AACN News—April 2002—Practice

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Vol. 19, No. 4, APRIL 2002

The Power of One: The Ethics of Restraints

By Pamela Popplewell, RN, BSN, CCRN
Ethics Work Group

The use of physical restraints has recently received considerable attention. In the past, physical restraints have been used routinely in the acute care setting, because it was believed that they reduced falls, restrained wandering and prevented removal of invasive therapies, such as endotracheal tubes, foley catheters and intravenous access. However, the evidence now supports that restraints are associated with longer hospital stays; continued falls and other injuries; nosocomial infections and pressure ulcers; increased mortality; and increased risk of complications from immobility.

Recent regulatory oversight from the Food and Drug Administration and the Joint Commission on Accreditation of Healthcare Organizations has focused on limiting restraint use. The reason can at least partly be attributed to an individual patient�s constitutional right to be free from restraint. When the subject of a patient�s rights emerges, so does the ethical expectation for healthcare workers to protect that right.

The use of restraints involves the ethical principles of autonomy (individual choice), beneficence (doing good), and nonmaleficence (avoiding harm). To use restraints when other effective therapies, such as proper medications, are available is an ethical concern for ICU nurses. Consider the following scenario:

When Mr. Z. arrived at 9 a.m. for his scheduled admission for surgery to repair an enlarging abdominal aortic aneurysm, he was unshaven and had the smell of alcohol on his breath. He was pleasant and cooperative during the admission process and readily admitted that he drank 10 to 12 beers each weeknight, and sometimes more on weekends. However, he denied eating or drinking anything since midnight. His consent form for surgery had been signed the previous week during an outpatient visit.

After his surgery, he was taken to the ICU. He had experienced episodes of hypotension during surgery and had received a large amount of fluid to maintain adequate pressures. His vital signs remained labile in the ICU, necessitating additional fluid and vasopressor support his first night.

To better manage his fluid and respiratory status, Mr. Z. remained intubated and sedated for two days following surgery. Finally, on postoperative day 3, he was successfully extubated. However, late that evening, he became agitated and attempted to crawl out of bed. He dislodged his central venous line, pulled out his peripheral IVs, appeared disoriented and spoke incoherently. His heart rate was 110, he was hypertensive with blood pressure around 180-90, and he was diaphoretic.

His nurse notified the on-call physician, advising that the patient was experiencing symptoms of alcohol withdrawal. The doctor ordered 0.5 to 1 mg Lorazepam to be given intravenously every six hours as needed to control withdrawal symptoms. Although the nurse immediately gave the full dose, the patient was unaffected by the medication and continued to try to climb out of bed. He also managed to pull out his foley catheter, with the balloon fully inflated. Contacted again, the doctor ordered that the foley be replaced and that the patient be restrained to keep him in bed and to prevent him from dislodging more lines or tubes. Soft wrist restraints were applied. However, the patient had now become suspicious, paranoid and agitated, and struggled against the restraints. He was able to move his legs to the side of the bed and intertwine them with the bed rails, which gave him leverage to try to slide out of bed. He required frequent repositioning and often kicked and punched at the nurses who came to assist at t
he bedside.

The nurse reported to the physician that Mr. Z. was being under medicated for his withdrawal symptoms and was likely to hurt himself, or one of the nurses, if adequate medications were not ordered. However, concerned about oversedation, the physician was reluctant to prescribe the amount of medication that the nurse requested. Although the nurse presented an article from a recent nursing journal that described dosing based upon withdrawal symptoms, the physician remained unconvinced.
Unfortunately, Mr. Z. continued to be combative and fight his restraints. He struggled so hard that his abdominal wound dehisced, requiring a return trip to the operating room to close the wound.

In relationship to the Synergy Model, Mr. Z. could be described as minimally resilient and highly vulnerable. In addition, he was minimally stable (at high risk) and highly complex. He was alone in the hospital without family resources. Although he wanted to participate in decision making, his ability to do so was significantly restricted by his alcohol withdrawal. He required a nurse with high level clinical judgment and collaboration techniques.

Mr. Z.�s nurse applied systems thinking, advocacy and patient caring skills, and requested a meeting with the on-call physician, the staff physician responsible for Mr. Z.�s care and her nurse manager. Through collaboration, they were able to develop a care pathway for patients withdrawing from alcohol that utilized appropriate medications before considering the use of restraints. An educational module was developed for the unit nurses that provided education on alternatives to consider before using restraints, including treatment of the underlying condition (medications), music, quiet verbal support, activity and distraction.

