Promoção do conforto ao cliente pediátrico: intervenções de enfermagem à criança com síndrome de abstinência iatrogénica / Promotion of comfort to pediatric clients: nursing interventions for children with iatrogenic withdrawal syndrome

A hospitalização é uma situação causadora de ansiedade, stress e disrupção do decorrer normal do dia-a-dia da pessoa, afetando em especial a criança e a sua família, podendo condicionar o seu desenvolvimento harmonioso. Em situações de doença crítica há a necessidade de internamento em cuidados intensivos, onde técnicas e procedimentos especializados e diferenciados, frequentemente invasivos e dolorosos, sujeitam a criança e família a experiências difíceis de lidar e superar. No sentido de minimizar a dor, a ansiedade, o stress e o sofrimento associados aos cuidados intensivos e aos procedimentos realizados são utilizadas estratégias nãofarmacológicas e farmacológicas, sendo a sedoanalgesia a estratégia farmacológica mais frequentemente utilizada. Contudo, a sua utilização não é isenta de risco, havendo evidência de que doses elevadas de opióides e benzodiazepinas, o seu uso prolongado e descontinuação abrupta estão associados a eventos adversos em particular a Síndroma de Abstinência Iatrogénica. Procurando entender a ocorrência desta síndroma, a sua prevenção e tratamento, e identificar a intervenção do enfermeiro na criança, jovem e família no contexto desta síndroma, bem como desenvolver competências de Enfermeiro Especialista de Enfermagem de Saúde Infantil e Pediátrica, foi delineado um projeto de aprendizagem enfatizando a reflexão na ação e a reflexão crítica sobre as situações e práticas nos diversos contextos de estágio. Por forma a desenvolver conhecimentos e capacidades ao nível de mestrado, elaborou-se um projeto de investigação sobre a temática em estudo, a ser concluído após término deste percurso formativo, integrado na Unidade de Investigação da Escola Superior de Enfermagem de Lisboa. O resultado deste conjunto de atividades é exposto neste relatório onde se apresentam a pertinência da temática escolhida, a filosofia de cuidar em enfermagem pediátrica enquadrando a intervenção e aplicando a teoria do conforto de Kolcaba, as competências desenvolvidas ao longo de todo o percurso relacionando-as com as atividades realizadas e as limitações encontradas, e por último os projetos de desenvolvimento futuros bem como as considerações finais de todo o processo.

Hospitalization is a situation that causes anxiety, stress and disruption of the person's normal day-to-day life, affecting especially the child and his family, eventually conditioning their harmonious development. When critical illness occurs, admission to intensive care is needed, where specialized and differentiated techniques and procedures, often invasive and painful, turn the child and family´s experience harder to deal with and overcome. To minimize pain, discomfort, and suffering associated with intensive care and the procedures needed non-pharmacological and pharmacological strategies are frequently used, with sedoanalgesia being the most frequent pharmacological strategy. However, its use is not without risk, and there is evidence that high dose of opioids and benzodiazepines, its prolonged use and abrupt discontinuation, can lead to the occurrence of adverse events mainly the Iatrogenic Withdrawal Syndrome. Searching to understand the occurrence of this syndrome, how it can be prevented or treated, and to identify the interventions of the paediatric nurse to the child and family in the context of this syndrome, as well as to develop skills for acquiring the title of Specialist Nurse in Child and Paediatric Health Nursing, a learning project was outlined, emphasising the reflection in action and critical thinking processes regarding the experiences and nursing practices occurring in the diverse clinical practice contexts. In order to develop knowledge and skills at master's level, a research project on the subject under study was elaborated, to be concluded after the end of this formative path, integrated in the Escola Superior de Enfermagem de Lisboa Research Unit. The result of this set of activities is exposed in this report, presenting the relevance of the chosen theme, the philosophy of paediatric nursing care framing the intervention and applying Kolcaba's theory of comfort, the skills developed throughout the entire formative path relating them with the activities carried out and the limitations found, and finally the future development projects as well as the final considerations of the entire process.

Nursing: Addressing substance use in the 21st century.

