AACN News—October 1999—Practice

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Vol. 16, No. 10, OCTOBER 1999


Thunder Project Data Collection Completed

Data collection for Thunder Project II has been completed, and analysis of the extensive data from more than 6,000 patients is under way.

A total of 161 sites participated in the multisite research project, which studied the pain perceptions and responses of critically ill patients to six commonly performed clinical procedures—tracheal suctioning, nonburn wound care, drain removal, turning, femoral sheath removal and central line placement.

The study included children age 3 and older, as well as adults. A total of 21 sites collected data on children. Femoral sheath removal, turning and tracheal suctioning were the most common procedures at sites studying adult patients. Turning and tracheal suctioning were more prevalent at pediatric sites.

Results of the study are expected to be analyzed and a manuscript ready for submission by the end of the year. The Thunder Project II Task Force is also scheduled to present the findings at the National Teaching Institute,™ May 20 through 25, 2000, in Orlando, Fla.

The task force thanks the nurses who coordinated study activities and participated in data collection and the institutions that served as study sites for their valuable contributions to this project.

Thunder II Data Collection Coordinators and Sites

Jacqueline Brock, RN, MSN, CCRN
Parkland Health and Hospital System
Dallas, Tex.


Bernice Budz, RN, MSN, CNCC
St. Paul’s Hospital
Providence Healthcare
Vancouver, British Columbia, Canada


Joey Chickering, RN, CCRC
Northern Michigan Hospital
NISUS Research
Petoskey, Mich.


Shauna Andrus, RN, BSN, CCRN
University of Washington
Medical Center
Seattle, Wash.


Cindy Davis, RN, MSN, CCRN
Cleveland Regional Medical Center
Shelby, N.C.


Joan Deal, RN, MSN
Lynchburg General Hospital
Lynchburg, Va.


Laura Devine Jacob, RN, MSN
Swedish Covenant Hospital
Chicago, Ill.


Jill Donaldson, RN, MSN, CCRN
Mission Regional Medical Center
Mission Viejo, Calif.


Marty Douglas, RN, DNSc, CCRN
VA Palo Alto Health Care System
Palo Alto, Calif.


Donna Garrett, RN
Butterworth Hospital
Grand Rapids, Mich.


Yvonne Ford, RN, MS
Blodgett Memorial Medical Center
Grand Rapids, Mich.


Bradi Granger, RN, MSN
Duke University Heart Center
Durham, N.C.


Cathy Headrick, RN, MS, APN
Children’s Medical Center
of Dallas
Dallas, Tex.


Sydney Lange, RN, MSN, CCRN
Presbyterian Healthcare System
Charlottesville, N.C.


Carol Higgins, RN, MSN, CCRN
McLaren Regional Medical Center
Flint, Mich.


Kathleen Hudson, RN, MS, CCRN
Wesley Hospital
Brisbane, Queensland, Australia


Sue Hughes, RN, MS, OCN
Jewish Hospital
Louisville, Ky.


Brenda Mygrant, RN, MSN, CCRN
Brooke Army Medical Center
San Antonio, Tex.


Flerida Imperial-Perez, RN, MN
UCLA Medical Center
Los Angeles, Calif.
Cherimarie James, RN
VA Medical Center
San Diego, Calif.


Lisa Jarvis, RN, MSN, CCRN
Robert Packer Hospital
Sayre, Pa.


Nancy Jones, RN, MSN
Sentara Norfolk General Hospital
Norfolk, Va.


Brenda Chilton, RN
Legacy Good Samaritan Hospital
Emanuel Hospital
Portland, Ore.


Karen Knight, RN
San Joaquin General Hospital
Stockton, Calif.


Tonya Kraus, RN, MSN
Inova Institute of Research
and Education
Falls Church, Va.


Melva Kravitz, RN, PhD
Yale-New Haven Hospital
New Haven, Conn.


Brenda Lastrilla, RN, BSN
Community Memorial Hospital
Menomonee Falls, Wis.


June Curran, RN, MSN, CCRN
Hospital of the University
of Pennsylvania
Bear, Del.


Kathy Dittmann
Memorial Hospital
York, Pa.


Brenda Luffman, RN, BNSc
Kingston General Hospital
Kingston, Ontario, Canada


Kay Luft, RN, MN, CEN
Saint Luke’s Hospital of Kansas City
Kansas City, Mo.


Dianne Marshburn, RN, MSN, CNA
Pitt County Memorial Hospital
Greenville, N.C.


Cheryl Mattas, RN, MS, CCRN
Palomar Hospital Medical Center
Escondido, Calif.


Katherine McWhorter, RN, MSN, CCRN
St. Tammany Parish Hospital
Covington, La.


Carol Metcalf, RN, MN
Harborview Medical Center
Seattle, Wash.


Wanda Moore, RN, MS, CCRN
Phelps Memorial Hospital Center
North Tarrytown, N.Y.


Jody Osteyee, RN, CPNP, CCRN
Primary Children’s Medical Center
Salt Lake City, Utah


Lisa Baldwin Halvorsen, RN, MS, CS
CCRN
Providence Portland Medical Center
Portland, Ore.


Deborah Courtney, RN, MS
Maine Medical Center
Portland, Maine


Lori Riley, RN, MS
Keesler Medical Center
Keesler AFB, Miss.