This synergy between the patients� needs and the nurse�s characteristics is found in many ICUs. The Ethics of Restraints of caring for critically ill patients is one of the core concerns of ICU nurses everywhere. Learning prompt identification of ethical issues and how best to respond to protect the rights of the patient is paramount. Nurses are the patient�s ultimate advocate. They need to be able to orchestrate the processes to ensure that their patient�s safety is protected and their needs are met.

Submit Research and Creative Solutions Abstracts

Sept. 1 is the deadline to submit research and creative solutions abstracts for AACN�s 2003 National Teaching Institute and Critical Care Exposition, scheduled for May 17 through 22 in San Antonio, Texas.
Abstracts must be relevant to the care of the acute and critically ill or critical care nursing and must be noncommercial in nature. The first author must be a nurse holding current AACN membership. Only completed research and finished projects are eligible, and abstracts must not have been previously published or presented nationally.

The designated presenters of accepted abstracts receive a $75 reduction in NTI registration fees. All other expenses are the responsibility of the presenter, who can be either the first author or a designate of the author.

In addition, four awards will be presented for oral research abstracts reflecting outstanding original research, replication research or research utilization. Each of these awards provides an additional $1,000 toward NTI expenses.

Following is information about the abstracts:

Abstracts can focus on any aspect of critical care nursing research, including reports of research studies or reports of research utilization. Only abstracts of completed projects will be accepted. Abstracts reporting research studies must address the purpose; background and significance; methods; results; and conclusions.

Creative Solutions
Abstracts should focus on specific strategies and practice innovations that are used by nurses to solve difficult, unique or interesting problems in patient care, nursing practice, nursing management or nursing education. The creative solution must have been implemented, with outcomes evaluated. Abstracts must address the purpose of the project and include a description of the creative solution, as well as evaluation and outcomes.

To obtain abstract forms, call (800) 899-AACN (2226) and request Item #6007, or visit the AACN Web site at http://www.aacn.org > Clinical Practice > Research > General Information.

Looking for Guidance? Apply to be a Wyeth Nursing Fellow

Acute and critical care nurses can further develop their professional leadership skills and be published through the AACN Wyeth Nursing Fellows Program, now celebrating its 10th anniversary.
This nine-month fellowship, which pairs mentors and fellows, is sponsored by Wyeth Pharmaceuticals in collaboration with AACN and the American Journal of Nursing.

Under the program, the mentors will guide their fellows in preparing personal plans that include completing individualized projects, attending AACN�s National Teaching Institute and Critical Care Exposition and developing manuscripts on a current cardiopulmonary topic for publication in a supplement to the May 2003 issue of AJN.

The mentors and fellows will be honored at the 2003 NTI, May 17 through 22 in San Antonio, Texas. The fellows receive complimentary NTI registration, travel and lodging, and the mentors receive complimentary NTI registration and a $500 educational grant.

Applications for the 2002-03 class of mentors and fellows must be received by June 21, 2002. To obtain an application, call (800) 899-2226 and request Item #2005 or AACN Fax on Demand at (800) 222-6329 and request Document #2005. Applications are also available online at http://www.aacn.org > Membership > Awards, Grants, Scholarships.

For further information, call (800) 394-5995 for AACN Clinical Practice Specialist Kathleen Schrader, RN, DNSc, CEN, at ext. 372 or Research Associate Dolores Curry at ext 377.


The AACN-sponsored American Nurses Foundation Research Grant awards up to $5,000 for studies that advance the practice of nursing, promote health or prevent disease. Applications are due at ANF by May 1.

Additional information and applications are available from the American Nurses Foundation/NRG00, 600 Maryland Avenue, SW, Suite 100W, Washington, DC 20024-2571; phone, (202) 651-7298; e-mail, anf@ana.org; Web site, www.nursingworld.org/anf.

Research Corner: Myth Versus Reality: Do We Need to Filter Medication Ampules?

