AACN News—July 2000—Practice

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Vol. 17, No. 7, JULY 2000

Practice Resource Network: Frequently Asked Questions

In striving for a patient-driven healthcare system, where critical care nurses make their optimal contribution, AACN must continually identify issues important to critical care nurses and provide resources to address these issues.

The Practice Resource Network (PRN) is designed to help critical care nurses address questions by connecting them with the most current clinical practice and research information, providing them opportunities to network with colleagues and assisting them in working more effectively with technology. Since mid-1998, PRN has received more than 6,000 calls from critical care nurses.

Following is a list of Frequently Asked Questions topics that have been published in AACN News. These columns are available on the AACN Web site at http://www.aacn.org. Click on “Practice Resources,” then “FAQ.”
• Mandatory ACLS
• AACN Preceptor Resources
• Staffing Blueprint Emphasizes Patient Focused Care
• AACN Staffing Resources
• Nosocomial Pneumonia
• PA Catheter Line and Site Care
• Orientation and Competency Validation

• Advanced Practice Graduate Programs
• Nursing Shortage
• Pericardial Drains
• Resources for Infants and Children
• Zeroing Arterial Catheter Transducers
• Family Visitation in the ICU
• Monitoring in Progressive Care/Telemetry Units
• PA Catheter Education

Apply for a Nursing Research Grant

Several grants to support research relevant to critical care nursing practice are available from AACN. The deadlines to submit proposals for some of these grants are approaching. Following is information about these grants:

Agilent Technologies-AACN Critical Care Nursing Research Grant
Cosponsored by Agilent Technologies and AACN, this grant supports research conducted by a critical care nurse.

The total of $35,000 includes $33,000 for research and $2,000 for travel expenses associated with presentations of the study findings. The recipient may use up to $3,000 of the research award to purchase a personal computer, utility software and printer to support the study. Computer-related expenses should be included and justified in the project budget.

The grant is intended to support a well-defined, well-described research project. The award selection will be based upon the scientific merit of the project; scientific and professional background of the applicant; adequacy of facilities and resources available for the research; originality; and potential benefits to the care of critically ill patients.

The preferred topic for this grant is the information technology requirements of patient management in critical care. Because this grant is intended to support research that has direct clinical application to critical care nursing practice, proposals for basic science or animal studies are not eligible. Reviewers’ comments will not be provided to applicants.

To be eligible, the applicant must be both an RN and an active AACN member. The grant can be used to fund research associated with an academic degree.

Proposals must be received by Sept. 1, 2000.

AACN Data-Driven Clinical Practice Grant
This program provides six awards 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.

Funds are available for new projects, projects in progress or projects required for an academic degree as long as all other project criteria are met. Collaborative projects involving interdisciplinary teams, multiple nursing units, home health, subacute and transitional care, other institutions or community agencies are encouraged.

To qualify for an AACN Data-Driven Clinical Practice Grant, the principal investigator must be a regular or affiliate member of AACN and not currently conducting a study funded by an AACN research grant.

Applications must be received by Oct. 1, 2000.

AACN Clinical Practice Grant
This $6,000 grant supports research that focuses on at least one of AACN’s research priorities.

The principal investigator must be both an RN and current member of AACN. Research conducted in fulfillment of an academic degree is acceptable.

Proposals must be received by Oct. 1, 2000.

AACN-Sigma Theta Tau Critical Care Grant

This $10,000 grant, which is cosponsored by AACN and Sigma Theta Tau International, funds research that is relevant to critical care nursing practice.

The principal investigator must be an RN. The proposed study may be used to meet requirements of an academic degree.
Proposals must be received by Oct. 1, 2000.

To obtain application materials and instructions, call (800) 899-AACN (2226), or visit the “Research” section of the AACN Web site at http://www.aacn.org.

The Power of One: Who Should Decide What Is Best for the Patient?

By Jeanne PaPa, RN, BSN, CCRN, RRT

Naomi was a 41-year-old female with Down Syndrome. Prior to being admitted to our ICU, she had been in an assisted-living apartment for five years. However, her difficulties in caring for herself had led to her admission into a nursing home.

Naomi subsequently was diagnosed with acute respiratory distress syndrome (ARDS) and admitted to a community hospital. From there she was transferred to our university hospital for mechanical ventilation and vasopressor administration to maintain her blood pressure.
In our ICU, numerous unsuccessful attempts were made to wean Naomi from the ventilator and her vasopressors. She remained on dopamine for blood pressure support. We were unable to feed her enterally. She required multiple antibiotics for chronic pulmonary aspirations. Her deteriorating status worsened when she was placed in contact isolation for methicillin-resistant Staphylococcus aureus. She could no longer communicate with her caregivers and responded only to painful stimuli. At this point, the medical team scheduled a conference with the family to decide what would be best for Naomi.

Naomi’s family had not been closely involved in her care. Her sister and father had only visited on the first night she was admitted. Another sister called frequently for updates. Naomi’s “other” family was the nursing home staff, who visited her during her hospitalization. They too were invited to the family meeting.

