AACN News—January 2002—Practice

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Vol. 19, No. 1, JANUARY 2002

Research Corner: Myth vs. Reality: Do Patients Need Repositioning When Specialty Beds Are in Use?

By Sue Barnason, RN, PhD, CCRN, CEN, CS
Research Work Group

Consider this: You and an orienting critical care nurse are providing care for a 55-year-old male patient who has sepsis following major bowel surgery for a ruptured diverticuli. His Braden score indicates he is at high risk for pressure ulcer development, and you have placed the patient on a mattress overlay per your hospital policy for prevention of pressure ulcers. The orienting nurse comments, �This will really help him to be more comfortable, plus then we won't need to reposition him while he has this special mattress.�

Myth: Patients on pressure-reducing surfaces do not need to be repositioned.

Reality: Research has found that conventional hospital beds are associated with poor pressure-relieving qualities and often contribute to friction and shearing of the skin. The Agency for HealthCare Research and Quality (AHRQ) guidelines and other research clearly advocate the use of pressure-reducing surfaces for high-risk patients to decrease the risk of tissue trauma that can precipitate pressure ulcers. Pressure ulcers are lesions caused by unrelieved pressure resulting in damage to underlying tissue. Pressure-reducing support surfaces, such as a mattress overlay, redistribute the pressure of the patient's body over a larger surface area, which is also referred to as reducing the interface pressure.

The primary, causative factor in pressure ulcer development occurs when there is continued or sustained compression of the tissue between the bony prominence and the surface on which the patient is lying. While the recommendation to use a pressure-reducing surface is important, it is equally important, and also recommended by the AHRQ guidelines, that patients be repositioned regularly to offload pressure that occurs between the bony prominence and the support surface. Remember that the mattress overlay reducing the pressure is static, and therefore the interface pressure remains constant when the patient is not moving or repositioned regularly, which results in a potential for tissue breakdown.

When repositioning the patient, the AHRQ guidelines recommend the use of the 30-degree, side-lying position to relieve pressure on key pressure sites over the sacrum and trochanter.
The AHRQ guidelines on pressure-ulcer management highlight the fact that no technology can take the place of good nursing care. Although special equipment can help ensure more positive patient outcomes, the ultimate achievement of these goals relies on sound nursing judgments and practices.

Copies of the AHRQ guidelines on pressure-ulcer management can be ordered online

Suggested Reading
Allman RM, Goode PS, Patrick MM, Burst N, Bartolucci AA. Pressure ulcer risk factors among hospitalized patients with activity limitations. JAMA. 1995;273:865-870.

Bergstrom N, Allman RM, Carlson CE, et al. Pressure ulcers in adults: Prediction and prevention. Guideline Report No. 3 (AHCPR Publication No. 93-0013). Rockville, Md: US Department of Health and Human Services. 1992.

Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden Scale for Predicting Pressure Sore Risk. Nurs Res. 1987;36:205-210.

Ek AC, Gustavsson G, Lewis DH. Skin blood flow in relation to external pressure and temperature in the supine position on a standard hospital mattress. Scand J Rehabil Med. 1987;19:121-126.

Feldman DL, Sepka RS, Klitzman B. Tissue oxygenation and blood flow on specialized and conventional hospital beds. Ann Plast Surg. 1993;30:441-444.

Harrison MB, Wells G, Fisher A, Prince M. Practice guidelines for the prediction and prevention of pressure ulcers: evaluating the evidence. Appl Nurs Res. 1996;9:9-17.

Holzapfel SK. Support surfaces and their use in the prevention and treatment of pressure ulcers. J ET Nurs. 1993;20:251-260.

Jay R. Other considerations in selecting a support surface. Adv Wound Care. Nov-Dec 1997;10:37-42.

Jiricka MK, Ryan P, Carvalho MA, Bukvich J. Pressure ulcer risk factors in an ICU population. Am J Crit Care. 1995;4:361-367.

Maklebust J. An update on horizontal patient support surfaces. Ostomy Wound Manage. 1999; 45(Suppl 1A):70S-77S.