By Paula Lusardi, RN, PhD, CCNS, CCRN
Chair, Research Work Group

�Withdrawing medication from ampules through a filter straw or filter needle takes time, especially during a code,� lamented Alice. �Do we really need to filter ampules? I find it hard to believe that there would be any glass particles in these ampules that would hurt patients.�

Is Alice correct in assuming that there is little need to filter medication from ampules?

Myth: There is no need to filter ampules when withdrawing medication for patient injection.

Reality: Glass ampules contain macroscopic glass particles that, if broken, may be harmful to patients.

Is there particulate matter in ampules?
Particulate contamination of small-volume parenteral products has been considered since single-dose ampules were developed nearly 30 years ago for ease of administration and accuracy.1 In 1972, Turco and Davis first noted that glass fragments greater than 5�m could be aspirated from open ampules of furosemide.4 Today, the fact that snap-opening of ampules leads to contamination of contents with glass fragments is well known.1-4 Numerous studies confirm particulate contamination of ampules upon opening, implicate a variety of side-effects from injecting nonfiltered ampule medication into patients3-7 and offer suggestions for changes in practice.

What is the fate of injected particles?
The fate of infused particles has been studied in both animals and humans. Systemic side effects of infused particles, though not clearly understood, exist.2 Phlebitis is the most common side effect of infused particulate matter in humans.8,9

What does filtering do?
Several studies have investigated particulate contamination from ampules and a variety of aspiration techniques.1,3,4,7,8 Both needle and straw filters reduce the number of particles and the potential side effects of infused particulate matter. However, forced aspiration of ampule contents, even with a filter, does not protect patients from particulate matter infusion.1

Practice Implications and Suggestions

Some of the common medications packaged in ampules are adrenaline (epinephrine), Cordorone (amiodorone), Furosemide (lasix), Inapsine (droperidol), Lanoxin (digoxin), Levophed (norepinephrine), Lopressor (metoprolol), Naloxone (narcan), Sublimaze (fentanyl).

All hazards related to microparticles should be eliminated for high-risk patients, such as neonates and those who are immunosuppressed, critically ill or who require long-term infusion therapy.3

Use filter straws or needles when aspirating fluid from glass ampules.2

Do not force aspirate when withdrawing medication from glass ampules.1

Filtration is a simple and relatively inexpensive way to prevent phlebitis.3,8

1. Waller D, George C. Ampoules, infusions, and filters. British Medical J. 1986;292:714-715.
2. Shaw N, Lyall E. Hazards of glass ampoules. British Medical J. 1985;291:1390.
3. Carbone-Traber K, Shanks C. Glass particle contamination in single-dose ampules. Anesth Analg. 1986;65:1361-1363.
4. Turco S, Davis N, Glass particles in intravenous injection. New Eng J Med. 1972:287:1204-1205.
5. Falchuk K, Peterson L, McNeil B. Microparticulate-induced phlebitis Its prevention by inline filtration. New Eng J Med. 1985;312:78-82.
6. Furgang F. Glass particles in ampules. Anesthesiology. 1973;41:525-526.
7. Gillies I, Thiel W, Oppenheim R. Particulate contamination of Australian ampoules. J Pharm. Pharmacol. 1986;38:87-92.
8. Sabon R, Cheng E, Stommel K, Hennen C. Glass particle contamination: Influence of aspiration methods and ampules types. Anesthesiology. 1989;70:859-862.
9. Turco S. Infusion phlebitis. Hosp Pharm. 1974;9:422-426.

Readers Respond to Article on CNSs and NPs

An article titled �CNS or NP? What�s in a Name?� (AACN News, February 2002) attracted particular interest on a number of fronts. Following are some of the responses to this article by Advanced Practice Work Group members Julie Stanik-Hutt, RN, PhD, CCRN, ACNP, and Sandra J. Cagle, RN, MSN, CCRN, ACNP.

Concise Information Helps Articulate Roles
I very much enjoyed the article and thought it was the best I have read contrasting the NP, CNS and PA roles. I have reproduced the article to share with the surgeons with whom I work, as well as with my NP peers.

I am delighted to have such concise information to share and help me to articulate the different roles and what they provide for physicians and patients. I will also share this information with the NPAM and with the Oncology Nursing Society�s Advanced Practice Nurses Legislative Team, of which I am a member.

Thank you for providing me and other APNs with this most important and useful information.

Jo Ann Coleman, RN, MS, CS, NP
Baltimore, Md.