Some interesting details developed at the family meeting. The nursing home staff claimed that they had been declared Naomi’s power of attorney. These staff members wanted Naomi to return to the home. However, it was determined that they did not legally have decision-making rights. This meant that Naomi’s family would make the final decision about her care, because Naomi had never been declared incompetent or a ward of the state. Her biological family noted that they were pleased with the care that Naomi received both in the hospital and in the nursing home. Her family and the healthcare team decided that, after six weeks in the ICU, they would recommend that ventilator support be withdrawn and she would be allowed to die. Shortly after the ventilator support was discontinued, Naomi died peacefully, with her family at her bedside.

This difficult case raised many ethical concerns, primarily whether continuing aggressive treatment would promote or contribute to Naomi’s well being. However, the team was also concerned about the question of who was the surrogate decision maker. Our physician’s question about who had legal authority to make decisions for Naomi helped us come to a consensus regarding her care. The nursing home staff continued to advocate for continued, indefinite care, which was difficult to understand, given the gravity of Naomi’s condition.
After determining the ultimate decision-maker for Naomi, the physician helped the family to understand the prognosis, and the healthcare team provided emotional support to assist them in coming to the decision to withdraw care.

Some of the most controversial cases in medical ethics involve care decisions when patients are unable to speak for themselves. In this case, we had a family who had little contact with the patient, there was no advance directive and a surrogate family (the nursing home) who had no legal responsibility for the decisions to be made. Above all, this was the decision to choose what is best for the patient. The media and the literature has devoted much attention to decisions surrounding the use of life-sustaining therapies and technologies for incompetent patients who face a known, compromised quality of life. There is some agreement that incompetent patients need to have substitute decision makers. The healthcare team can assist by providing the fullest information possible in cases where the substitute decision makers have little information on the desires of the patient. In this case, the physicians and the healthcare team, those closest to the actual clinical situation, helped the family to make the decision for withdrawal of care. With the support of the healthcare team in the ICU, Naomi’s family was comfortable with the decision to withdraw care. Sometimes the power of one requires more than one person.

Jeanne PaPa is a Level 3 staff nurse in the Medical Intensive Care Unit at the Hospital of the University of Pennsylvania, Philadelphia, Pa. She is a member of the AACN Ethics Integration Work Group.

Geriatric Corner: New Pocket Resource Is Now Available

In the past two years, this column has attempted to bring to light many problems, issues and concerns that critical care nurses have regarding care of their older patients. Some of you asked for a pocket card that contained key assessment information or facts regarding this population.

The “AACN Geriatric Critical Care Pocket Reference” was showcased at the 2000 NTI in Orlando, Fla., in May. This pocket reference is structured to be a helpful addition to your assessment arsenal. The card features key information for comprehensive geriatric assessment. Included is information regarding functional assessment and common problems that face the hospitalized elderly. The laboratory evaluation focuses on the values that have specific changes as one ages. For example, calculations of renal function and creatinine clearance, water deficit, transferrin percentage saturation and alveolar-arterial oxygen gradient are included. Also included are assessment tools that could assist you in determining acute confusion, depression and measuring other cognitive changes.

Make your assessment of your older patient comprehensive and consistent using all the tools available!

The “AACN Geriatric Critical Care Pocket Reference” is available online from the AACN Bookstore at www.aacn.org, or by calling (800) 899-AACN (2226)). Request Item #400853. Price is $2 for members ($4 for nonmembers), plus shipping and handling. A discount is available for orders of five or more.

Do you have an age-related care story or idea? AACN wants to provide a vehicle for the sharing of information that can enhance practice for all members who provide care to the older population. Send information to AACN Clinical Practice Specialist, Justine Medina, RN, MS, 101 Columbia, Aliso Viejo, CA 92656; fax, (949) 448-5520; e-mail, Justine.Medina@aacn.org,
or call (800) 394-5995, ext. 401.

Circle of Excellence: Outstanding Advanced Practice Nurses for 2000

The AACN Outstanding Advanced Practice Nurse Award recognizes acute and critical care advanced practice nurses who function as advanced practitioners. Recipients received complimentary registration, airfare and hotel accommodations for the NTI in 2000 in Orlando, Fla. The deadline to nominate yourself or a colleague for this award for 2001 is Sept. 1, 2000. Recipients will receive complimentary registration, airfare and hotel accommodations to NTI 2001, May 19 through 24 in Anaheim, Calif. For more information, call (800) 899-AACN (2226), or visit the AACN Web site at http://www.aacn.org.
Following are excerpts from the exemplars submitted for the award recipients for 2000:

Jane Cunneen, RN, MSN, CCRN
Indianapolis, Ind.
Clarian Health Partners
Methodist Hospital

The morning news sent chills up my spine. A 34-year-old man with burns covering more than 65% of his body was now at the trauma center, where I was the critical care clinical nurse specialist.