Wind S, Happ E, Kerstein MD. Pressure ulcers: collaboration in wound care: Is there a reasonable approach? Ostomy Wound Manage. 1997;43:40-44, 46, 48-50.
Sharing the Experience: Publishing Opportunity Was a Memorable Experience

Editor's Note: In celebration of the 10th anniversary of the AACN Wyeth-Ayerst Nursing Fellows Program, AACN invited alumni mentors and fellows to share their thoughts about and experiences with the program. These accounts will be published in AACN News throughout this anniversary year.

By Mary S. McCarthy, RN, MN, CNSN
Wyeth-Ayerst Fellow

Being selected as a Wyeth-Ayerst fellow for 2000 was an incredible honor. I initially viewed the program simply as a way to develop my writing skills and finally publish an article in a professional journal. The yearlong experience helped me accomplish this and much more!

Even before my mentor and I were selected for the program, I had admired and respected her scholarship, leadership and professionalism. Our professional relationship grew yet stronger as I relied on her for constructive criticism of my writing style and for feedback on the content of the developing manuscript. She was there for me every step of the way.

When the May supplement to the American Journal of Nursing arrived, I could hardly believe we had written the article as it appeared. The organization of the article was perfect, the graphics were clean and clear, and the final result was polished and professional, thanks to the hardworking editors at AJN. It was a very proud moment for me.

Now, every time I submit a resume in connection with a professional opportunity, I look at that publication listed there and remember this wonderful opportunity. Because I have been conducting research in the field of acute respiratory distress syndrome, having an article published related to that topic helps validate my expertise.

I cannot say enough about the memorable events honoring the mentors and fellows at the NTI in Orlando, Fla. You could almost feel the special relationship that had developed between many mentors and fellows as they spoke proudly of one another. The award celebrations, the gifts, the accommodations, the food, the reserved seating, the early entrance to the exhibits and the networking were just a few of the numerous rewards, and each one was greatly appreciated.

I cannot remember another time in my nursing career that I felt so honored for an accomplishment that I truly consider a professional responsibility. We should all carefully select mentors to guide us through challenges in our careers. And, as nurses, we must accept the responsibility for sharing scientific knowledge and experiences that advance our practice and serve our patients by publishing in our professional journals. I am most grateful for having had this opportunity and I encourage my junior colleagues to apply every time I see the spark of ambition and dedication so aptly rewarded by AACN.

Initiatives to meet the needs of patients and families are part of AACN's research agenda to promote the creation of cultures of inquiry, broad sharing of research findings and evidence-based practice. Toward that end, AACN offers several grants each year to fund studies that are relevant to critical care nursing practice and that address one or more of AACN's research priorities. These priorities were developed to guide research and to provide a framework for identifying potential gaps in the development or use of nursing knowledge. They are:
� Effective and appropriate use of technology to achieve optimal patient assessment, management or outcomes
� Systems and interventions that create a healing, humane environment
� Processes and systems that foster the optimal contribution of critical care nurses
� Effective approaches to symptom management
� Prevention and management of complications in critically ill patients

Following are grants for which application deadlines are approaching:

Due Feb. 1, 2002

AACN Datex-Ohmeda Grant�funds up to $5,000 to support research related to nutritional assessment of the critically ill patient. Suggested topics include the impact of continuous metabolic monitoring, assessment of the nutritional and metabolic condition, current practices of nutritional assessment, use of the Harris-Benedict Equation vs. indirect calorimetry in nutritional assessment, and evaluation of the accuracy or efficacy of continuous metabolic monitoring.

AACN Certification Corporation Research Grant�awards up to $10,000 for up to 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.

AACN Critical Care Grant�awards up to $15,000 to support research that focuses on one or more of AACN's research priorities.

AACN Mentorship Grant�awards up to $10,000 to provide support for a novice researcher, who will be directed by a mentor experienced in the area of proposed investigation.