Cherie Wieder, RN
Easton Hospital
Easton, Pa.


Cindy Russell, RN
University of Missouri-Columbia
Columbia, Mo.


Carolyn Santora, RN, MSN
University Hospital at Stony Brook
Stony Brook, N.Y.


Rosemary Scoppetuolo, RN, BSN
Clara Maass Medical Center
Nelleville, NJ


Julie Shurba, RN, BS, CCRN
Gottlieb Hospital
Melrose Park, Ill.


Maria Laslop, RN, MSN
Hospital for Sick Children
Toronto, Ontario, Canada


Heidi Summers, RN, MN
David Grant Medical Center
Vacaville, Calif.


Janet Swanson, RN, BSN, CCRN
Winchester Medical Center
Winchester, Va.


Andrea Valenta, RN, MSN, CCRN
Washington Hospital Center
Washington, D.C.


Michaelynn Paul, RN, BSN, CCRN
Adventist Medical Center
Portland, Ore.


Jan Shanahan, RN, MSN, CCRN
Sparrow Health System
Lansing, Mich.


Sarah Zacharias, RN, MSN, CCRN
Denver Health Medical Center
Denver, Colo.


Rebecca Zapatochny Rufo, RN, MSN,
CCRN
Resurrection Medical Center
Chicago, Ill.


Kori Zirbel, RN, MS
Mercy Heart Institute
Sacramento, Calif.


Diane Brown, RN, MSN
Hoag Memorial Hospital
Newport Beach, Calif.


Rosemary Keller, RN, PhD
University of South Florida
College of Nursing
Tampa, Fla.


Suzanne Savoy, RN, MN, CS, CNRN,
CCRN
Saginaw General Hospital
Saginaw, Mich.


Emily Garofalo, RN, CNIV
Medical College of Virginia
Hospitals
Richmond, Va.


Audrey Wiggan, RN, MSN, CCRN,
CNS
Bayfront Medical Center
St. Petersburg, Fla.


Janice Hull, RN, MS
UCSF Medical Center
San Francisco, Calif.
Margaret Rollins, RN, MSN, CCRN
Medical College of Georgia Hospitals and Clinics
Augusta, Ga.


Mae Ann Fuss, RN, MSN, CCRN
Lehigh Valley Hospital
Allentown, Pa.


Janice L. Ables, RN, MSN, CCRN
Malcolm Grow Medical Center
Andrews AFB, Md.


Denise L.C. Adams, RN, MSN
Henry Ford Hospital
Detroit, Mich.


Shirley Ambutas, RN, MS, CCRN
St. Joseph Medical Center
Joliet, Ill.


Connie Barden, RN, MSN, CCRN
Mt. Sinai Medical Center
Miami Beach, Fla.


Rhonda Armour, RN, MSN
Zale Lipshy University Hospital
Dallas, Tex.


Joan Beard, RN, BSN
Mercy Hospital Medical Center
Des Moines, Iowa


Tamara Pastor-Lacey, RN, MSN,
CCRN, CEN, ACNP
Wilford Hall Medical Center
Lackland AFB, Tex.


Cecilia Beauprie, RN, MSN, CCRN
Saint Mary of Nazareth
Hospital Center
Chicago, Ill.


Nancy Blake, RN, MN
Children’s Hospital of Los Angeles
Los Angeles, Calif.


Christine Green, RN, MSN
Cardinal Glennon Children’s
Hospital
St. Louis, Mo.


Marion Broome, RN, PhD, FAAN
Children’s Hospital of Wisconsin
Milwaukee, Wis.
Carol Brudenell, RN, MSN, AOCN
North Ridge Medical Center
Ft. Lauderdale, Fla.


Pat Burkle, RN, MS, CS, CCRN
Good Shepherd Medical Center
Longview, Tex.


Diana Butorac, RN, MSN, CCRN
VA Medical Center-Nashville
Nashville, Tenn.


Vickie Byler, RN, MSN
Rex Healthcare
Raliegh, N.C.


Diane Carroll, RN, PhD
Massachusetts General Hospital
Boston, Mass.


Patricia Clark, RN, MSN, CCRN
Huron Valley Hospital
Commerce Township, Mich.


Robin Clark, RN, CCRN
Santa Rosa Memorial Hospital
Santa Rosa, Calif.


Susan Cole, RN, MSN, CCRN, CS-APN
Saint Francis Medical Center
Cape Girardeau, Mo.


Karen E. Coppin, RN, MSN
Southwestern Vermont
Medical Center
Bennington, Vt.


Karen Deison, RN
Columbia Lawnwood Regional
Medical Center
Fort Pierce, Fla.


Kathleen Dermott, RN, MSN, CCRN
Crozer Chester Medical Center
Upland, Pa.


Joan Duda, RN, MS, CCRN, CEN
Cook County Hospital
Chicago, Ill.


Melanie Duffy, RN, MSN, CCRN
Harrisburg Hospital
Harrisburg, Pa.


Colleen J. Dunwoody, RN, MS
University of Pittsburgh
Medical Center
Pittsburgh, Pa.


Kelly Ernst, RN, MSN
Saint Thomas Hospital
Nashville, Tenn.


