Call to action: Blueprint for change in acute and critical care nursing.

Herein, we propose a blueprint for action to completely measure and recognize the care provided by acute and critical care nurses to be incorporated into policy that shapes and supports practice. We address the nature of nurses' work by identifying nine practice domains, hospital practice environment assumptions, and expected outcomes. Nurses' work, as a cross-system process, needs to be included in hospital-based core measures to fully reflect nurses' impact on patient care. We call for a balanced measurement portfolio focused on patient/family-, unit-, and systems-level outcomes. We focus on what nurses do and what patients and their families can expect rather than only on the elimination of select adverse events. We provide a way forward to allow measure development and implementation with incentives for their use. This approach to making nurses' contributions and impact on outcomes visible will enhance acute and critical care nursing practice and benefit patients and their families.

Is Perception Reality? Using Person-in-Context Simulation to Promote Empathic Understanding of Dementia Among Nurse Practitioner Students.

ABSTRACT: This one-group nonexperimental pretest/posttest repeated-measures design plus interpretative phenomenological analysis explored nurse practitioner students' perceptions of dementia using virtual simulation. Perceptions of dementia and its associated challenges differed after the simulation. A critical theme that emerged was "developing empathic understanding"; the two subthemes were "mirroring dementia behaviors" and "provoking emotions." Virtual dementia simulation is an inexpensive, low-fidelity strategy to challenge assumptions and preconceived belief systems about dementia. Person-in-context experiential learning is valuable in nurse practitioner education for facilitating empathic understanding. Further research is needed to explore the correlation between empathic understanding and altruistic helping behaviors in professional practice.

Delirium Screening of Patients on a Neuroscience Step-Down Unit.

This project aimed to identify patients who had experienced a stroke and were at risk for delirium earlier, and implement evidence-based protocols to reduce overall length of stay and mortality. Nurses were motivated to perform screening and implement strategies that benefit patients who had experienced acute stroke. Results suggest early identification and treatment of delirium, use of prevention strategies, and treatment of the underlying etiology can improve patient outcomes and reduce cost of care.

Methods of identifying delirium: A research protocol.

Delirium is an acute disorder affecting up to 80% of intensive care unit (ICU) patients. It is associated with a 10-fold increase in cognitive impairment, triples the rate of in-hospital mortality, and costs $164 billion annually. Delirium acutely affects attention and global cognitive function with fluctuating symptoms caused by underlying organic etiologies. Early detection is crucial because the longer a patient experiences delirium the worse it becomes and the harder it is to treat. Currently, identification is through intermittent clinical assessment using standardized tools, like the Confusion Assessment Method for ICU. Such tools work well in clinical research but do not translate well into clinical practice because they are subjective, intermittent and have low sensitivity. As such, healthcare providers using these tools fail to recognize delirium symptoms as much as 80% of the time. Delirium-related biochemical derangement leads to electrical changes in electroencephalographic (EEG) patterns followed by behavioral signs and symptoms. However, continuous EEG monitoring is not feasible due to cost and need for skilled interpretation. Studies using limited-lead EEG show large differences between patients with and without delirium while discriminating delirium from other causes. The Ceribell is a limited-lead device that analyzes EEG. If it is capable of detecting delirium, it would provide an objective physiological monitor to identify delirium before symptom onset. This pilot study was designed to explore relationships between Ceribell and delirium status. Completion of this study will provide a foundation for further research regarding delirium status using the Ceribell data.

Fronto-temporal dementia: a case study and strategies and support for caregivers.

Fronto-temporal dementia, also known as fronto-temporal lobular degeneration, is the second most common form of early-onset dementia with a prevalence equal to Alzheimer's dementia. Behavioural variant fronto-temporal dementia primarily involves the frontal and temporal lobes of the brain. Myelination of nerve fibres in these areas allow for highly synchronized action potential timing. Diagnosis is often significantly delayed because symptoms are insidious and appear as personality and behavioural changes such as lack of inhibition, apathy, depression, and being socially inappropriate rather than exhibiting marked memory reductions. In this article, a case study illustrates care strategies and family education. Management of severe behavioural symptoms requires careful evaluation and monitoring. Support is especially important and beneficial in the early to middle stages of dementia when nursing home placement may not be required based on the individual's condition.

Is Nursing Care Missed? A Comparative Study of Three North Carolina Hospitals.

Results of a survey measuring frequency, types, and reasons for missed care at three acute care hospitals in North Carolina are described. Results also are compared to those of a previous, similar study in the midwestern United States.