There�s More to the Story
Congratulations to the members of the Advanced Practice Work Group on their article. Although the underlying information is generally correct, there are several areas that warrant further clarification.
Although the article states that the CNS and NP roles were created in the early 1970s, both actually emerged much earlier. In fact, the CNS role is approaching 50 years of recognition and practice. The CNS role was described by Frances Reiter in 1943,1,2 and the first CNS program, under the direction of Hildegarde Peplau, RN, PhD, opened at Rutgers University in 1954.2,3 The first NP program, which was for pediatric NPs, was established at the University of Colorado in 1966 under the auspices of Loretta Ford, RN, EdD, and Henry Silver, MD.4,5 CNS and NP programs both require clinical hours.

Ford, the founder of the NP movement, corroborated that advanced practice nurses must begin to study the structure, process and outcome in the centrality of the nursing profession�s interest, concern and values�the patient and family.6 In doing so, the needs of the public for healthcare in all settings will be addressed and met through responsive, sensitive, and caring practice.6.7
Diane J. Mick, RN, PhD, CCNS
Rochester, N.Y.

1. Reiter F. The nurse-clinician. Am J Nurs. 1966;66:274-280.
2. Sparacino PSA. (1990). An historical perspective on the development of the clinical nurse specialist role. In Sparacino PSA, Cooper DM, Minarik, Pa, editors. The clinical nurse specialist: Implementation and impact. Norwalk, Conn: Appleton & Lange; 1990. p. 4.
3. Peplau H. Specialization in professional nursing. Nurs Sci. 1965; 2:268-287.
4. Silver HK, Ford LC, Day LR. The pediatric nurse-practitioner program: Expanding the role of the nurse to provide increased health care for children. JAMA 1968; 204:298-302.
5. Silver HK, Ford LC, Stearly SG. A program to increase health care for children: The pediatric nurse practitioner program. Pediatrics. 1967; 5:756-760.
6. Kleinpell RM. The acute care nurse practitioner: An expanding opportunity for critical care nurses. Crit Care Nurs/Supplement, Feb. 2002; 12-14; 16; 74.
7. Mick DJ, Ackerman MH. Deconstructing the myth of the advanced practice blended role. Support for role divergence. In revision for Heart Lung.

More About the Role of PAs
Although the article was focused on the CNS and NP roles, our PA colleagues asked us to clarify some facts by expanding on information regarding their practice. Following is information provided by Nancy Hughes, vice president of communications and information services at the American Academy of Physician Assistants.

To practice in all 50 states, PAs must complete a nationally accredited program that includes more than 2,000 hours of clinical rotations and pass the national certifying exam. Of the more than 130 accredited programs in the U.S., only four are at the community college level. The majority are at four-year colleges, and some are even graduate programs. Like the medical profession, PA programs are competency based, not academically based. The requirement is that an individual be a graduate of an accredited program, not that he or she achieve a particular level of academic education.

Although prior experience in healthcare is not a prerequisite to practice as a PA, most PA students have more than four years of healthcare experience. In fact, the largest segment of these students have a nursing background.

Although the scope and regulation of PA practice varies by state, PAs are able to develop and implement their own patient management plans, prescribe in almost all states and assist in surgery.
Although PAs must list a physician of record to be licensed, their licenses are in their own names and are not tied to the physician's license. The relationship is similar to that of NPs who practice in states that require physician supervision.

Surgery and wound care are not taught �on the job� but are basic elements in all PA programs. State requirements vary regarding chart review, but not orders.

Nurse Doctorate Program Little Known
After reading the article, I wondered: Does the nursing profession realize that there is a nurse doctorate degree that is being offered by a number of universities within the U.S.? The description of the CNS role paralleled the education of an ND student who graduates from a postbaccaleureate, four-year program that prepares an RN for a variety of options.

Since graduating from the ND program at the University of Colorado in 1999, I have found that the nursing profession is ignorant of this degree. However, having gone through the program, I believe that this education process is what is needed to turn the nursing profession around and in an upward swing.

The role of an ND can vary greatly, depending on the need of the facility and the desire of the graduate. I am currently working as a staff RN in a rural facility with an ICU, medical-surgical unit and emergency department. However, I am not able to put the added education that an ND can bring to the table into action.
Erin Neill, RN
Steamboat Springs, Col

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