Due March 1, 2002
Evidence-Based Clinical Practice Grant�awards multiple grants of up to $1,000 to stimulate the use of patient-focused data or previously generated research findings to develop, implement and evaluate changes in acute and critical care nursing practice. New projects, projects in progress and projects required for an academic degree are eligible for funding. Eligible projects may include research utilization studies, CQI projects or outcomes evaluation projects. Interdisciplinary and collaborative projects are encouraged.
Make a Difference: Discussion, Counseling Can Help Clarify Patient's Wishes

By Benny Bolin, RN, ADN, MS
Ethics Work Group

Joe was a well-educated professional in his 50s, whose wife of many years was his primary support person. He had a history of heart and vascular problems that had been treated with multiple surgeries, including an aortic aneurysm repair, a coronary artery bypass graft and an aortic valve replacement. Unfortunately, these had not been successful in eradicating his disease nor in significantly slowing its debilitating effects on his health. He had completed a living will that stated he did not want to be kept alive by artificial means and had discussed his wishes with his physician and his wife.

After his last surgery, Joe had been transferred to a rehabilitation facility. One morning, he was found to be in respiratory distress, lethargic and hypotensive. He was transferred back to the acute care hospital in pronounced respiratory distress with a diagnosis of sepsis. On admission, his doctor wrote that Joe was in �respiratory distress and hypoxic. Patient does not want to be intubated.� However, Joe suddenly had a change of heart and, though he knew that treatment of any type would not have a positive impact on the course of his disease, he agreed to intubation only if it was for a short time.

Joe, who was moderately resilient and had good response to his treatment, was able to be extubated. However, his underlying condition left him physiologically vulnerable, and he soon developed even more severe respiratory distress and was again struggling to breathe. As his respiratory distress worsened, his respiratory rate increased to 50 and his sputum became thick and blood tinged, yet his nurse stated that this time he refused to be intubated.

His wife, who had his medical power of attorney and had been very involved with his medical decisions and preplanning, became overwhelmed by the change in his condition and was unable to support Joe's previous decision. She asked that he be reintubated. The medical team complied. When Joe awoke and found he had again been intubated and placed on a ventilator, he was furious with the doctors, to whom he had expressly told his wishes, and even more so with his wife, who had directed the team to reintubate him.

The ICU nurses called for an ethics consult because they believed his reintubation was a clear violation of not only his wishes, but also his expressly and duly completed living will. A meeting of the healthcare team as well as a family conference was held to discuss his straightforward wishes and treatment choices and to resolve the issue if possible. Through rational and heartfelt discussions, the patient was able to reconcile with his wife, and the team created a more comfortable extubation plan. Joe died peacefully, with his wife at his side.

Clinical ethics consults take place for a wide variety of reasons and in a variety of clinical contexts. Most occur in the setting of a critical illness, where life hangs in the balance. Some occur when the family wishes to stop a treatment that the physicians and nurses want to continue. These are sometimes referred to as �right to die� cases. Others happen when treatment options have been exhausted and the treatment team considers further life-sustaining treatment futile, but the family wishes to continue. These are often referred to as �futility consults.� Others occur when there are disagreements about the course of care or the appropriate treatment options offered to patients.

Because there is no system to ensure that these consults will not be needed, the healthcare team must be proactive to ensure that our profession best serves patients needs. Through proactive, preventive actions, a more positive outcome can be achieved than if we wait and need to revert to a reactive mode. �Preventive ethics� is a two-armed process, with an early education arm (primary prevention) and a later arm intended to prevent further problems from arising (secondary prevention).

The early education arm encompasses educating the healthcare team, our patients and the public at large. Of course, avoiding problems through appropriate education is preferable. However, if the education of the general public is not successful, which history has shown to be the case, the key is to educate those people caring for patients�primarily the nurses and physicians. Through inservices, sharing of articles and the development of quality and thorough ethics policies, many potential problems can be handled before they become burdensome. When problems do arise, we should change our focus from �preventive ethics� to the second arm, with a goal of preventing further harm or a violation of a patient's autonomy, provision of nonbeneficial treatments or failure to provide adequate palliative care.