Over the past two decades, there has shift from focusing on the most severe end of the substance use continuum to earlier detection of persons who are at risk given the consequences associated with alcohol and other drug use. In 2017, the Association for Multidisciplinary Education and Research in Substance Use and Addiction (AMERSA) undertook the development of core competencies for specific disciplines addressing substance use in the 21st century. This article presents the core competencies for nursing in accord with the 16 standards of practice and performance for nursing. The competencies for the registered nurse and the advanced practice nurse are intended to inform and guide nursing practice with a focus on prevention, intervention, treatment, and recovery supports for persons who are affected by substance.

Supervised Multidimensional Item Response Theory Modeling of Pediatric Iatrogenic Withdrawal Symptoms.

Item-level data from composite scales can be analyzed with pharmacometric item response theory (IRT) models to improve the quantification of disease severity compared with the use of total composite scores. However, regular IRT models assume unidimensionality, which is violated in the scale measuring iatrogenic withdrawal in children because some items are also affected by pain, undersedation, or delirium. Here, we compare regular IRT modelling of pediatric iatrogenic withdrawal symptom data with two new analysis approaches in which the latent variable is guided towards the condition of interest using numerical withdrawal severity scored by nurses as a "supervising variable:" supervised IRT (sIRT) and supervised multi-dimensional (smIRT) modelling. In this example, in which the items scores are affected by multiple conditions, regular IRT modeling is worse to quantify disease severity than the total composite score, whereas improved performance compared with the composite score is observed for the sIRT and smIRT models.

Risk Factors for Severe Alcohol Withdrawal Syndrome in an Acute Hospital Population.

BACKGROUND: The literature lacks consensus to the factors that increase the risk of a patient developing severe alcohol withdrawal syndrome (SAWS). AIM: The study set out to identify the variables that increase the risk of SAWS in patients who have alcohol dependence syndrome. METHODS: A case-control study was designed to investigate the variables associated with SAWS in an acute hospital setting. Three hundred eighty-two case and 382 control patients were randomly selected retrospectively from referrals to the acute addiction liaison nursing service during a 12-month period (January 1, 2015, to December 31, 2015). Statistical significance (p < .05) and association with SAWS were calculated using chi-square, Cramer's V test, odds ratio, and Levene's test. RESULTS: Twenty-four variables have been identified as associated with SAWS development. Five of the 24 variables had a moderate-to-strong association with SAWS risk: Fast Alcohol Screening Test, Glasgow Modified Alcohol Withdrawal Scale score, AWS admission, hours since the last drink, and systolic blood pressure. The study also identified that comorbidity was associated with not developing SAWS. CONCLUSION/RECOMMENDATIONS: These findings confirm that noninvasive variables collected in the emergency department are useful in identifying a person's risk of developing SAWS. The results of this study are a useful starting point in the exploration of SAWS and the development of a tool for use in the emergency department that can stratify risk into high and low and is the next stage of this program of work.

Alcohol Withdrawal Syndrome: Improving Recognition and Treatment in the Emergency Department.

Alcoholism continues to be a persistent health problem in the United States, accounting for up to 62% of emergency department (ED) visits. This quality improvement (QI) project examined whether identifying the benefit for early use of Alcohol Use Disorders Identification Test (AUDIT C) and Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIW-ar) in the ED would avoid escalation of care and offset poor outcomes of alcohol withdrawal syndrome (AWS). A preimplementation chart review (N = 99) showed an average of 12%-15% of patients requiring escalation of care at the project site. The QI project utilized a single-group, pre-/posttest design. The setting was a Southwest Veterans Affair tertiary care referral center. Thirty-five ED staff members were surveyed for baseline knowledge and attended education sessions, led by an advanced practice nurse, on the use of AUDIT-C and CIWA-ar. Posteducation, patients admitted to the hospital were screened with AUDIT-C and treated with CIWA-ar. Postimplementation, charts were reviewed for admitted patients (N = 42) on the use of AUDIT-C, CIWA-ar, length of stay (LOS), and area patient treated. Although the test scores after didactic education were statistically significant (p ≤ 0.050), there was no significant difference in the use of AUDIT-C or CIWA-ar in the ED, nor a significant decrease in LOS for those patients with CIWA-ar ordered. However, the potential for clinical benefit could not be disavowed. Barriers to implementation included survey fatigue, inability to embed AUDIT-C in the electronic medical record, inconsistency in completing AUDIT-C, interrater reliability, and patient fear of stigmatization. Advanced practice nurses provide an integral role to augment early identification and treatment of AWS in the ED.

A Psychometric Analysis of CIWA-Ar in Acutely Ill and Injured Hospitalized Patients.