Leslie Evans, RN, MS, AOCN
VA Medical Center-West Los Angeles
Los Angeles, Calif.


Cathy Ford, RN, BSN
Franciscan Skemp Healthcare
La Crosse, Wis.


Jacqueline Fowler-Byers, RN, PhD
Orlando Regional Medical Center
Orlando, Fla.
Neil Golden, RN, MSN, CCRN


St. Francis Hospital
Education Department
Tulsa, Okla.


Deb Gordan, RN, MS
University of Wisconsin Hospital
& Clinics
Madison, Wis.


Irene Vasquez, RN, BSN, CCRN
Robert Wood Johnson
University Hospital
New Brunswick, N.J.


Linda Griego, RN, MSN, CS, CCRN
Presbyterian Hospital
Albuquerque, N.M.


Margo Halm, RN, CCRN, CS
United Hospitals
St. Paul, Minn.


Jackie Harper, RN, MSN
Summit Medical Center
Hermitage, Tenn.


Jeanne M. Heatlie, RN, BSN
William Beaumont Hospital
Royal Oak, Mich.


Christine Hedges, RN, MS, CCRN
Valley Hospital
Ridgewood, N.J.


Michele Hiscock
Royal Brompton Hospital
London, United Kingdom


Donna Hoffeld, RN, MS, CCRN
Helix Heart Care
Union Memorial Hospital
Baltimore, Md.


E. Amy Hong, RN, CCRN
Johns Hopkins Hospital
Baltimore, Md.


Ann Hotter, RN, MSN, CCRN
Mayo Foundation Hospital
Rochester, Minn.


Sarah Hutchison, RN, CCRN
Vanderbilt University Medical Center
Nashville, Tenn.


Rita Ives, RN, MS, OCN
Mercy Hospital
Wilkes-Barre, Pa.


Louise Jacob, RN, MS, CCRN
Mercy Hospital
Coon Rapids, Minn.


Michelle Jonas, RN, MA, CCRN
St. Luke’s Hospital
Cedar Rapids, Iowa


Margaret Kearns, RN, BSN
Fox Chase Cancer Center
Philadelphia, Pa.


Carolyn Koepke, RN, MSN
Hendrick Medical Center
Abilene, Tex.


Ann Lang, RN, MS, CCRN
Gundersen-Lutheran Medical Center
LaCrosse, Wis.
Sheila Lawton, RN, MSN, CCRN

Education Department
Tulsa, Okla.


Deb Gordan, RN, MS
University of Wisconsin Hospital
& Clinics
Madison, Wis.


Irene Vasquez, RN, BSN, CCRN
Robert Wood Johnson
University Hospital
New Brunswick, N.J.


Linda Griego, RN, MSN, CS, CCRN
Presbyterian Hospital
Albuquerque, N.M.


Margo Halm, RN, CCRN, CS
United Hospitals
St. Paul, Minn.


Jackie Harper, RN, MSN
Summit Medical Center
Hermitage, Tenn.


Jeanne M. Heatlie, RN, BSN
William Beaumont Hospital
Royal Oak, Mich.


Christine Hedges, RN, MS, CCRN
Valley Hospital
Ridgewood, N.J.


Michele Hiscock
Royal Brompton Hospital
London, United Kingdom
Donna Hoffeld, RN, MS, CCRN
Helix Heart Care
Union Memorial Hospital
Baltimore, Md.


E. Amy Hong, RN, CCRN
Johns Hopkins Hospital
Baltimore, Md.


Ann Hotter, RN, MSN, CCRN
Mayo Foundation Hospital
Rochester, Minn.


Sarah Hutchison, RN, CCRN
Vanderbilt University Medical Center
Nashville, Tenn.


Rita Ives, RN, MS, OCN
Mercy Hospital
Wilkes-Barre, Pa.


Louise Jacob, RN, MS, CCRN
Mercy Hospital
Coon Rapids, Minn.


Michelle Jonas, RN, MA, CCRN
St. Luke’s Hospital
Cedar Rapids, Iowa


Margaret Kearns, RN, BSN
Fox Chase Cancer Center
Philadelphia, Pa.


Carolyn Koepke, RN, MSN
Hendrick Medical Center
Abilene, Tex.


Ann Lang, RN, MS, CCRN
Gundersen-Lutheran Medical Center
LaCrosse, Wis.
Sheila Lawton, RN, MSN, CCRN
Bergan Mercy Medical Center
Omaha, Neb.


Mary Lyons, RN, MSN, ONC
Central Dupage Hospital
Winfield, Ill.


Jane Martin, RN, MSN, CCRN
Sheboygan Memorial Medical
Center
Sheboygan, Wis.


Maria Matsco, RN
Catholic Medical Center
Optima Health Center
Manchester, N.H.


Ann McPhillips, RN
Alegent Health
Immanuel Medical Center
Omaha, Neb.


Karen Adele Miller, RN
VA Pittsburgh Health Care
System
Pittsburgh, Pa.


Betty Milligan, RN, MSN, CS
Carilion Roanoke Memorial
Hospital
Roanoke, Va.


Lydia Mittermaier, RN, BSN, CCRN
Hunterdon Medical Center
Flemington, N.J.


Deidra Morse, RN, CCRN
St. Joseph Hospital of Atlanta
Heart Institute
Atlanta, Ga.