Sometimes, emotions prevail, regardless of planning and rational decision making. Although honoring Joe's original wishes would have been preferable, the actions of the ICU nurses to involve the ethics committee was key to resolving this case. Acting as patient advocates, ICU nurses must use their knowledge, skills and caring attitudes to meet the needs of their patients and families. Through innovative redirection of discussion and refocusing of the team on patients and their desires, autonomy can be protected and patients can be spared further suffering.

This type of intervention does not work in all cases. However, in most, early intervention, discussion and counseling from a multidisciplinary team can help a patient's family accept a patient's decision and honor his or her wishes. The earlier this happens, the better. In this case, though the end result was positive, early notification to the ethics committee that the patient was acting contrary to his own advance directive might have prevented some of the problems that did arise.
Personal Digital Assistant Can Be Professional Ally

By Sheila Melander, RN, DSN, ACNP, FCCM, and Julie Marcum, RN, MS, CCRN, CS
Advanced Practice Work Group

As a cutting-edge, high-tech nursing professional, you probably have thought about getting a personal digital assistant (PDA). You probably have questions not only about its professional and personal advantages but also about the types and capabilities of those that are available.

Following is an overview of the benefits of PDAs as a professional resource and a list of Web sites you can visit to find out more.

Several features, such as e-mail, a calendar, to do lists, an address book, a calculator, expense logs, handwriting recognition and a memo pad, are built into the software that is preloaded in the PDA. In fact, one advanced practice nurse said he purchased a PDA mainly because, unlike his hand-written day-timer, the PDA provided an audible reminder of an impending meeting or appointment. You can even download appointments from your desktop computer to your PDA with a program, such as Microsoft Outlook, with just a push of the �hot sync� button.

An excellent overview of the capabilities of the PDA can be found online at > PDAs & Nursing and at http://www.nearlymobile.com. At is an online journal as well as other useful information for nurses using PDAs.

Of course, you will want to explore the free healthcare software that is available. To discover this �freeware,� search for the keywords �palm medical freeware.� Although the list of sites is quite lengthy, several stand out, including www.healthypalmpilot.com. This site provides a healthcare resource index where you can find out about a number of free as well as commercial software applications. It also rates each application and describes the various attributes.

Multiple healthcare links can be found at another useful site, pbrain.hypermart.net/medapps.html. Here you can also access an area called Current Clinical Strategies, which will give you a list of medical books in palm format, courtesy of the Library of the National Medical Society. For a one-time charge of $9, you can download as many of these references as desired. This site also lists numerous medical calculators, such as ABG pro, Infusicalc (an IV drug calculator), MedMath (designed for rapid calculation of common equations used in adult internal medicine such as body surface area and creatinine clearance) and several statistical analysis programs.

A widely known drug database is ePocrates RX (http://www.epocrates.com), which also includes current ACLS algorithms. A �DocAlert� feature, which alerts the practitioner to relevant Federal Drug Administration warnings concerning pharmaceuticals, can be downloaded with every PDA hot sync.

Other useful pharmacology references include Tarascons Pharmacopeia at http://www.medscape.com/MedscapeMobile/Tarascon/public/learn_tarascon.ht and http://www.PDR.net. PDR.net can be customized for specific audiences, including consumers, physicians, RNs, advanced practice nurses and pharmacists.

The 2000 Guide to Handheld and Palmtop Computing Resources for Health Care Professionals reviews medical-nursing PDA software. This online book, which costs $4.99, can be accessed at http://themedicalguide.hypermart.net/.

Sites specific to advanced practice nurses are NP Central (costs $25 per year); http://www.npclinics.com, and http://www.MDLinx.com.

Other advanced practice topics can be accessed via http://www.medscape.com, where there are multiple specialty links to areas such as advanced practice, nursing, women's health, cardiology and critical care. Once you select one or more of these specialty pages, they can be downloaded into you PDA with a software called Medscape mobile.

Medscape mobile (http://www.medscape.com/mobile) brings you current clinical content on any specialty you choose and includes journal articles, journal scans and next-day summaries of conferences, such as the American College of Cardiology, American Academy of Nurse Practitioners 16th Annual National Conference, and the 30th International Educational and Scientific Symposium of the Society of Critical Care Medicine.

