Saturday, November 29, 2008
New Fall Prevention Policy and Procedure-SEE EDUCATION BOARD IN PCU BREAKROOM TO SIGN OFF ON
You may have already seen the new yellow wrist bands on patients and signs outside patient rooms. On the Bulletin Board in the PCU break room there is a review of the new Policy and Procedure as well as a sign off/attendance sheet that you all need to sign. The Board is generally changed monthly by educational services so time is of the essence. This is all part of best practice for our patients, new to the policy is the HOMESAFEHOME Tips to Improve Home Safety that will will provide at discharge to patients so this is a slight change to our current practice but the items on the sheet are things that all of us review but there is no written education provided for discharge...problem solved. Thanks for all each of you do to give good care.
Sunday, November 9, 2008
Critical Care Online Expo
I wanted to post this awhile ago but couldn't get the links to work before the event was webcasted on November 5th but I finally got on and here is a link to a webcast/powerpoint from a national speaker AnneMarie Palatnick-her name is well known as an educator for nursing in critical care. There are many available offerings in this expo so take advantage of some great FREE education here.
http://vts.inxpo.com/scripts/InXpo.nxp?LASCmd=AI:1;F:SF!42000&EventKey=7556
Enjoy!
Tracy
http://vts.inxpo.com/scripts/InXpo.nxp?LASCmd=AI:1;F:SF!42000&EventKey=7556
Enjoy!
Tracy
Sunday, November 2, 2008
From Medscape for Nurses-Evidence Based Best Practice for ETT suctioning-Is Saline Instillation Beneficial?
Instilling Normal Saline With Suctioning: Beneficial Technique or Potentially Harmful Sacred Cow?
Margo A. Halm, RN, PhD, CNS-BC; Kathryn Krisko-Hagel, RN, MS
Am J Crit Care. 2008;17(5):469-472. ©2008 American Association of Critical-Care Nurses
Posted 10/28/2008
Introduction
Normal saline has been widely used in acute care settings during endotracheal and tracheostomy suctioning. Clinicians have held fast to this long-standing tradition because many were taught that normal saline breaks up secretions and aids in their removal (especially tenacious secretions). In this clinical review, we summarize current evidence related to the following questions: Does instilling normal saline during suctioning increase sputum yield? Alternatively, is this practice associated with adverse physiological and psychological effects?
Methods
The strategy included searching MEDLINE, CINAHL, Cochrane Library, Joanna Briggs Institute, and TRIP databases. Key words included endotracheal tubes, tracheostomies, normal saline, and suctioning. All types of evidence (nonexperimental, experimental, qualitative studies, systematic reviews) were included.
Results
In the past 2 decades, investigators have studied the physiological and psychological effects of instillation of normal saline. The impact of the instillation of normal saline on sputum recovery, oxygenation, subjective symptoms, hemodynamic alterations, and infection was measured in 14 studies[1-14] ( Table 1 ). The effects of 2, 5, or 8 mL of normal saline on physiological parameters were evaluated at intervals of 5, 10, or 20 minutes (5 minutes most common). In one study,[1] researchers investigated saline deposition by radioactively labeling normal saline with technetium (Tc 99m). Samples included anesthetized dogs and ventilator-dependent patients in general, coronary artery bypass, and neurological intensive care units (ICUs). In addition to these studies, a guideline on tracheal suctioning from the Joanna Briggs Institute[15] was retrieved.
Sputum Recovery
Sputum volume or weight was measured in 5 of the 14 studies (36%).[1-5] In 3 of those 5 studies (60%), instillation of normal saline was associated with significantly increased retrieval of sputum. The difference in sputum volume ranged from 1 to 2 g, which may not be of clinical importance. In another study,[1] radioactively labeled normal saline was noted near the bottom of the endotracheal tube within 1 minute of instillation (rather than mixing with secretions) and was then rapidly absorbed by the cardiopulmonary system, providing evidence that normal saline and secretions do not mix. Furthermore, suctioning recovered a mean of only 18.7% of normal saline instilled in humans.
