Determining the relationship between end-of-life decisions expressed in advance directives and resuscitation efforts during cardiopulmonary resuscitation.

In recent years, there has been an increased focus on end-of-life decisions and the use of medical technology. It is not well documented in the literature whether or not and to what extent patients' advance directives are used for directing resuscitative efforts. The purpose of this study was to determine how useful patients' advance directives were to members of the health care team in determining treatment and end-of-life decisions among patients who received cardiopulmonary resuscitation (CPR) efforts. Medical records of 135 adult patients who had undergone CPR efforts within the previous year were reviewed to determine if and to what extent advance directives were useful in directing end-of-life care and treatment decisions. Only 35 of these patients had advance directives. Three categories for advance directives emerged: those that were "independently directive," those that were "vague and required further clarification," and those that were "nondirective." Information from this study may be used to clarify treatment options for end-of-life care and to determine if and what further interventions are required to ensure that advance directives can be executed as meaningful documents.

Interruption of enteral feedings in head injured patients.

This study was undertaken to determine differences between caloric intake and requirements of critically ill, enterally fed, neurosurgical and neurotrauma patients and to determine the nature and frequency of interruptions in enteral feedings in this same population. This descriptive, prospective study was conducted in a surgical intensive care unit (ICU) in a university teaching hospital. The sample consisted of 52 mechanically ventilated, critically ill patients with a mean age of 48.96 years who were receiving enteral nutrition for at least two days. Basal energy requirements, daily nutritional intake and enteral feeding interruption characteristics were recorded for a total of 586 study days. Underfeeding due to interruptions occurred in the majority of patients for the first eight days following initiation of enteral feeding. Reasons for underfeeding were interruptions of continuous tube feedings due to medication administration via the feeding tube (31%), feeding tube displacement (27%), surgery (12%), ileus (9%), radiologic studies (9%), airway management (8%), bedside procedures (3%) and agitation (1%). The frequency of these enteral feeding interruptions may indicate inadequate nutritional support, highlighting the importance of performing daily nutritional monitoring to prevent malnutrition.

Coordinated care for the neuroscience patient: future directions.

A coordinated care model was developed on a neuroscience unit to achieve positive outcomes in a cost-effective environment. This included the development of a patient care coordinator (PCC) role, critical paths and a system for variance tracking. The PCC was responsible for coordinating care of patients and ensuring that patients progressed toward expected outcomes. Multidisciplinary critical paths were developed for four medical diagnoses. To evaluate the effectiveness of the program, an analysis of length of stay data, cost comparison, patient and staff satisfaction, and variance reports of one critical path, the microvascular decompression for trigeminal neuralgia were completed. Results from the pilot project were positive and provided valuable information for the use of coordinated care as a hospital-wide patient care delivery model.

A pilot program to promote professional growth for neuroscience nurses.

A pilot program was developed as a strategy to increase professional growth on a neuroscience unit. The primary objective of the program was to allow staff nurses to participate in activities that interface with the neuroscience patient population. Nurses could choose an area of interest that related to their unit responsibilities. This experience provided the participants with the unique opportunity to participate in patient care from the perspective of another discipline. The staff were enthusiastic about the experience and shared it eagerly with their peers. Participants' evaluation of the program was overwhelmingly favorable. The data suggest that this program was an effective means of increasing professional growth and staff development.

The elderly neuroscience patient: implications for the critical care nurse.

The elderly patient may present to the critical care unit with neurologic deficits such as acute confusion, loss of consciousness, or signs of a cerebrovascular accident. Recognizing the normal age-related changes that occur in the nervous system enables the critical care nurse to evaluate the patient's response to neurologic disorders. The normal neurologic changes associated with aging provide implications for assessment, response to the critical care environment, and the time needed for education and rehabilitation. Other changes, especially decreased immunity, malnutrition, and pulmonary and cardiac pathology, significantly increase the risk for morbidity and mortality after an acute neurologic event. Changes in pharmacokinetics and the likelihood of polypharmacy in the older patient greatly increase the risk for complications and side effects of the commonly used treatments. Important elements of nursing management for the elderly neuroscience patient include performing an accurate neurologic assessment, including noting changes in cognition, observing for adverse drug reactions, optimizing ventilation, and maximizing mobility and nutritional status. This article focuses on these aspects of nursing care for the elderly neuroscience patient.