D.A. Nordquist, RN, MSN, CS, FNP
Immanuel St. Joseph’s Hospital
Mankato, Minn.


Joan Ruppman, RN, MS
Saint Francis Medical Center
Peoria, Ill.


Maureen O’Brien, RN, MSN, CCRN
Mercer Medical Center
Trenton, N.J.


Theresa DiMaggio, RN, MSN, CRNP,
CNS
Children’s Hospital of Philadelphia
Philadelphia, Pa.


Catherine Owens, RN, BSN, CCRN
VA Medical Center
Denver, Colo.


Nancy Pakutz, RN, MSN, CNS
University Hospital of Cleveland
Cleveland, Ohio


Kristine Peterson, RN, MS, CCRN
Methodist Hospital
Health System Minnesota
St. Louis Park, Minn.


Susan Pragacz, RN, MSN
Marquette General Hospital
Marquette, Mich.


Vida Reid, RN
Hinsdale Hospital
Hinsdale, Ill.



Patricia Rosier, RN, MS, CNOR
Berkshire Medical Center
Pittsfield, Mass.


Robert Rothwell, RN, MN, CCRN
VA Puget Sound Healthcare
System
Seattle, Wash.


Julie Sabo, RN, MN, CCRN
Fairview-University Medical Center
Minneapolis, Minn.


Mary Jo Schreiber, RN, MSN, CCRN
Winter Haven Hospital
Winter Haven, Fla.


Sue Sendelbach, RN, MS
Abbott Northwestern Hospital
Minneapolis, Minn.


Carole Siegfried, RN, MS, CNA
King’s Daughter’s Medical Center
Ashland, Ky.


Nancy L.D. Smith, RN
Frederick Memorial Hospital
Frederick, Md.


Teresa Solberg, RN, MSN, CCRN
University of South Dakota & Sacred Heart Hospital
Vermillion, S.D.


Shirley Storch-Sherman, RN, CCRN
Virginia Mason Medical Center
Seattle, Wash.


Carolyn Strimike, RN, MSN, CCRN
St. Joseph’s Hospital
and Medical Center
Paterson, N.J.


Helen Sullinger, RN, BSN, CCRN
St. Paul Ramsey Medical Center
St. Paul, Minn.


Veronica Sumodi, RN, MSN, CCRN
Meridia Health System
Hillcrest Hospital
Mayfield Heights, Ohio


Deborah Sutton, RN, MSN, CS
Craven Regional Medical Center
New Bern, N.C.


Megan Switzer, RN, MSN, CCRN
St. Joseph Hospital
Lexington, Ky.


Tanna Thomason, RN, MS, CCRN
Sharp Healthcare System
San Diego, Calif.


Diana Vance, RN, CCRN
Summa Health System
Doylestown, Ohio
Mary Beth Flynn, RN, MS, CCRN
University Hospital
Denver, Colo.


Melody Henderson, RN, PhD
Ivinson Memorial Hospital
Laramie, Wyo.


Ann Manees, RN
St. Vincent Infirmary Medical
Center
Little Rock, Ark.


Sharon Martin, RN
Moses Cone Health System
Greensboro, N.C.


Dorothy Hamilton, RN, MSN, ACNP,
CCRN
Cleveland Clinic Foundation
Cleveland, Ohio


Stacey Erdelshky, RN
Mount Carmel Health System
Columbus, Ohio


Rosarina Pelikan, RN, MN
Little Company of Mary Hospital
Torrance, Calif.


Julie Russell, RN, CCRN
St. Joseph’s Hospital Health Center
Syracuse, N.Y.



Marybeth Navas, RN, MN
Jerry L. Pettis Veterans
Medical Center
Loma Linda, Calif.


Virginia R.G. Spencer, RN, BSN, CCRN
Walter Reed Army Medical Center
Bethesda, Md.


Lucy Feild, RN, PhD, CS
Brigham and Women’s
Children’s Hospital
Boston, Mass.


Betsy Barnes-McDowell, RN, PhD,
CCRN
Children’s Hospital of Richland Memorial Hospital
Columbia, S.C.


Julie Anderson, RN, MS
Altru Health Research Center
Grand Forks, N.D.


Marion Giammarinaro, RN, MS
Memorial Health Care
Memorial Hospital
Worcester, Mass.


Peggy Lenke, RN, BSN, MSN
Columbia Medical Center-East
El Paso, Tex.


Theresa Lacy, RN, MS, CS, CCRN
Presbyterian Hospital of Dallas
Dallas, Tex.

Work Group Pursues Ways to Enhance Advanced Practice

Participating in the meeting of the Advanced Practice Work Group were (from left, front row) Paul P. Logan, Learning Connection partner Bernice Coleman, Kathleen M. Vollman, Marilyn P. Hravnak, Chairperson Jill T. Jesurum, Steven W. Branham, Carol Lynn Thompson and national office representative Marilyn Herigstad, and (from left, back row) Tom Ahrens, staff liaison Megan Whalen, board liaison Connie Barden, Karen K. Giuliano and Judy Trivits Verger.

By Steven Branham
RN, MSN, CCRN, CS, ACNP
Member, Advanced Practice Work Group

Strategies to support the contributions of advanced practice nurses are being developed by the Advanced Practice Work Group for 1999-2000.