References such as Harrison's Principles of Internal Medicine ($99) and the Merck Manual ($79.99) can be purchased as well as other commercial downloads at http://www.handheldmed.com.
Selected sites that specialize in PDA accessories and devices include http://www.franklin.com/estore/platform, and and http://www.handspring.com.
Prices for PDAs are declining dramatically, while the capabilities of these handheld devices continue to increase along with the resources available. Projections are that PDAs will be even smaller, lighter and more versatile and that they will be PowerPoint compatible, with increased memory, more add-ons and longer-lasting batteries. A PDA will certainly increase the information you have at your fingertips and enhance your professional practice.

Practice Resource Network: Frequently Asked Questions

Q: I achieved my CCRN certification almost three years ago and am now ready to renew. How do I use continuing education units to recertify?

A: CCRN renewal candidates must have accumulated 100 continuing education recognition points (CERPs) during the three-year certification period. One CE is equal to 50 minutes of classroom time, which is equal to 1 CERP. For example, a six-hour ACLS course is calculated as follows: 6 hours x 60 minutes = 360 minutes. Divide 360 by 50 to get 7 CERPs. In addition, candidates must hold a current, unrestricted RN license and have at least 432 hours in direct bedside care of critically ill patients during the three-year certification period, with 144 of these hours accrued in the most recent year preceding the renewal application.

Q: What is the difference between Category A and O CERPs?

A: Category A CERPs are earned by attending acute and critical care educational programs or by completing academic credit courses specific to patient care. Examples would be physical assessment, pathophysiology, pharmacology, ABG interpretation, infection control or BLS/ACLS/PALS. Of the 100 CERPs required for CCRN renewal, 25 must be in Category A. Category O CERPs are granted for a broad range of activities, including professional publication, professional presentations, professional memberships, volunteer activities, academic credit courses (i.e., chemistry, psychology, sociology, medical Spanish), activities to improve care (i.e., preceptorship; committee work; revising a nursing policy, procedure or protocol; designing patient educational aids).

If you have a practice-related question, call AACN's Practice Resource Network at (800) 394-5995, ext. 217, or post your question online
In the Circle: Award Honors Excellence in Clinical Practice

The following excerpts are from exemplars submitted in connection with the 3M Health Care-AACN Excellence in Clinical Practice Award for 2001, a part of AACN's Circle of Excellence recognition program. Sponsored by 3M Health Care, this award honors acute and critical care nurses who embody, exemplify and excel at the clinical skills and principles that are required in their practice. Recipients were provided complimentary registration, airfare and hotel accommodations for NTI 2001 in Anaheim, Calif.

Lorna Garrison Benton, RN, BSN, CCRN
High Point, N.C.
High Point Regional Health Systems

Ralph, a 46-year-old factory worker, was readmitted to our unit approximately two weeks after his first myocardial infarction.

When his physician asked him what his activity level had been since discharge, he replied, �I went back to work the next day, because I was feeling fine.� It was then that I realized I had failed in my teaching efforts with Ralph during his first admission.

I decided I needed to devise a teaching tool that patients could relate to and easily comprehend. Combining my ideas with illustrations from a variety of nursing resources, I developed a color flip chart to depict the post MI, pre- and postinvasive procedures.

This method of teaching has had a positive impact on our patients. Patients who have completed and returned the Press Ganey Satisfaction Survey have specifically mentioned how helpful this tool has been for them.

During my 34 years in nursing, I have found that improvisation works. Patient education and discharge teaching remain primary functions for us. We strive to apply both old and new teaching techniques to meet the patients' learning needs.

I often think of Ralph when I teach, because he was such a great teacher for me. Of course, Ralph does not realize the difference he made in my professional life nor the fact that his influence has touched the lives of every patient and family member we teach in our unit.

Marcia A. DePolo, RN, CCRN, CNRN, ONC, TNCC
Springfield, Va.
Inova Fairfax Hospital

Angela survived the critical phase of her accident injuries and, after two weeks, was transferred from the trauma ICU to intermediate care. Sometimes, sending patients to another level of care is difficult, even though it means that they are improving.