Hyperbaric oxygen therapy: treatment for spinal cord decompression sickness.

Spinal cord injury (SCI) may result from decompression sickness associated with sport and commercial diving. Decompression sickness is caused by the formation of gas bubbles in the vessels and tissues secondary to a reduction in ambient pressure. A complete or incomplete spinal cord injury may result from decompression sickness. Recompression and hyperbaric oxygen therapy is the primary treatment. The use of hyperbaric oxygen therapy (HBO) as a treatment for these injuries can greatly influence the patient's outcome. Early intervention in a recompression chamber may result in complete recovery. If treatment is delayed however, the prognosis for recovery is poor.

The effect of familiar and unfamiliar voice treatments on intracranial pressure in head-injured patients.

Limited research has been conducted exploring the relationship between verbal stimulation and intracranial pressure (ICP). The purpose of this study was to investigate effects of verbal stimulation on ICP in head-injured patients. The sample consisted of 12 head-injured patients with a mean age of 31.5 years and mean Glasgow Coma Scale score of 7.8. A message was recorded by a familiar voice (family) and an unfamiliar voice (researcher). The familiar voice message was played to each subject. After a rest period, the unfamiliar voice message was played. ICP was recorded before, during and after playing both taped messages. Results demonstrated little change in ICP of head-injured patients when exposed to recorded verbal stimuli. Paired t-tests demonstrated no statistically significant differences between means. Results suggest families of head-injured patients with normal ICP can verbally interact with the patients for short periods without significant increases in ICP.

Implementation of a patient fall prevention program.

Falls among hospitalized patients are common occurrences and can have detrimental effects on patient outcomes. Identifying high-risk patients and taking measures to prevent patient falls have been successful. The purpose of this project was to decrease the fall rate in adult neuroscience patients. This was accomplished through implementation of a patient fall prevention program. Patients were assessed for risk factors associated with patient falls. Risk factors were identified through the use of the patient's history, nursing data base and patient classification system. Patients with identified risk factors were placed on fall precautions which included interventions specifically designed to prevent patient falls. This project resulted in a decrease in the number of patient falls and increased staff awareness of the risk factors associated with falls among adult neuroscience patients.

The efficacy of six heel pressure reducing devices.

Twenty to 90 percent of pressure ulcers are located on the heel. The purpose of this study was to evaluate the pressure exerted on the heel when the foot in both the supine and the 30 degree elevated position was placed in various heel pressure reducing devices. Interface pressures of six heel devices were measured to determine their performance. Other factors, such as body weight, height shoe size, shoe width, as well as whether the device provided leg support were examined.

Interface skin pressures on four pressure-relieving devices.

Nurses employed in acute care hospitals frequently encounter patients who require a pressure-relieving device. It is often difficult for nurses to decide which support surface should be used to best meet a patient's need for a pressure-reducing device because of the multiplicity of products available. One of the variables studied was found not to statistically influence the effectiveness of the various pressure-relieving devices. Body build is not a consideration when determining which support surface is effective in a healthy population of subjects. The two air-flotation low air-loss beds would be defined as effective pressure-relieving devices. The interface pressure readings vary from individual to individual on various bony prominences. The population studied was that of healthy volunteers. Healthy subjects have an increased fat pad in their sacral area compared with the critically ill patient. The heel had the highest interface pressure of the five that were studied. This is a bony prominence that requires additional attention if skin integrity is to be maintained.

Standardized nursing care plans for acute care SCI: improved documentation.

Adequate documentation of spinal cord injury (SCI) nursing care is necessary for evaluation of patient progress and compliance with standards of care. The objective criteria used to evaluate nursing care include the nursing data base, the care plan, and the nurses' notes. The nursing care plan reflects the needs of the SCI client and is the basis from which documentation about these needs arises. Standards for acute care SCI nursing were recently developed for the 10 designated SCI centers in Florida. To improve the documentation of these standards, neuroscience nurses at Shands Hospital developed standardized care plans that can be individualized for each SCI client. The implementation of these care plans improved documentation of the standards for acute care SCI nursing. Additional benefits included an increased awareness of the nursing diagnoses among staff nurses and improved equality of care for the SCI client.