Medicine (SCCM).

The NTI, which also features five educational tracks, and the API will be May 16 through 20.

The target audience for the Fundamental Critical Care Support Course is experienced critical care nurses who are seeking a provider course that they can offer in their institutions.

A lecture format is planned the first day. Skills stations focusing on mechanical ventilation, vascular access, trauma, neurological support, and electrolyte metabolic disturbances will be offered the second day.

The course offers an approach to initial management of the critically ill patient and extended care over the first 24 hours as well as guidance for acute problems encountered in the ICU and for sudden patient deterioration.

Participants will find the course highly structured. High-tech slides, a CD-ROM, and a textbook, which can also be used as a reference tool, will be provided.

Presentation of the Fundamental Critical Care Support Course is cosponsored by AACN and SCCM.

For more information or to register, call (800) 899-AACN (2226) or visit the NTI Web site.

Practice Resource Network: Frequently Asked Questions: Caring for Patients With an Indwelling Pericardial Catheter

QWe recently began caring for patients with pericardial drains in our critical care unit. Does AACN offer resources to assist us in caring for these patients?

AAACN recently published an article titled “Care of Patients With an Indwelling Pericardial Catheter” in Critical Care Nurse. This article is also available in the “Earn CE” area of the AACN Web site at www.aacn.org. Readers have told us that this article has been a helpful resource at the bedside as well as in developing nursing policies and procedures related to pericardial drains.

Pericardial catheters are indwelling catheters placed between the 2 layers of pericardium to drain recurrent pericardial effusions or infuse medications to the pericardial space. Catheter blockage and infection are the greatest concerns when caring for patients with indwelling pericardial catheters.

Catheter blockage is best prevented through proper positioning and securing of the catheter, tubing, and drainage system. Slow, continuous drainage is best obtained by positioning the drainage system lower than the insertion point.

Normally, the pericardial space contains 10 mL to 50 mL. The actual amount of drainage varies from patient to patient.

To prevent infection, maintain a clean, dry, and intact dressing over the site, and replace it when soiled, loosened, or wet. When changing the dressing, clean around the site with hydrogen peroxide, followed by a povidone-iodine solution.

Apply an occlusive, sterile gauze dressing around the catheter. Maintain a closed system with tight connections to prevent entry of organisms via the stopcocks, drainage tubing, or collection bags. Meticulously clean all ports with alcohol prior to aspiration or medication administration. Some centers recommend culturing the fluid daily to detect infection at the earliest stage. Avoid frequent emptying and changing of drainage bags. Examine the fluid for color and consistency changes. Normal fluid is clear and straw-colored, similar to chest tube drainage.

Source
Hamel WJ. Care of patients with an indwelling pericardial catheter. Crit Care Nurs. 1998;18(5):40-45.

Reprints are available from InnoVision Communications, 101 Columbia, Aliso Viejo, CA 92656; phone, (800) 899-1712 or (949) 362-2050 (ext. 515); fax, (949) 362-2049; e-mail, ivcReprint@aol.com.

What’s the Difference? CNS and NP Complement One Another

Editor's note: In October 1998, AACN’s Advanced Practice Work Group discussed the similarities and differences between the clinical nurse specialist (CNS) and acute care nurse practitioner (ACNP) roles. The group concluded that there were more similarities than differences in these roles, and that the manner in which the roles were enacted was driven by the individual advanced practice nurse’s expertise and perceived value of the subroles, combined with patient, staff, and overall institutional needs. In fact, some CNSs may practice in a manner more consistent with a traditional nurse practitioner (NP) role, whereas some NPs may function in a role that mirrors traditional CNS practice. AACN values both of these important roles and supports a collegial/complementary working relationship to meet the needs of patients, families, staff, and healthcare institutions. In this article, Carin Mehan, RN, MS, ACNP, an NP, and Sue Sendelbach, RN, MS, a CNS, describe how their roles complemented the services they provided when both were employed in the Department of Nursing at Abbott Northwestern Hospital in Minneapolis, Minn. Mehan, who is now with Medtronic, Inc., Minneapolis, practiced at the time in collaboration with cardiologists. Sendelbach continues to work at Abbott Northwestern as a population-based CNS in cardiovascular surgery.

By Carin Mehan
and Sue Sendelbach

The CNS role was developed as part of an effort to decrease the fragmentation of patient care in the midst of knowledge explosion of new technology and the increasing complex healthcare system. The first CNS program was established in 1954 at Rutgers University. The first NP program was developed collaboratively by nurses and physicians in 1965 at the University of Colorado, Boulder. Creation of the NP role was part of an effort to expand the nursing role and to solve dilemmas in the healthcare delivery system such as inequitable distribution of providers, escalating costs, a predominance of specialists and subspecialists, and a shortage of primary care providers.

