An evaluation of interventions for meeting the information needs of families of critically ill patients.

OBJECTIVE: To evaluate the effectiveness of two methods of meeting the information needs of families of critically ill patients: an open visiting hour policy and a family information booklet. SETTING: Medical intensive care unit of a university medical center. SUBJECTS: Family members (N = 147) of patients admitted to the medical intensive care unit. INTERVENTIONS: Implementation of an open visiting hour policy and information booklet. MEASUREMENTS AND MAIN RESULTS: Questionnaires were distributed to family members 24 to 48 hours after the patient's admission. The questionnaire addressed family satisfaction with having specific information needs met and posed questions that tested their knowledge of unit policies and personnel. The questionnaire was distributed to three groups: families who had restricted visiting hours and no booklet (group 1, n = 48), families who had open visiting hours but no booklet (group 2, n = 50), and families who had open visiting hours and an information booklet (Group 3, n = 49). Implementation of an open visiting hour policy increased family satisfaction. Families exposed to both the open visiting hours and the information booklet were more knowledgeable about specific details than were those exposed to only the open visiting hour policy. CONCLUSIONS: Flexible visiting hours and information booklets were two practical methods of meeting the information needs of families. Open visiting hours, as a singular intervention, significantly improved family satisfaction. The effectiveness of the booklet in assisting families to recall discrete pieces of information supports the further development and use of preprinted materials to assist in meeting family information needs.

Effect of do-not-resuscitate orders on the nursing care of critically ill patients.

BACKGROUND: The effect of a do-not-resuscitate order on the standard of care of critically ill patients is of concern to practitioners, patients, and their families. Because "do not resuscitate" may be misconstrued to include more than "no cardiopulmonary resuscitation," it may influence the aggressiveness with which some patients are managed. Nurses play a central role in determining standards of care. Hence, confusion on their part as to the meaning of this term can have a significant impact on patient care. OBJECTIVES: To compare nurses' attitudes about standards of care for critically ill patients with and without a do-not-resuscitate order. METHOD: A quasi-experimental design using simulation measurement was used for this study. RESULTS: Nurses reported that they would be significantly less likely to perform a variety of physiologic monitoring modalities and interventions for patients with a do-not-resuscitate order than for patients without such an order. Patients with a do-not-resuscitate order were more likely to receive psychosocial interventions including assessment of their spiritual needs and more flexible visiting practices. CONCLUSIONS: Our findings suggest that "do-not-resuscitate" may be misinterpreted to include more than "no cardiopulmonary resuscitation" even if the patient is receiving aggressive medical management. Misinterpretation of orders not to resuscitate may be related to a variety of factors including lack of understanding about hospital policy and ethical and moral values of the staff. We suggest replacing orders such as "Do not resuscitate" with clearly defined resuscitation plans that are jointly determined by the multidisciplinary team, patient, and family.

Effect of nursing contact on the stress response of patients being weaned from mechanical ventilation.

A prospective, randomized study was undertaken to determine the effect of direct nursing contact on the stress response of patients being weaned from mechanical ventilation. Twenty-six patients being weaned via T-piece for the first time were randomly assigned to either an experimental or a control group. Patients in the experimental group received touch and verbal interaction during weaning whereas the control group did not. Strict control was maintained over the patient's environment during the data collection period, including restriction of all nonessential medical and nursing interventions. No significant increases were found in heart rate or mean arterial pressure in either the control or experimental group during weaning. Respiratory rate 5 minutes after the ventilator was discontinued increased from baseline in both the control (18.0 to 24.4 breaths/min, p = 0.03) and experimental (18.0 to 22.4 breaths/min, p = 0.04) groups. Because both groups had similar responses to weaning, the differences between the groups was nonsignificant and therefore the hypothesis was not supported.

Evaluating oxygen delivery and oxygen utilization with mixed venous oxygen saturation monitoring: a case study approach.

Three cases studies are presented to demonstrate clinical application of mixed venous oxygen saturation (SvO2) monitoring in critical care nursing practice. Examples of critically ill patients are used to demonstrate how SvO2 monitoring can be used in clinical practice to reflect an imbalance between oxygen delivery and oxygen utilization. In the first case, the patient had a problem with oxygen delivery. Continuous SvO2 data aided nurses in guiding, adjusting, and assessing therapy. The second case demonstrates how SvO2 monitoring can provide an early sign of a life-threatening complication. The final case is one in which the patient had a problem with oxygen utilization. In all the cases, continuous SvO2 data provided important information about the balance between oxygen delivery and oxygen utilization.