Care redesign: a higher-quality, lower-cost model for acute care.

OBJECTIVE: The aims of this study were to design, pilot, and evaluate a care team model of shared accountability on medical-surgical units. BACKGROUND: American healthcare systems must optimize professional nursing services and support staff due to economic constraints, evolving Federal regulations and increased nurse capabilities. METHODS: A redesigned model of RN-led teams with shared accountability was piloted on 3 medical/surgical units in sample hospitals for 6 months. Nursing staff were trained for all functions within their scope of practice and provided education and support for implementation. RESULTS: Clinical outcomes and patient experience scores improved with the exception of falls. Nurse satisfaction demonstrated statistically significant improvement. Cost outcomes resulted in reduced total salary dollars per day, and case mix-adjusted length of stay decreased by 0.38. CONCLUSION: Innovative changes in nursing care delivery can maintain clinical quality and nurse and patient satisfaction while decreasing costs.

Rapid Handheld Continuous Electroencephalogram (EEG) Has the Potential to Detect Delirium in Older Adults.

BACKGROUND: Delirium-related biochemical derangements lead to electrical changes that can be detected in electroencephalographic (EEG) patterns followed by behavioral signs and symptoms. Studies using limited lead EEG show a large difference between patients with and without delirium while discriminating delirium from other causes. Handheld rapid EEG devices may be capable of detecting delirium before symptom onset, thus providing an objective physiological method to detect delirium when it is most amenable to interventions. OBJECTIVE: The aim of this study was to explore the potential for rapid EEG to detect waveform pattern changes consistent with delirium status. METHODS: This prospective exploratory pilot study used a correlational design and mixed models to explore the relationships between handheld portable EEG data and delirium status. RESULTS: While being under powered minimized opportunities to detect statistical differences in EEG-derived ratios using spectral density analysis, sleep-to-wake ratios tended to be higher in patients with delirium. CONCLUSIONS: Limited lead EEG may be useful in predicting adverse outcomes and risk for delirium in older critically ill patients. Although this population is at the highest risk for mortality, delirium is not easily identified by current clinical assessments. Therefore, further investigation of limited lead EEG for delirium detection is warranted.

Urinary incontinence and overactive bladder in patients with heart failure.

PURPOSE: We explored the nature of the relationship between heart failure and urinary symptoms, specifically urinary incontinence and overactive bladder. MATERIALS AND METHODS: An 81-item written survey about urinary incontinence, urgency, frequency, nocturia and other symptoms was administered to hospitalized and clinic patients with heart failure. A medical records review was also conducted to determine types of medications, body mass index and documentation of the New York Heart Association Classification of heart failure. RESULTS: Of 408 respondents 296 (average age 62.2 years) had information about heart failure stage and urinary symptoms. Of these respondents 45% and 57% reported urinary incontinence and overactive bladder, respectively. Adjusted odds ratio for having overactive bladder over no symptoms for respondents with New York Heart Association Class III or Class IV heart failure was 2.9 (95% CI 1.344-6.250) and for higher fatigue-depression composite was 2.155 (95% CI 1.206-3.860). Adjusted odds ratio for having overactive bladder over frequency/nocturia for respondents with higher body mass index was 1.458 (95% CI 1.087-1.953) and for higher fatigue-depression composite was 1.629 (95% CI 1.038-2.550). CONCLUSIONS: Urinary incontinence and overactive bladder are prevalent in patients with heart failure. Evidence of late stage heart failure, higher fatigue-depression composite and higher body mass index were associated with overactive bladder. Sex, age and diuretic use were not associated with urinary incontinence and overactive bladder.

Conducting a Device Feasibility Study.

Feasibility studies are often the first attempt researchers use to test whether a new process or part of a process is practical for use in a clinical setting or a device will provide the desired information. When conducting a device feasibility study there are several unique considerations that must be addressed. This manuscript describes the processes and considerations.

Detecting Delirium Using a Physiologic Monitor.