The group met in August in Irvine, Calif., to discuss specific goals for the year. Charged with providing continued insight and feedback on issues related to advanced practice within the AACN membership, all members of the group are clinical nurse specialists or nurse practitioners who are involved in education or clinical practice throughout the acute care continuum. Regardless of the advanced practice role, many fundamental issues confront advanced practice nurses, who are on the front line each day.

Helping to plan the curriculum for AACN’s Advanced Practice Institutes, held in conjunction with the National Teaching Institute, as well as for graduate-level educational programs is a fundamental goal identified by the Advanced Practice Work Group. The API in 2000 is set for May 20 through 25 in Orlando, Fla.
In addition, the group addressed the potential development of resources to assist advanced practice nurses. Other work group initiatives will be presented in future issues of AACN News.

Chairing the Advanced Practice Work Group is Jill T. Jesurum, RN, PhD, CS, CCRN-R. Other members are Tom Ahrens, RN, DNS, CCRN, CS, Steven W. Branham, RN, MSN, CCRN, ACNP, Karen K. Giuliano, RN, MSN, CCNS, CCRN, ANP, CS, NP, Marilyn P. Hravnak, RN, MSN, CCRN, ACNP, CS, FCCM, Paul P. Logan, MSN, CCRN, CS, NP, Carol Lynn Thompson, RN, PhD, CCRN, ACNP, FCCM, Judy Trivits Verger, RN, MSN, CCRN, CS, NP, and Kathleen M. Vollman, RN, MSN, CCRN, CS. Connie Barden, RN, MSN, CCRN, is the liaison for the AACN Board of Directors. Advanced Practice Director Megan Whalen, RN, MS, is the national office staff liaison.

The group’s recommendations will be forwarded to the AACN Board of Directors,

Current members of the Advanced Practice Work Group sincerely appreciate prior work group members for the clear foundation they laid on which this year’s group could build. Anyone wanting to provide insight on advanced practice issues can contact the work group through Megan Whalen, RN, MS, AACN advanced practice director, at (800) 394-5995, ext. 333.

Sharing Feelings About Crisis Is the Best Remedy

Jacqueline L. Claiborne-Wright, RN, BS, is primary nurse in the cardiac surgery ICU at the Medical College of Virginia Hospitals, Richmond. She received a 1999 Excellence in Caring Practices Award. Following are excerpts from the exemplar that Claiborne-Wright submitted in connection with her award, which is part of AACN’s Circle of Excellence recognition program. For more information about Circle of Excellence awards, call (800) 899-AACN (2226), or visit the AACN Web site at http://www.aacn.org and click on “awards.”

By Jacqueline L. Claiborne-Wright

L.C. was transferred to my hospital on an intra-aortic balloon pump (IABP), for coronary artery bypass graft (CABG) surgery. She was a 40-year-old wife and a mother of two girls, ages 12 and 2.

Her preoperative assessment was within normal limits. Although the leg with the IABP was slightly cool, the signal pulses were decent.

Following her surgery, I was shocked to find L.C. receiving multiple inotropic drugs, many at maximum or high doses, and on a ventricular assist device (VAD). She was sedated and paralyzed. The IABP leg was cold, mottled and lifeless.

L.C. had undergone a four-vessel CABG, a bilateral intramammary artery graft and a left radial vein graft. After 48 hours, she was scheduled to return to the operating room for removal of the VAD.

L.C.’s husband wept when he returned to her bedside. He was overwhelmed by the stampede of physicians needing his signature on consent forms for every potential procedure. After all the forms were signed and witnessed, I contacted the hospital chaplain to provide support.

The night before the procedure, I asked the attending physician to schedule a family conference to discuss the risks, including death, loss of limb and postoperative complications. He told the family that he would attempt to wean L.C. from the VAD, but would reinsert it for up to two days if she was not able to maintain. Reinsertion of a VAD had never been attempted at our hospital.

Fortunately, the VAD was successfully explanted and the IABP discontinued. Although L.C. remained sedated, paralyzed, ventilated and on multiple inotropic drugs, she was off to a good start.

Her status deteriorated in the next 36 hours. We could not find a pulse in one of L.C.’s feet. She became acidotic, secondary to necrosis of the leg. Amputation was the only alternative. L.C.’s husband, already overwhelmed with his wife’s condition, was being forced into making these life-altering decisions. I explained that L.C. would not survive this acidotic state. Her husband signed the consent form, frustrated and concerned about how this decision would affect their lives.

Following the above-the-knee amputation, the acidosis was quickly corrected and L.C.’s vital signs stabilized. We began slowly weaning L.C. from the sedative, paralytic and inotropic drugs.

L.C.’s husband was focused on the amputation. He frequently lifted the sheets to see the stump. Angry and wanting to find blame, he asked questions about the IABP. “Had it been necessary?” “Why wasn’t it removed sooner or changed to the other leg?”

L.C. awakened neurologically intact. The goals now were to tell her about the life-changing events in the past five days and to support her through her loss. I involved the psychiatric nurse liaison, the primary care team and her husband in the support process. We helped her husband find the words to to tell her he loved her and reassure her that the loss of the limb would not alter their relationship. Holding her hand, he informed L.C. that her leg had been removed. She lifted the sheet to see the stump and briefly wept; then she asked if she could get out of bed. Her strength and fortitude inspired me every day.