I pulled together the burn-care team and developed the plan of care to include sending a skin biopsy to grow cultured epidermal autografts (CEAs). In four weeks, delicate epidermal skin, costing $60,000, would be returned for final skin grafting. Jim’s course was highly complicated by septic shock, renal failure, gastrointestinal (GI) bleeding and acute respiratory distress syndrome (ARDS).

The skin healed with a 99% take, and the narcotics and sedation were tapered off. However, Jim did not awaken, and the neurologist’s prognosis was grim. I searched the literature and engaged my medical director in a thorough case review, as well as exotic tests to find a cause of the encephalopathy.

Jim’s wife sought my advice. Although the neurologist was recommending withdrawal of life support, his wife shared with me that she wanted Jim back, regardless of his condition. I suggested more time. Two weeks later, Jim woke up! He gradually developed motor movement and is now home. He can walk and enjoys life.

The neurologist related a visit with Jim, telling him, “You owe your wife your life. She insisted we keep you going. Thank her every day that you are alive!” I just smiled.

Karen Johnson, RN, PhD, CCRN
Tucson, Ariz.
University of Arizona
College of Nursing
University Medical Center
Bobbie was a 20-year-old man admitted to our ICU after a motor vehicle crash. Residents and nurses, busy with resuscitation efforts, had not had an opportunity to update his family. I found Bobbie’s dad, explained his injuries and our resuscitation efforts, and brought him to Bobbie’s room.

Within three days, Bobbie developed acute respiratory distress syndrome (ARDS). Pressure control ventilation and therapeutic paralysis were initiated. Bobbie’s dad sat by his bed, afraid to talk to or touch him. I knew from my own research that patients who had experienced therapeutic paralysis recalled that their loved ones were present. Soon, Bobbie’s dad was actively involved in assisting the nurses with his physical care.

One day as Bobbie’s dad and I talked in our ICU family waiting room, I thought: “We call this the family waiting room; It looks more like a bus terminal, with gray walls and straight-back chairs that are lined in rows.”

My supervisor and I submitted a proposal, titled “Creating a Caring Environment for Critically Ill Patients and their Families” to our hospital’s fund-raising board. The proposal was chosen as the recipient of its annual major fund-raising event to create a more “family-friendly” atmosphere in our ICU family waiting room!

After 65 days in the ICU, Bobbie was transferred to a rehabilitation center. The rehabilitation team was amazed at his muscle strength after five weeks of therapeutic paralysis. I wasn’t. I know the healing power of families who are encouraged and supported to actively participate in recovery.

Jan Powers, RN, MSN, CCRN, CWCN
Indianapolis, Ind.
Clarian Health Partners
I can identify five roles that exemplify an advanced practice nurse, more specifically a clinical nurse specialist—advanced practitioner, educator, manager, researcher and consultant. I would add mentor. The advanced practitioner is the most integral role. Without this skill, there is no foundation for the other roles.

One of the most challenging cases with which I have been involved was a pregnant woman who had sustained a first- and second-cervical vertebra fracture, which left her ventilator dependent. Because our usual rehabilitation facilities could not accommodate a high-risk pregnancy, she stayed in our unit for acute care, rehabilitation issues and her obstetric needs. At 34 weeks she delivered a healthy baby in a normal delivery. I was honored to have the privilege of sharing this moment and being part of her life for the five months that she was in our unit.

As an educator, there is the opportunity in every contact to teach in both formal and informal settings. It is in the daily contact with the staff, patients and families that I see the full potential of the educator role. I want nurses to be aware that there is a great need to base our field of practice on science and fact, as well as art to further nursing knowledge.

As I look at my years as a CNS, I have repeatedly filled all of these roles in my practice. However, the one that I always feel is the most rewarding is that of mentor. I am proud and honored to know that I had a part in the making of a wonderful nurse or clinical nurse specialist.

CD ROM Clinical Simulations Focus on Shock and Complex Problems

Two new CD ROMs, designed to provide staff with essential techniques, diagnostic tests and nursing care on a variety of topics, have been released by Lippincott Williams & Wilkins.

The Clinical Simulations: Shock Management CD ROM presents core and advanced information for the care of patients who develop various types of shock. Coverage includes nursing care related to effective pharmacological and medical treatment.

AACN Clinical Simulations: Complex Problems in Critical Care is an interactive program that covers topics involving patients with a variety of problems that are commonly seen in the critical care area.

For more information, call Lippincott Williams & Wilkins at (800) 326-1685.


Online Quick Poll Update

Does your hospital have a mandatory overtime policy?

Yes 43%

No 53%

Don’t Know 4%

To what do you attribute the mandatory overtime?

Nursing Shortage 38%

Sick Calls 14%

Routine Short Staffing 38%

Other 10%

How often are you required to work mandatory overtime on your unit?

Excessively (once a week or more) 7%

Frequently (once every two weeks or more) 22%

Infrequently (once a month or less) 31%

Never 40%

Number of Responses: 2,125

The AACN Online Quick Poll is a voluntary, nonscientific survey on a variety of topics. Participate by visiting the AACN Web site at http://www.aacn.org.

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