For the past 2500 years, delirium has been described based on the presence of behavioral symptoms. Each year, as many as 1 in 5 acute care and 80% of critically ill patients develop delirium. The United States spends approximately $164 million annually to combat the associated consequences of delirium. There are no laboratory tools available to assist with diagnosis and ongoing monitoring of delirium; therefore, current national guidelines for psychiatry, geriatrics, and critical care strongly recommend routine bedside screening. Despite the significance, health care teams fail to accurately identify approximately 80% of delirium episodes.The utility of conventional electroencephalogram (EEG) in the diagnosis and monitoring of delirium has been well established. Neurochemical and the associated neuroelectrical changes occur in response to overwhelming stress before behavioral symptoms; therefore, using EEG will improve early delirium identification. Adding EEG analysis to the current routine clinical assessment significantly increases the accuracy of detection. Using newer EEG technology with a limited number of leads that is capable of processing EEG may provide a viable option by reducing the cost and need for expert interpretation. Because EEG monitoring with automatic processing has become technically feasible, it could increase delirium recognition. Electroencephalogram monitoring may also provide identification before symptom onset when nursing interventions would be more effective, likely reducing the long-term ramifications. Having an objective method that nurses can easily use to detect delirium could change the standard of care and provide earlier identification.

Atrial fibrillation among older adults: pathophysiology, symptoms, and treatment.

Atrial fibrillation is the most common arrhythmia among older adults. Valvular heart disease, dilated cardiomyopathy, aortic stenosis, hypertension, coronary artery disease, pericarditis, thyrotoxicosis, pulmonary disease, cardiac surgery, alcohol excess, and alcohol withdrawal are associated with atrial fibrillation. Nurses caring for older adults need to understand the condition's pathophysiology, signs and symptoms, diagnostic data and treatment protocols, and adherence issues to prevent the formation of emboli in chronic atrial fibrillation and to understand treatment of this common arrhythmia. This article presents an individual example of an elderly man exhibiting a new onset of atrial fibrillation and the interventions required to manage the associated complications. Atrial fibrillation places patients at risk for stroke from a thromboembolism; thus, pharmacological and nonpharmocological care strategies for managing patients with atrial fibrillation are discussed.

Pathophysiology Review: Seven Neurotransmitters Associated With Delirium.

Delirium affects 70% to 80% of intensive care unit patients and is associated with a 10-fold increase in rates of cognitive impairment at discharge and a 3-fold increase in mortality rates. Estimated costs are $152 billion in Medicare charges annually, 17.5 million inpatient days, and 30-day postdischarge costs of $238 726 per patient. Delirium is an acute disorder of attention and global cognitive function characterized by fluctuating symptoms occurring in the face of an underlying organic cause. As patients adapt to physiological stressors, neurotransmitter changes lead to electroencephalogram pattern changes. The ability to compensate for the chemical (neurotransmitter) imbalances is surpassed, causing the behavioral symptomatology we know as delirium. This article seeks to describe the pathophysiology behind the behavior core to the prevention and management of delirium.

Choosing the Right Delirium Assessment Tool.

Delirium is an increasing concern with current combined annual costs for the United States and Europe of approximately $350 billion. Although standardized definitions and diagnostic criteria exist, more than 80% of delirium in the acute care setting is overlooked or misdiagnosed. Delays in identification result in increases in severity and mortality and a reduction in quality of life. Selecting an assessment tool is the first step toward improving recognition.

Cardiac disease and sexuality: implications for research and practice.

Many symptoms of cardiovascular disease can impact the patient's level of sexual desire. Nurses are in a position to assess sexuality of the cardiovascular patient and to provide a high degree of counseling on the subject; yet, nurses frequently complain that they lack the proper knowledge to provide this education and counseling. This article attempts to provide the necessary information regarding the physiologic effects of sexual intercourse on the heart, the role of sexuality in various types of cardiovascular disease, and the evidence-based nursing interventions needed to provide holistic care to patients with cardiovascular disease.

Cat's claw: an Amazonian vine decreases inflammation in osteoarthritis.

Cat's claw (Uncaria tomentosa and Uncaria guianesis) is a medicinal plant from the Amazon commonly used to treat disorders such as arthritis, gastritis and osteoarthritis. The mechanism of cat's claw appears to be as an inhibitor of TNFalpha and antioxidant. Understanding the processes in osteoarthritis may facilitate and clarify the potential role of cat's claw as a complementary therapy to assist in the reduction of pro-inflammatory mediators and effectors. The clinical relevance of this therapy as a viable modality of intervention will be discussed.

What's Your Position? Strategies for Safely Reaching Patient Comfort Goals After Cardiac Catheterization via Femoral Approach.