Oxygenation
Arterial blood gas analysis and measurement of the nadir and recovery time of oxygen saturation (most common) or mixed venous oxygen saturation were done in 9 studies.[2-6,9,10,12,13] Results of 56% of those studies indicated that use of normal saline was significantly associated with decreased oxygenation and desaturation that worsened over time after suctioning. Oxygen saturation was a mean of 1% to 2% lower when normal saline was used, which may, in itself, not be clinically significant. However, instillation of normal saline may impair gas exchange as evidenced by continued desaturation. More clinically impressive was the 6-point decrease in mixed venous oxygen saturation that Kinloch[10] observed in patients suctioned 5 minutes after instillation of normal saline (compared with controls), as well as the doubled recovery time. These findings demonstrate the detrimental effect of normal saline on global tissue oxygenation.
Subjective Symptoms: Pain, Anxiety, Dyspnea
Subjective symptoms associated with instillation of normal saline were explored in 2 studies[8,11] (14%). Exploring the experience of being suctioned with normal saline, Jablonski[8] found that patients reported anxiety and dread, as well as increased pain. In another study, O'Neal et al[11] found increased perceived dyspnea in patients over age 60 that persisted for up to 10 minutes after suctioning, a finding that may be related to decreased pulmonary compliance with aging.
Hemodynamic Alterations
Hemodynamic effects were investigated in 3 studies[4,9,12] (21%). Results of 1 of these studies[12] demonstrated that instillation of normal saline was associated with increased heart rate 4 to 5 minutes after suctioning; however, no effect on blood pressure or respiratory rate was uncovered. The increased stimulation of the cough reflex associated with instillation of normal saline may have other detrimental effects such as increased mean arterial pressure and intracranial pressure.[15,16]
Infection
Risk of infection was investigated in 2 studies[7,14] (14%). Hagler and Traver[7] found sputum cultures that showed growth due to the dislodgment of bacterial colonies. Up to 5 times as many colonies were dislodged when normal saline was instilled, and therefore this practice may contribute significantly to lower airway contamination. Newer evidence from a randomized controlled trial[14] suggests that instillation of normal saline was associated with a lower incidence of ventilator-associated pneumonia. It is unclear from this abstract whether the researchers controlled for other standard interventions to avoid ventilator-associated pneumonia[17,18] such as oral care, aspiration of subglottic secretions, maintenance of cuff pressure on the endotracheal tube, and prophylaxis of peptic ulcer and deep vein thrombosis.
Recommendation Based on Current Evidence
Collectively, these studies provide class III evidence of the adverse physiological and psychological effects of instillation of normal saline, and therefore, support against the routine use of normal saline with suctioning ( Table 2 ). Normal saline and mucus do not mix. Therefore, normal saline does not thin or mobilize secretions. Rather, ensuring adequate hydration is one way that nurses can facilitate removal of secretions.[15] The best-known interventions for managing thick tenacious secretions and preventing mucus plugs in ventilator-dependent patients are hydration, adequate humidification, use of mucolytic agents, and effective mobilization.[16,18,20]
In addition to an unappreciable increase in sputum recovery, use of normal saline adversely affects arterial and global tissue oxygenation and dislodges bacterial colonies, thus contributing to lower airway contamination. Because no solid scientifically based benefits for routine use of normal saline have been shown, it is highly recommended that this potentially harmful "sacred cow" be abandoned. Instead, treatment considerations should center on ways to prevent the development of thick, tenacious secretions.[20]
Normal saline may be indicated in situations where it is necessary to elicit a cough,[4,18] and normal saline may be useful for clearing the catheter after suctioning to avoid reintroducing pathogens into the airway.[21] Good handwashing is essential to reduce infection when opening vials of normal saline because increased contamination has been documented when clinicians use the nongloved thumb to twist off the tops of the vials.[22]
Despite these recommendations, organizational change toward best suctioning practices has not been without challenges. In a recent multisite study,[23] three large institutions had policies that recommended instilling normal saline for thick secretions. Suctioning surveys[23,24] also indicate that 2 to 3 times as many respiratory therapists as nurses report continued use of normal saline—a finding that is not so surprising given that the American Association of Respiratory Care's guideline[25] has not been updated since 1993 (and still advocates that normal saline dilutes and mobilizes secretions).