Mehan and Sendelbach agree that their roles as an NP and a CNS, respectively, share the components of expert clinician, educator, consultant, collaborator, and researcher. Nursing theory and leadership were the foundations of graduate education. Mehan’s acute care nurse practitioner (ACNP) education was concentrated in the diagnosis and management of common acute illnesses, disease prevention, health promotion, and management of stable, chronic illness. Sendelbach’s education focused on the patient’s response to illness, patterns involved in their response, nursing interventions, and research.

How Their Daily Roles Differed
The main focus of Mehan’s ACNP role, in working in collaboration with a cardiologist, was to see preoperative patients for open heart surgery (OHS) or invasive cardiovascular procedures. She performed patient history and physical exam, and communicated the plan of care to the referring physician. Mehan made daily rounds in the cardiovascular surgery ICU, the cardiac care unit, and telemetry units, and wrote orders and progress notes on her patients. In addition to ongoing patient education, Mehan was responsible for prescribing medications, billing, and triaging patient phone calls.

In the CNS role, Sendelbach focuses on research and integrating evidenced-based research and best practice into the care of OHS patients. Sendelbach facilitates the interdisciplinary group that looks at clinical practice, facilitates the practice change, and is responsible for monitoring patient outcomes in response to the practice change. The interdisciplinary group, which involves physicians, nurses, administrators, and finance, is the key to the success of any practice change. This approach has been used in patient extubation, activity guidelines, and pain management after OHS.

How the Roles Work Together
The following example describes how Mehan and Sendelbach worked together to better manage a patient’s postoperative cardiac surgical care. Historically, OHS patients have been transferred out of the ICU only after they have been seen by and had their orders written by the cardiovascular surgeon and cardiologist. Although many patients were ready to go to the telemetry unit the morning after surgery, physicians’ busy schedules delayed the writing of necessary transfer orders. In addition, telemetry unit beds were not always open for transferring patients. As a result, some patients who were ready to be cared for on a telemetry unit had to wait.

To address the problem, Sendelbach facilitated a multidisciplinary group whose goal was to create systems that would allow patients to be placed on the units where the care was most appropriate for their needs. The group included cardiovascular surgeons, cardiologists, internists, nurses from the ICU and telemetry units, and the nurse practitioners. Sendelbach worked with the group on the planning, implementation, and evaluation of patient outcomes with this new initiative. The outcome of the group’s work was the development of standardized orders, which allowed patients to be transferred from the ICU on postoperative day 1 to the telemetry unit when they met specific criteria. This change allowed staff on the telemetry unit to plan for the patient transfer, reserve a room, and assign a nurse. The percentage of patients transferred by 9:30 am rose from 1% to approximately 30%, with no increase in re-admission.

One of Mehan’s priorities was to see OHS patients on the day of surgery. At that time, Mehan would examine the patient, write a progress note, and fill out telemetry orders that had not already been completed. Because patients were being transferred out of the ICU early in the morning on postoperative day 1, Mehan was able to go directly to the telemetry unit to see her patients. She was able to provide one perspective of the transfer process and identify issues that could enhance the transition for patient and telemetry staff nurse.

Mehan and Sendelbach believe the roles of the CNS and NP are complementary and enhance patient care. They were able to function in the same institution effectively. Mehan and Sendelbach respected the contributions each of their roles provided to patients. Both could agree on and had a very clear understanding of each other’s scope of practice. And both recognized how important collaboration and professionalism were to maintaining a successful working relationship not only for themselves but also for patients and multidisciplinary team members.

Suggested Reading
1. Fenton MV, Brykczynski KA. Qualitative distinctions and similarities in the practice of clinical nurse specialists and nurse practitioners. J Prof Nurs. 1993:9(6):313-326.
2. Lithgow D, Kleinpell R. Roles, issues, policies, and trends. In: Gawlinski A, Hamwi D eds. Acute Care Nurse Practitioner Clinical Curriculum and Certification Review. Philadelphia, Pa: WB Saunders: 1999:950-994.
3. Wojner AW, Rauch P, Mokracek M. Collaborative ventures in outcomes management: roles and responsibilities in a service line model. Crit Care Nurs Q. 1997;19(4):25-41.
4. Gawlinski A, Kern LS. The Clinical Nurse Specialist Role in Critical Care. Aliso Viejo, Calif: AACN; 1994.