Knowing that our patients have been precariously balanced between life and death, we realize that our interventions have made a difference. Although families often promise to keep in touch, we don't always hear about how our patients' progress after they leave our care. Busy with the next trauma, we have little time to follow up with these families with whom we have shared intimate moments.

As her nurse, I felt a unique connection with Angela, whose name means �messenger� in Greek. Because of her, I realized that, if our unit had a �family book,� the patients would be remembered, and the stories of courage and bravery could be shared with subsequent families.

As nurses, we carry special patient memories in our hearts every day. In this Trauma ICU Family Thoughts Book, our families are able to see evidence of this.

They know that, though they have left our immediate environment, they are not forgotten. They know that they can write a story, even a year later, to add to the book.

The nurses on our unit are also encouraged to share their thoughts and to take photographs of patients when they come back for a visit. We have started a lasting tribute to our patients and families.

Teresa Foulke, RN, CCRN
Laguna Hills, Calif.
Mission Hospital Regional Medical Center

My coworkers were already busy caring for two newly admitted, critical trauma cases when my patient, Bill C., arrived in the ICU. I realized that my assignment would be more of a solo effort than usual.

When Bill returned from surgery, he was precariously close to dying. The immediate crises I faced in dealing with hypoxia, severe hypotension and a climbing ICP were overwhelming. I had to triage Bill's needs, selectively communicate and coordinate with other overtaxed staff members and be vigilant in monitoring the patient's status. I was inundated with the need to deal with physiological crises, assist with procedures, prevent potential problems and communicate with members of the care team and Bill's family.

Bill spent 22 more days in the ICU. Because our unit has developed a strong sense of teamwork, staff members from many disciplines contributed in unique ways to Bill's care and to his family. We all felt we had made a difference.

Nevertheless, when he left the ICU, Bill was only beginning to follow simple commands, and we didn't know how much he would recover cognitively.

Although we learned that Bill was doing well in rehabilitation, we heard little more until a smiling Bill came to the unit several months later. We were delighted to learn that he was back at work in a demanding job.

We knew that we had made a real difference when he said that, though he did not remember his stay in the ICU, he wanted to take a picture of the team that cared for him to send to his mom as her Mother's Day gift.

Anna E. Lambert, RN, ADN, CCRN
Rochester, N.Y.
Strong Memorial Hospital, University of Rochester
Critical care nurses face unexpected, extraordinary events working in an ICU.

This exemplar recounts one of those situations, when a nurse unexpectedly needs to accompany a patient requiring an air ambulance transport to a heart transplant program.

Kevin, a college student, was suddenly taken from his vibrant life because of a severe cardiomyopathy requiring biventricular support and the anticipation of a heart transplant. He was intubated and on nitric oxide and multiple drips. Because our unit did not have a transplant program, Kevin needed to be transported to a facility that did.

The transfer of care was a challenge. We needed to create safe passage in both the literal and figurative sense. A safe journey would not have been possible without the synergistic efforts of a multidisciplinary team.

Ultimate continuity of care was realized, because an in-person report could be made upon arrival at the destination unit. Kevin had a positive outcome. After receiving a new heart, he was able to return to a productive life.

The challenges of critical care nursing, though sometimes difficult, often allow us to reflect on our own destiny, strengthen our skills for future complex patients, and reinforce how proud we are to be critical care nurses.

M. Constance Roy, RN, BSc, CCRN
Edgewood, N.M.
University of New Mexico Hospital

Frank was admitted to our unit following a lung biopsy. He had had no previous significant medical history when he presented to the emergency department with dyspnea.

For most of his hospitalization, his significant other, Sue, was an important presence for him, reading to him and providing some care to his unresponsive body. However, his worsening condition caused her stress, with which she was unable to cope.

As Frank's terminal condition was confirmed and he sank into multidisciplinary organ failure, the focus shifted to meeting the needs of Sue. She had poor inner resources and a complete lack of support from other family members.

We assisted Sue through the final and most difficult hours of Frank's life. We identified the interdisciplinary support and commented on how special it was to be the nurse to both Frank and Sue.

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