Intricacies of blood pressure measurement: reexamining the rituals.

Critical care clinicians are often frustrated when blood pressure values derived via direct monitoring methods (i.e., arterial lines) do not "correlate" with values obtained via indirect methods (e.g., auscultatory). Precious time has been spent attempting to troubleshoot monitoring systems and ascertain why these discrepancies exist. Greater insight into the intricacies of blood pressure monitoring reveals that both direct and indirect methods are subject to many external and physiologic influences that have the ability to significantly affect the value ultimately accepted as the "true" blood pressure. Direct blood pressure monitoring is influenced by normal physiologic changes in the pressure pulse configuration as it travels to the periphery, as well as by properties of the external monitoring system. Indirect monitoring is also influenced by a variety of factors, and may be unreliable in the very clinical situations where it is used the most. Finally, the relationship between blood pressure and blood flow, particularly in critically ill patients, suggests that it is unreasonable to expect that pressures obtained by direct monitoring methods will be the same as those derived by indirect methods that are flow dependent.

Clinical assessment and neurodiagnostics.

Effective brain resuscitation demands the expert clinical assessment skills of a multidisciplinary team. The nurse's role in the evaluation of a patient with acute brain injury is the ongoing monitoring of vital signs and neurological status. A comprehensive clinical evaluation includes obtaining a medical history, performing a clinical examination, and securing appropriate neurodiagnostic tests. The initial assessment of the brain-injured patient focuses on an evaluation of cardiopulmonary as well as neurological function. Priority in brain resuscitation is given to the evaluation of the adequacy of oxygenation and circulation. Once circulation is re-established, specific brain-oriented evaluation begins. This assessment includes a comprehensive neurological exam, as well as an evaluation of metabolic factors believed to influence neuronal recovery. Data derived from the clinical assessment is useful in guiding therapy and determining patient prognosis. This information is critical to informed decision-making regarding the appropriateness of aggressive therapy.

Evaluating cardiopulmonary instability with continuous monitoring of mixed venous oxygen saturation.

This article presents three cases that demonstrate the clinical application of mixed venous oxygen saturation monitoring. These case studies reflect how the critical care nurse integrates the physiology of oxygen delivery and consumption as well as critical thinking in making decisions regarding the care of patients with cardiopulmonary instability. This information gives the clinician immediate data from which therapeutic decisions are made to achieve positive patient outcomes.

Need for information. Interventions for practice.

Information is an important need of families of critically ill patients. Meeting this need requires a multidisciplinary approach and an environment that values the delivery of humanistic care. Critical care nurses require special skills in assessment, planning, intervention, and evaluation to effectively meet the information needs of families. Research is available to guide nurses in meeting the family's need for information.

Comprehensive patient care and documentation through unit-based nursing rounds.

Unit-based nursing rounds is an advanced practice educational program implemented through collaboration between a unit-based clinical nurse specialist and an education nurse specialist. The purpose of this program is to provide an informal, time efficient means of teaching staff nurses during work hours. The format emphasizes utilization of the nursing process through presentation of selected case studies. The goal is to enhance incorporation of a nursing model into patient care planning to ensure comprehensive patient care and documentation. Each phase of coordinating, implementing, and evaluating this educational program will be reviewed.

Nurse-physician collaboration: a poststructuralist view.

The impact of various world views on nurse-physician collaboration is discussed in this paper. The poststructuralist perspective, in particular that of Michel Foucault, is presented as a means of advancing collaborative relationships. This approach allows nursing to move beyond the limitations and structure imposed by traditional philosophies. Free of these encumbrances, nursing can achieve its goals as a practice discipline, which includes collaboration with physician colleagues.

Collaboration: a concept analysis.

Collaboration is a complex phenomenon, yet one that is of significance to nursing. This concept analysis presents definitions and defining characteristics of collaboration so that the concept may be used in the creation of operational definitions, or to develop and evaluate tools for measuring collaboration. Antecedents, consequences and empirical referents of collaboration are explored. Model, contrary and related cases are presented to clarify this concept further.