BACKGROUND: Patients frequently complain of back pain after cardiac catheterization, and there is a lack of evidence to guide practice regarding patient comfort while maintaining hemostasis at femoral access site after cardiac catheterization. OBJECTIVE: The aim of this study was to examine if frequent position changes affect a patient's pain level or increase incidents of bleeding in the recovery period after cardiac catheterization. METHODS: A quasi-experimental pretest/posttest design was used to evaluate a patient's reported pain levels and positioning changes during bed rest period postprocedure. Twenty charts were reviewed to note documentation of patient position, self-reported pain rating related to pain relief goals, and occurrence of bleeding at the procedure site. A survey was conducted to reveal nurse attitudes, knowledge, and beliefs regarding positioning and pain management for patients in the post-cardiac catheterization period. Results from this survey were used to develop education and data collection tools. Education regarding perceived barriers and importance of maximizing activity orders for patient comfort was provided to nursing staff. After nurse education, an additional 20 charts were reviewed to note if increasing frequency of position change affects pain levels reported by patients or if any increased incidence of bleeding was noted with greater frequency of position change. RESULTS: Data were analyzed using correlation analyses. Greater levels of pain were associated with higher pain ratings (r = 0.796, P < .000). Use of position change only as a comfort measure was negatively associated with pain ratings; in other words, lower patient pain ratings were associated with use of positioning only without addition of medications to address complaint (r = -0.493, P < .023). There was a significant increase in number of pain management goals met from before to after education intervention (P < .046). DISCUSSION: Nurse concern for increased bleeding was found to be the most common barrier for use of position changes for comfort after cardiac catheterization. This initial analysis suggests position changes in conjunction with pain medication are beneficial in managing pain after cardiac catheterization. There was no increase in bleeding or complications reported; however this study had a small sample size, and caution should be used regarding generalization of findings.

Monitoring peripheral edema of heart failure patients at home: Device, algorithm, and clinic study.

Continuous monitoring of heart failure (HF) patients is desirable in order to better manage their illness and reduce unnecessary hospitalization. A comprehensive cloud-based HF patient management system is proposed to collect patients' health status information and provide just-in-time intervention. To date, an HF patient edema monitoring system prototype, including the device and its algorithm, has been developed. The hardware features multiple sensors whose data are fused using an edema classification algorithm based on a standard linear solid (SLS) edematous tissue model. Clinical data have been collected and analyzed to verify the effectiveness of the hardware and software. While the analysis results show some promise, full validation of the device and the algorithm warrant further study.

Design of peripheral edema measurement device for home use.

Due to improvements in cardiovascular care, more patients are living longer but ultimately developing heart failure. It is important for patients with chronic conditions, like heart failure, to self-manage and monitor their symptoms. One symptoms that can be indicative of worsening heart failure is peripheral edema. Therefore, we present a concept for a HeartSMART system capable of edema measurement in the home with remote connection to and feedback from providers. The goal of the system is to provide a tool for heart failure patients to manage their disease. The work presented herein describes the system design and preliminary testing using simulated edema models. The system uses displacement and force sensors and mimics the gold standard finger indentation performed by care providers. The results for the edema models (foam) show increasing displacement with edema severity.

The quality of life of hospice patients: patient and provider perceptions.

The purposes of this study were to describe the quality of life (QOL) of terminally ill patients in a home-based hospice program and to examine the relationship between QOL data and patients' symptom distress, ability to function, interpersonal communication (support from family and friends), well-being (their affairs in order), and transcendence (religious comfort/support) as recorded in their charts. QOL was measured by the Missoula-Vitas Quality of Life Index (MVQOLI), an instrument designed specifically for use with terminally ill patients. The study was conducted over a three-year period with 129 terminally ill patients enrolled in a home-based hospice program of care. The MVQOLI was administered to patients within 20 days of their admission to hospice. A retrospective chart review was conducted to determine patients' levels of symptom distress, ability to function, social support, whether or not their affairs were in order, and religious comfort/support. The mean age of participants in this study was 67, with 54.3 percent male and 45.7 percent female. Cancer was the primary diagnosis for 92.2 percent of the sample, and 35 percent of these patients had a diagnosis of lung cancer. Of the 7.8 percent non-cancer diagnoses, five were diagnosed with AIDS, four with chronic obstructive pulmonary disease, and one with chronic heart failure. The results of this study revealed positive scores on the five dimensions of the MVQOLI QOL scale, indicating that within 20 days of admission to hospice, patients rated their QOL as good to very good. Data obtained from the chart review also indicated that patients did not experience a great deal of symptom distress (e.g., pain, nausea, shortness of breath, and restlessness). A significant correlation existed between age and QOL; number of interventions and pain levels; and marital status, well-being, interpersonal relationships, and transcendence. Shortness of breath and well-being were significantly correlated with QOL. There was no significant correlation between gender, race, or closeness to death and the five dimensions of the MVQOLI and chart review assessments.