L.C. became stronger and more determined. She progressed so well that her physician decided she could be transferred directly to the rehabilitation unit. I was careful to pass on the details of her care, as well as what was still needed, such as following up on a dental consult about repairing teeth that loosened during intubation.

I regularly visited L.C. in the rehabilitation unit. In a short time, she was transferring herself from the bed to the wheelchair. She also had taken over managing all forms and making and returning phone calls. It was easy to see her in the managerial role at home.

On one of my visits, L.C. told me that her husband had become very possessive of their youngest daughter and was not going to work, because he didn’t want anyone else to take care of her. In addition, he had begun drinking with his brothers.

Given the stress he had experienced, I believed that he was releasing tension and venting anger. He had not shared his own experience with her, so I related what went on during the five days when her life hung in the balance. I gave L.C. the number of the chaplain and the psychiatric liaison nurse for support. L.C. stopped by my unit every day to update me or to seek advice.

I also encouraged L.C.’s husband to share his feelings with his wife about what he had been through. I told him I had been aware of his anger, frustration and feelings of hopelessness, but that his wife had no way of knowing. As a result, L.C. and her husband began communicating about the crisis they had endured separately, but now were able to share.

Practice Resource Network: Dealing With Issues of Age

Q:Can you refer me to age-specific competency resources for critical care nurses who work in a general intensive care environment,
especially in units that accept children?

A:Many adult units are now dealing with this issue. Several resources may be helpful. Among the best is A Framework for Assessing Age-Related Competency, by JoAnn Grif Alspach, RN, MSN, EdD, which has been published in two parts.

Part 1, Distinguishing Attributes of Various Age Groups, summarizes the distinguishing characteristics of nine age groups: neonate, infant, toddler, preschool, school age, adolescent, young adult, middle age and later adult.

The full scope of age-related competency development content is described in Part 2, Staff Competencies & Program Design Strategies. This includes clinical practice implications of the distinguishing attributes of the nine age groups summarized in Part 1. These are presented in the form of competency statements, which allows users to select the competencies that are most relevant to the staff positions involved.

Included are some JCAHO survey process-related hints from the National Nursing Staff Development Organization. For example, NNSDO cautions that teaching in this area must not be equated to appraising competency, because JCAHO will not accept instruction as evidence of staff appraisal.

In addition, the appendix provides an extensive list of resources related to age-specific competency. These resources are divided into books, journal articles and audiovisual programs.

Both parts of A Framework for Assessing Age-Related Competency are available through NNSDO, 7794 Grow Drive, Pensacola, Fla.; phone, (800) 489-1995.
In an interview published in the December 1998 issue of Critical Care Nurse, Fran Hazinski, RN, MSN, outlines the types of expertise that are needed in caring for children in the mixed ICU setting. In addition to actual critical care skills, Hazinski the bedside nurse in a mixed unit must have knowledge of how children differ from adults and their anatomical, physiological and psychosocial differences.

AACN has many other resources that can help you meet age-related care challenges. Many of these can be found in the AACN Resource Catalog, which is also available online at http://www.aacn.org. Click on “Bookstore.”

Grants Provide Funding for Studies Relevant to Critical Care Nursing

Grants to support research relevant to critical care nursing practice are available from AACN. Grant deadlines vary. Following is information about grants for which deadlines are approaching. To request application materials, call (800) 899-AACN (2226).

Clinical Inquiry Grants
Funded by an anonymous donor, this grant awards up to $250 each for clinical research projects that will directly benefit patients or their families. Funds are awarded to projects that address one or more AACN research priorities and link with AACN’s vision.

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 Jan. 1, 2000.

Small Projects Grants

Sponsored by Medtronic/Physio-Control Corporation, this grant supports projects that focus on aspects of acute myocardial infarction and resuscitation. Up to $500 will be awarded to projects selected.

Eligible projects can include patient education; staff development or competency-based educational programs; continuous quality improvement or outcomes evaluations; and small research studies.

Applicants must be an active or affiliate member of AACN and not currently conducting another study funded by an AACN research grant.

Applications must be received by Jan. 15, 2000.

Mentorship Grant

Cosponsored by AACN and Mallinckrodt Inc., this grant awards up to $10,000 to a novice researcher to work with an experienced research mentor on a study that is relevant to critical care nursing practice.

The novice research applicant, who must be an RN and current member of AACN, should have only limited or no experience in the area proposed for investigation. The research funded may be used toward an academic degree.

The mentor must have research expertise in the area proposed for study by the novice researcher. The mentor cannot be designated as a mentor on another AACN mentorship grant for two consecutive years and cannot be conducting the research toward an academic degree.

Proposals for this grant must be received by Feb. 1, 2000.

Critical Care Research Grant
This grant provides for one award of up to $15,000 to a nurse investigator who is actively involved in acute and critical care nursing practice. The study selected must be relevant to critical care nursing practice.

The principal investigator must be an RN and a current AACN member. The proposed study may not be used to meet the requirements for an academic degree.
Proposals must be received by Feb. 1, 2000.