Promisingly, among nursing circles, researchers in the United Kingdom reported that although observed suctioning practices were contrary to many research recommendations,[26] educational interventions proved effective in advancing the knowledge and translation of research-based suctioning practices of critical care nurses at the bedside.[27]
Others have also reported high compliance rates of nurses with evidence-based guidelines recommending avoidance of normal saline.[28] More studies are needed to document clinical adherence to evidence-based guidelines so that we can better connect processes of care to outcomes for patients.
I think that this evidence says it all-No Saline!
And here is the link to the same article-
http://www.medscape.com/viewarticle/581620_print
Margo A. Halm, RN, PhD, CNS-BC; Kathryn Krisko-Hagel, RN, MS
Am J Crit Care. 2008;17(5):469-472. ©2008 American Association of Critical-Care Nurses
Posted 10/28/2008
Introduction
Normal saline has been widely used in acute care settings during endotracheal and tracheostomy suctioning. Clinicians have held fast to this long-standing tradition because many were taught that normal saline breaks up secretions and aids in their removal (especially tenacious secretions). In this clinical review, we summarize current evidence related to the following questions: Does instilling normal saline during suctioning increase sputum yield? Alternatively, is this practice associated with adverse physiological and psychological effects?
Methods
The strategy included searching MEDLINE, CINAHL, Cochrane Library, Joanna Briggs Institute, and TRIP databases. Key words included endotracheal tubes, tracheostomies, normal saline, and suctioning. All types of evidence (nonexperimental, experimental, qualitative studies, systematic reviews) were included.
Results
In the past 2 decades, investigators have studied the physiological and psychological effects of instillation of normal saline. The impact of the instillation of normal saline on sputum recovery, oxygenation, subjective symptoms, hemodynamic alterations, and infection was measured in 14 studies[1-14] ( Table 1 ). The effects of 2, 5, or 8 mL of normal saline on physiological parameters were evaluated at intervals of 5, 10, or 20 minutes (5 minutes most common). In one study,[1] researchers investigated saline deposition by radioactively labeling normal saline with technetium (Tc 99m). Samples included anesthetized dogs and ventilator-dependent patients in general, coronary artery bypass, and neurological intensive care units (ICUs). In addition to these studies, a guideline on tracheal suctioning from the Joanna Briggs Institute[15] was retrieved.
Sputum Recovery
Sputum volume or weight was measured in 5 of the 14 studies (36%).[1-5] In 3 of those 5 studies (60%), instillation of normal saline was associated with significantly increased retrieval of sputum. The difference in sputum volume ranged from 1 to 2 g, which may not be of clinical importance. In another study,[1] radioactively labeled normal saline was noted near the bottom of the endotracheal tube within 1 minute of instillation (rather than mixing with secretions) and was then rapidly absorbed by the cardiopulmonary system, providing evidence that normal saline and secretions do not mix. Furthermore, suctioning recovered a mean of only 18.7% of normal saline instilled in humans.
Oxygenation
Arterial blood gas analysis and measurement of the nadir and recovery time of oxygen saturation (most common) or mixed venous oxygen saturation were done in 9 studies.[2-6,9,10,12,13] Results of 56% of those studies indicated that use of normal saline was significantly associated with decreased oxygenation and desaturation that worsened over time after suctioning. Oxygen saturation was a mean of 1% to 2% lower when normal saline was used, which may, in itself, not be clinically significant. However, instillation of normal saline may impair gas exchange as evidenced by continued desaturation. More clinically impressive was the 6-point decrease in mixed venous oxygen saturation that Kinloch[10] observed in patients suctioned 5 minutes after instillation of normal saline (compared with controls), as well as the doubled recovery time. These findings demonstrate the detrimental effect of normal saline on global tissue oxygenation.
Subjective Symptoms: Pain, Anxiety, Dyspnea
Subjective symptoms associated with instillation of normal saline were explored in 2 studies[8,11] (14%). Exploring the experience of being suctioned with normal saline, Jablonski[8] found that patients reported anxiety and dread, as well as increased pain. In another study, O'Neal et al[11] found increased perceived dyspnea in patients over age 60 that persisted for up to 10 minutes after suctioning, a finding that may be related to decreased pulmonary compliance with aging.