Alcohol withdrawal syndrome (AWS) manifests after alcohol-dependent individuals suddenly cease alcohol consumption. Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar) is a widely used tool to assess and guide treatment of AWS. CIWA-Ar was developed in voluntarily detoxification centers, and the reliability and validity of CIWA-Ar have been minimally evaluated in hospitalized patients. We performed a retrospective chart review of 479 cases of screening and treatment of AWS using CIWA-Ar, of which 118 were admitted to a trauma/orthopedic (T/O) service and 361 to an internal medicine (IM) service. Exploratory factor analyses with varimax rotation were applied for each population, and reliability testing was performed on the determined subscales. Exploratory factor analyses yielded 2 unique structures, each explaining 56% of the variance of CIWA-Ar. The IM group had a 3-factor structure with the Physical Disturbances (23%), Anxiety (19%), and Confusion (14%) subscales. The T/O group had a 2-factor structure with the Neurological Disturbances (36%) and Physical Disturbances (20%) subscales. Overall, Cronbach's alphas were acceptable (0.74 and 0.82 for IM and T/O, respectively); however, Cronbach's alphas for the IM subscales were 0.66 and 0.69 for physical disturbances and anxiety, respectively. Cronbach's alpha for the Confusion subscale was not calculated because only 1 scale item loaded. The subscales of the T/O factor structure yielded Cronbach's alphas of 0.81 for neurological disturbances and 0.62 for physical disturbances. Our analyses did not support the reliability or validity of CIWA-Ar in acutely ill or injured patients, warranting further investigation and tool development for AWS management in the hospital setting.

CE: Acute Pain Management for People with Opioid Use Disorder.

: Medication-assisted treatment for opioid use disorder (OUD), which incorporates methadone, buprenorphine, or naltrexone, has been shown to reduce all-cause mortality rates in patients with this disease-and the numbers of patients receiving such treatment is substantial. In 2016, among U.S. patients with OUD, nearly 350,000 were treated with methadone, more than 60,000 were treated with buprenorphine, and more than 10,000 were treated with naltrexone. Managing acute pain in patients receiving this treatment can be a significant nursing challenge. The authors discuss the attributes of the three medications used to treat OUD and, through a composite patient case, review how to manage acute pain effectively in patients receiving this type of treatment.This article is one in a series on palliative care developed in collaboration with the Hospice and Palliative Nurses Association (https://advancingexpertcare.org), which offers education, certification, advocacy, leadership, and research on palliative care.

Preparing Nursing and Social Work Students to Care for Patients in Acute Alcohol Withdrawal.

Alcohol and other drug abuse has become a national crisis with approximately 26% of general medical patients having alcohol-related problems. New nurses and social workers are often not prepared to care for patients with severe alcohol withdrawal symptoms because they lack experience in actual crisis situations. The purpose of this study was to prepare nursing and social work students to care for a patient undergoing an acute alcohol withdrawal process. Nine groups of 8-10 students participated in a 2.5-hour simulation event that included an alcohol withdrawal seizure, team meeting, and discharge of the patient. Students recognized the importance of all the professional roles and how each professional benefits patient care. Before the simulation, students thought they were prepared to care for patients experiencing alcohol withdrawal; however, the crisis of an alcohol seizure decreased the student's ability to perform skills and communicate effectively. These findings suggest that new nurses and social workers may not be prepared to care for the acute alcohol withdrawal patient.

[Benzodiazepine withdrawal syndrome in the elderly patient]. / Le syndrome de sevrage aux benzodiazépines chez le sujet âgé.

Withdrawal syndrome is a well known diagnostic entity. As the symptomatology related to this syndrome is extremely unspecific, care must be taken not to ignore withdrawal syndrome, the consequences of which, while rare, can lead to often long and complicated hospitalisations.

Withdrawal Phenomena: A Concept Analysis for the Development of a Nursing Diagnosis.

This study explored the concept of withdrawal phenomena from the perspective of nurses, with the aim of developing a nursing diagnosis. Concept analysis was used as the framework of the study, a systematized review was conducted to identify relevant studies, and interpretation was based on qualitative content analysis. Specifying aspects, defining characteristics, related factors, and risk factors were extracted and classified into categories. Thirteen studies were identified as a basis for the construction of two nursing diagnoses: "withdrawal phenomena" and "risk of withdrawal complications." The proposed nursing diagnoses require further discussion. The NANDA International Diagnosis Development Committee was asked to examine the proposed diagnoses. However, it was too early to determine implications for nursing practice based on the results of this study.