To obtain grant applications, call (800) 899-2226, or visit the AACN Web site at http://www.aacn.org. For more information, call the AACN Practice and Research Department at (800) 809-2273.

New Grant: AACN Certification Corporation Research Grants

These grants, funded by AACN Certification Corporation, provide up to $10,000 each for four studies related to certified practice. Examples of eligible projects are studies that focus on continued competency; the Synergy Model; the value of certification as it relates to patient care or nursing practice; and credentialing concepts. The proposed research may be used to meet the requirements of an academic degree.

Although AACN members are encouraged to apply for this grant, AACN membership is not required. However, if all other factors are equal, AACN member applications will be given preference.

Proposals must be received by Feb. 1, 2000.

Clinical Nurse Researchers Draw Out Hidden Knowledge

Nursing practice is rich in hidden knowledge that, if shared with other practitioners, will help validate clinical practice, Barbara J. Riegel, RN, DNSc, CS, FAAN, emphasized in the Distinguished Research Lecture at the 1999 National Teaching Institute™ in May in New Orleans, La.

A professor at San Diego State University School of Nursing in California, Riegel titled her lecture “Uncovering What We Know: Adventures of a Clinical Nurse Researcher.”

The role of the clinical nurse researcher complements and supports that of the practicing clinician, she noted. Revealing what the researcher knows allows others to see its value.

Her presentation focused on helping participants analyze the process of uncovering this knowledge, describing contributions of clinical research in a practice setting and generating strategies that practitioners and researchers can use to build clinical practice knowledge.

Riegel outlined the roles that clinical nurse researchers fill in practice, research, consultation and education. She said her own research themes have included managing pain, teaching patients and treating myocardial infarction and heart failure patients. Her special focus has been on the role of the family in supporting patients.

As a clinical nurse researcher, Riegel said she had to combat perceptions about her role and re-educate co-workers. She worked to overcome perceptions
that there was a lack of relevance or staff time to accommodate her role by being visible and available to her peers, and also conducting mini-courses about her role.

She said she facilitated the research being conducted at her facility by forming nursing research committees and unit-based journal clubs. By consulting on ideas, she was able to facilitate the conduct of research.

Riegel said that the need to collaborate was one of the most important lessons she learned.

“Doing research with someone else was a lot more fun and a lot more productive than doing it alone,” she commented.

She cited the following keys to building nursing knowledge through collaboration:
• Valuing one another and the unique contributions
• Seeking collaborative situations
• Minimizing competition
• Communicating openly
• Consulting early in the process of change
• Sharing successes and failures

• Publishing results of research

The annual Distinguished Research Lecturer Award is part of AACN’s Circle of Excellence recognition program.

Nov. 1, 1999, Deadline to Apply for Distinguished Research Lecture Award

Nov. 1, 1999, is the deadline to apply for the Distinguished Research Lecture Award for 2000, which is part of AACN’s Circle of Excellence recognition program.

This award will honor a nationally known researcher, who will present the annual Distinguished Research Lecture at the 2001 National Teaching Institute,™ scheduled for May 19 through 24 in Anaheim, Calif. In addition to a $1,000 honorarium, the honoree receives $1,000 toward NTI expenses.

For more information or to obtain application materials, call (800) 899-AACN (2226), or visit the AACN Web site at http://www.aacn.org. Click on “Awards.”

Geriatric Corner: To See or Not to See

How often do you do a head-to-toe patient assessment? Somewhere near the beginning of any assessment , an evaluation of the eyes, including pupils and vision, will be done. Do you know the normal changes that occur when an eye ages?

Normal Changes
Ocular Structures
Conjunctiva

• The conjunctiva is the thin mucous membrane covering the sclera. Its goblet cells produce mucin, which is essential for lubricating eyelid movement and providing a protective layer to slow evaporation of tears. With aging, the number of mucous cells decreases and may lead to dry eyes and a scratchy sensation.
• The conjunctiva, or lining of the eye, can be inflamed or infected. This is a common eye problem in the elderly, particularly because the elderly are prone to dry eyes. Dry eyes may predispose the conjunctiva to infection by bacterial or viral agents. Conjunctivitis is associated with a red eye and purulent discharge, but discomfort is minimal. A painful red eye may signal iritis, glaucoma or an abrasion.
• The conjunctiva can also undergo metaplasia and hyperplasia, in which an accumulation of tissue may occur at the nasal or temporal junction of the sclera and cornea. This tissue is called pingueculae. Although it may increase in size with advancing age, it is benign and generally causes no vision problems.

Sclera/Cornea
• The sclera is seen most clearly when the overlying conjunctiva is thinning. The sclera is normally white, though it is uniformly yellow in patients with jaundice. In elderly people, the periphery of the sclera may be yellow, due to fat deposits that show through thinned scleral membranes. Arcus senilis is a striking finding in the eyes of some older people. Initially seen as a thin line that is limited to the upper portion of the eye, it becomes thicker and denser, and completely encircles the cornea. Although arcus is found with other signs in people with familial hypercholesterolemia, many people with arcus will have normal cholesterol levels.
• The major age-related change of the cornea is degeneration of the endothelial cells lining its surface. This normally does not interfere with vision. However, if corneal edema develops, the cornea will become hazy, and immediate referral to an opthalmologist will be required.