Hemodynamic Alterations
Hemodynamic effects were investigated in 3 studies[4,9,12] (21%). Results of 1 of these studies[12] demonstrated that instillation of normal saline was associated with increased heart rate 4 to 5 minutes after suctioning; however, no effect on blood pressure or respiratory rate was uncovered. The increased stimulation of the cough reflex associated with instillation of normal saline may have other detrimental effects such as increased mean arterial pressure and intracranial pressure.[15,16]
Infection
Risk of infection was investigated in 2 studies[7,14] (14%). Hagler and Traver[7] found sputum cultures that showed growth due to the dislodgment of bacterial colonies. Up to 5 times as many colonies were dislodged when normal saline was instilled, and therefore this practice may contribute significantly to lower airway contamination. Newer evidence from a randomized controlled trial[14] suggests that instillation of normal saline was associated with a lower incidence of ventilator-associated pneumonia. It is unclear from this abstract whether the researchers controlled for other standard interventions to avoid ventilator-associated pneumonia[17,18] such as oral care, aspiration of subglottic secretions, maintenance of cuff pressure on the endotracheal tube, and prophylaxis of peptic ulcer and deep vein thrombosis.
Recommendation Based on Current Evidence
Collectively, these studies provide class III evidence of the adverse physiological and psychological effects of instillation of normal saline, and therefore, support against the routine use of normal saline with suctioning ( Table 2 ). Normal saline and mucus do not mix. Therefore, normal saline does not thin or mobilize secretions. Rather, ensuring adequate hydration is one way that nurses can facilitate removal of secretions.[15] The best-known interventions for managing thick tenacious secretions and preventing mucus plugs in ventilator-dependent patients are hydration, adequate humidification, use of mucolytic agents, and effective mobilization.[16,18,20]
In addition to an unappreciable increase in sputum recovery, use of normal saline adversely affects arterial and global tissue oxygenation and dislodges bacterial colonies, thus contributing to lower airway contamination. Because no solid scientifically based benefits for routine use of normal saline have been shown, it is highly recommended that this potentially harmful "sacred cow" be abandoned. Instead, treatment considerations should center on ways to prevent the development of thick, tenacious secretions.[20]
Normal saline may be indicated in situations where it is necessary to elicit a cough,[4,18] and normal saline may be useful for clearing the catheter after suctioning to avoid reintroducing pathogens into the airway.[21] Good handwashing is essential to reduce infection when opening vials of normal saline because increased contamination has been documented when clinicians use the nongloved thumb to twist off the tops of the vials.[22]
Despite these recommendations, organizational change toward best suctioning practices has not been without challenges. In a recent multisite study,[23] three large institutions had policies that recommended instilling normal saline for thick secretions. Suctioning surveys[23,24] also indicate that 2 to 3 times as many respiratory therapists as nurses report continued use of normal saline—a finding that is not so surprising given that the American Association of Respiratory Care's guideline[25] has not been updated since 1993 (and still advocates that normal saline dilutes and mobilizes secretions).
Promisingly, among nursing circles, researchers in the United Kingdom reported that although observed suctioning practices were contrary to many research recommendations,[26] educational interventions proved effective in advancing the knowledge and translation of research-based suctioning practices of critical care nurses at the bedside.[27]
Others have also reported high compliance rates of nurses with evidence-based guidelines recommending avoidance of normal saline.[28] More studies are needed to document clinical adherence to evidence-based guidelines so that we can better connect processes of care to outcomes for patients.
I think that this evidence says it all-No Saline!
And here is the link to the same article-
http://www.medscape.com/viewarticle/581620_print
Thursday, October 23, 2008
Put down the Penlights...Neuro assessment
Changes in behavior are an early sign of neurologic compromise. They are not specific to neurologic problems, but they are the earliest sign. Keep a close eye on the patient for problems with speech and disorientation. Many nurses start assessing neurologic function by pulling out their penlight and checking the patient's pupils. This is very stimulating to your neuro patient and is not the first thing that is going to change.