A systematic nurse-led approach to withdrawal risk screening, prevention and treatment among inpatients with an alcohol use disorder in an ear, nose, throat and jaw surgery department-A formative evaluation.

INTRODUCTION: Among patients with head and neck cancer comorbid alcohol use disorder is frequent which contributes to higher risk of developing perioperative alcohol withdrawal syndrome/delirium or delirium due to medical conditions. Although guidelines emphasize prevention and treatment of alcohol withdrawal in hospitalized patients, a validated systematic approach for management of these patients is still lacking. Our aim was to formatively evaluate our newly developed systematic approach in view of nurses' adherence to screening patients for regular alcohol consumption and managing their withdrawal symptoms using the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised. METHODS: We conducted a formative evaluation to improve the project's design and performance and used a retrospective chart review in a consecutive sample of all adult inpatients with head and neck cancer being assigned for surgery in a university hospital. Our bundle of interventions consisted of nurses' screenings for regular alcohol consumption, withdrawal risk assessment, offering patients a substitution therapy, nurses' assessments of withdrawal symptoms and symptom oriented withdrawal management. Proximate endpoints were analyzed descriptively at each component of the bundle in terms of frequencies and severity of withdrawal symptoms, frequencies of nurses' and doctors' screenings and nurses' assessments performed as required. RESULTS: Between 2013 and 2014, 87 inpatients met inclusion criteria and screenings by doctors/ nurses revealed 49 alcohol consumers, where six screenings were omitted by nurses and six by doctors. Twenty-one consumers were at risk and six of them developed an alcohol withdrawal syndrome. None of the 87 showed an alcohol withdrawal delirium, but five developed a delirium due to medical conditions. Nurses correctly conducted all preventive elements of the intervention bundle in 14 (58%) patients at risk but overall, only performed 50% of the required assessments. CONCLUSIONS: Although nurses safely managed patients' symptoms, nurses' adherence to the interventions was suboptimal and requires stronger leadership.

Detoxification in medication-overuse headache, a retrospective controlled follow-up study: Does care by a headache nurse lead to cure?

AIM: J.A.P. and M.A.L. contributed equally to this manuscript.The aim of this article is to determine whether support by a headache nurse in the treatment of medication-overuse headache (MOH) increases successful withdrawal, and to study determinants of response to withdrawal therapy. METHODS: A retrospective, controlled follow-up study was performed with 416 MOH patients. All patients were treated with outpatient withdrawal therapy, with two treatment arms: with or without the support of a specialised headache nurse. The outcome measures were: i) successful withdrawal, defined as discontinuation of all headache medication according to the study protocol; and ii) the responder rate, defined as the percentage of patients with ≥ 50% reduction in headache days after successful withdrawal and iii) relative reduction in headache days after successful withdrawal. RESULTS: Successful withdrawal percentages were significantly higher in the group supported by the headache nurse than in the group without support (73.1% vs. 60.7%; p = 0.008), which was confirmed in multivariate analysis (OR 1.73, 95% CI 1.11-2.71, p = 0.016). Support by a headache nurse was not associated with response. The underlying primary headache diagnosis, determined after withdrawal, was significantly correlated with response. CONCLUSION: The support by a headache nurse results in an increased adherence to detoxification.

Development of a Clinical Competency Checklist for Care of Patients Experiencing Substance Withdrawal Delirium or Delirium: Use of a Delphi Technique and Expert Panel.

Health care providers are challenged by the presentation and management of inpatients experiencing substance withdrawal delirium (SWD) and delirium. The current Delphi study used an expert panel to develop a clinical competency checklist for nurse and physician educator use in teaching health care providers about the initial care of patients with SWD or delirium. The checklist includes categories of patient safety, history and information gathering, physical examination and assessment, treatment plan, and patient/family-centered care.

[Outpatient cannabis withdrawal programme]. / Sevrage ambulatoire du cannabis.

Cannabis is the most consumed illicit substance in France, and its use can lead to dependency. Lille university hospital, le Pari association, offers patients wanting to stop using cannabis a support therapy based on positive feedback led by nurses, as well as symptomatic treatment of anxiety and sleep disorders.