Iris/Lens
• The iris contains two sets of muscles that regulate pupillary size and reaction to light. With age, the pupil aperture becomes smaller (pseudoptosis), reacts more sluggishly to light and dilates more slowly in the dark.
• The lens of the eye produces new fibers throughout life, but loses none. These accumulate in the center of the lens, increasing its density and contributing to the development of senile cataracts, which are generally bilateral. The lens loses its elasticity with advanced age so that the eye becomes farsighted (presbyopia). This loss of lens elasticity with age results in reduced ability of the lens to change shape when focusing on close objects.
• The pupils may react more sluggishly to light, but should be of an equal size. Many disorders can cause asymmetry of the pupils, including central nervous system lesions and diabetes. Asymmetry can also be caused by drugs. After iridectomy, the pupil may be irregular.
• Because of a decline in extraocular muscle function, many people over the age of 70 are unable to rotate the eye upward more than 15 degrees from the horizontal plane.

Extraocular Structures
• The loss of orbital fat with age gradually displaces the eye backward into the orbit (enophthalmos). Thus, sunken eyes are not necessarily a sign of dehydration in the elderly. The margin of the lid may also roll backward toward the eye so that the eyelashes brush against the cornea, causing entropion, which may result in a slight obstruction of peripheral vision.
• Each eyelid has a central, relatively rigid tarsal plate that, in advancing age, may become lax, leading to ectropion (eversion of the lids), which exposes the eyes to drying and infection. Age-related changes of the eyes also include darkening of the skin around the orbits and crow’s feet. Xanthomas are fat deposits that are sometimes seen in the skin near the eyes and may be associated with elevated levels of blood lipids. Loss of the lateral third of the eyebrows, which can be a classic sign of hypothyroidism, may also be a normal finding in some elderly people.

Nursing Implications
• Comfort: A false foreign-body sensation may be related to a dry eye condition, entropion, chronic fatigue of the eye muscles from lack of sleep, poor health and edema.
• Headache: In the elderly patient, a complaint of a headache may be related to eye-muscle pain or to an acute ocular disorder, such as acute glaucoma.
• Light: The older person, perhaps because of diminished pupil size and increased thickness and opacity of the lens, needs more illumination to compensate than someone younger, and will often complain about the darkness or dimness of their environment.
• Effects on vision: Glare may be a frequent complaint and is related to changes in the lens and vitreous, which increase the scattering of light in the ocular media. Haziness, flashing lights and moving spots can be attributed to vitreous floaters. The vitreous humor is normally clear, but with age, opacities or structural changes may lead to a general haziness. Although these changes are not serious, they may be upsetting, requiring an explanation and reassurance. If complaints about these visual disturbances are not accompanied by decreased vision or change in visual function, they usually need no further evaluation. However, if they persist, a feeling of a veil over the eye or a decrease in the visual field develops, the patient should be immediately referred for evaluation of a potential retinal detachment.

Some Age-Related Eye Diseases
• Cataracts: Opacity of the lens reduces the visual acuity to 20/30 or less.
• Macular degeneration: This is a major cause of visual disability in the elderly. The macula, the region of the retina with the sharpest acuity, is affected. Although visual acuity is decreased, peripheral vision is preserved. Special studies by an ophthalmologist may be required to establish a diagnosis of macular degeneration.
• Glaucoma: The intraocular pressure is elevated and there is contraction of the visual field.
• Diabetic retinopathy: This is associated with diabetes mellitus. The reduced vision may be a result of microaneurysms and macular edema, and without treatment, can result in an irreversible loss of vision.

Suggested Reading
1. Gallo JJ, Reichel W, Andersen, LM. Handbook of Geriatric Assessment. Gaithersburg, MD: Aspen Publishers, Inc; 1995.
2. Abrams WB, Beers MH, Berkow R, eds. The Merck Manual of Geriatrics, 2nd ed. Whitehouse Station, NJ: Merck & Co., Inc; 1995.

Have you made changes to your practice because of information presented in the “Geriatric Corner” column? Was this type of information useful in caring for the older patient? Is there a clinical assessment, intervention or disease process that you would like to have featured here? Contact AACN Clinical Practice Specialist Justine Medina, RN, MS, at (800) 394-5995, ext. 401; fax, (949) 448-5520; e-mail, Justine.Medina@aacn.org.

ACNP Review Course Now on Video

The ACNP Review Course presented at the 1999 NTI is now available on video, as well as audio. Recorded from the 1999 NTI preconference, this six-hour course offers study tips for advanced practice nurses who are preparing to take the ACNP certification exam. A comprehensive syllabus accompanies both the video and audio program. In addition, sample questions and the ACNP testing blueprint are included. This program offers 8.0 contact hours of Category A CE credit.

7-videotape set, plus 95-page syllabus
Item #128881
Price $170 (nonmembers $220)
plus shipping and handling

4-audiotape set, plus 95-page syllabus
Item #128882
Price $79 (nonmembers $109)
plus shipping and handling

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

AACN Online Quick Poll

In your unit, do you routinely instill saline during endotracheal suctioning?

Yes 52%
No 48%

The AACN Online Quick Poll surveys a variety of topics. Participate by visiting the AACN Web site at http://www.aacn.org.