If your patient is alert and oriented and you are just trying to follow him to see if his condition is getting worse, the first thing that is going to change is his behavior. Behavior is the highest level of function. Next the patient will have changes in his speech. Speech patterns and the ability to perform speech tell you a lot about the patient's neurologic function. The third level down is content of arousability, and this is what is referred to as orientation. The forth level is arousability; whether or not the patient wakes up when you walk into the room or you have to touch him or use painful stimuli.
If your patient is already unconscious, assess systolic blood pressure as an indicator of intracranial pressure. As intracranial pressure increases, systolic pressure has to increase to continue to perfuse the brain. The very lowest level is the pupil reflex. Changes in pupils do not tell you much about the patient. Pupil changes indicate a very small lesion that is right around the optic nerve or a huge lesion that is causing the patient to herniate.
Check speech first. Put down the penlights and watch the patient's behavior changes.
Best wishes,David W. Woodruff, MSN, RN-BC, MSN, CENPresident, Ed4Nurses, Inc.www.Ed4Nurses.com www.dwoodruff.com
If your patient is alert and oriented and you are just trying to follow him to see if his condition is getting worse, the first thing that is going to change is his behavior. Behavior is the highest level of function. Next the patient will have changes in his speech. Speech patterns and the ability to perform speech tell you a lot about the patient's neurologic function. The third level down is content of arousability, and this is what is referred to as orientation. The forth level is arousability; whether or not the patient wakes up when you walk into the room or you have to touch him or use painful stimuli.
If your patient is already unconscious, assess systolic blood pressure as an indicator of intracranial pressure. As intracranial pressure increases, systolic pressure has to increase to continue to perfuse the brain. The very lowest level is the pupil reflex. Changes in pupils do not tell you much about the patient. Pupil changes indicate a very small lesion that is right around the optic nerve or a huge lesion that is causing the patient to herniate.
Check speech first. Put down the penlights and watch the patient's behavior changes.
Best wishes,David W. Woodruff, MSN, RN-BC, MSN, CENPresident, Ed4Nurses, Inc.www.Ed4Nurses.com www.dwoodruff.com
Friday, October 10, 2008
Amiodarone Competency~for RN's
You will find in your mailboxes a competency for Amiodarone. Each RN needs to complete the quiz and return it to Vilma's mailbox outside the office and while you are there sign the Attendance sheet posted there also.
Wednesday, October 8, 2008
AHRQ and You-Evidences Based Best Practice Handbook
You just never know what you find when you are surfing the net these days but looky here a handbook developed from the Agency for Healthcare Research and Quality (AHRQ) for nurses. Sponsored by the Robert Wood Johnson Foundation this is a virtual (literally) treasure trove of best practices from the nurses point of view and get this...researched as best practice, not just "we do it that way because that's how we've always done it" reasons.
The whole book can be accessed.....online-for nothing...and you can order your own 3 volume printed copy or a researchable CD if you so desire but why when this will be updated periodically long before the printed stuff will be available.
http://www.ahrq.gov/qual/nurseshdbk/
What a treat! Take a gander around and see what we can improve on to keep our patients safe and well cared for.
We all have a hand in this so read on McDuff !! :)
Tracy
The whole book can be accessed.....online-for nothing...and you can order your own 3 volume printed copy or a researchable CD if you so desire but why when this will be updated periodically long before the printed stuff will be available.
http://www.ahrq.gov/qual/nurseshdbk/
What a treat! Take a gander around and see what we can improve on to keep our patients safe and well cared for.
We all have a hand in this so read on McDuff !! :)
Tracy
Wednesday, October 1, 2008
And they're on their own..
The new grads are off orientation and are all doing great! We also had a great weekend at ACLS and I am happy to say that Susan Plissey passed without a speck of nerves showing, Dorothy, Jen and I all recerted successfully! The next ACLS is December 6 & 7th. The new grads will be scheduled in the spring class(es) once the dates are annouced I'll post them here.
Just a couple pix of the preceptors with their new grads...
Thank you to all who attended the Wound Update on Monday...if you missed it there will be more at the skills fair in November also. Remember the new regs go into effect today so let the providers know if there are any pressure ulcers on your patients so they can assess and document them in their admission work. Thanks for all you do!
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