Sistematização da assistência de enfermagem ao paciente com fratura de colo de fêmur: relato de experiência / Systematization of nursing care for patients with femoral neck fracture: experience report

Objetivo: descrever a aplicação da Sistematização da Assistência de Enfermagem a um paciente com Fratura de Colo de Fêmur no período perioperatório. Metodologia: Relato de experiência realizado no centro cirúrgico de um hospital geral, o qual atende demanda espontânea da capital e do interior do estado da Bahia. O período de realização do estudo foi em agosto de 2019, na cidade de Feira de Santana- BA. Esta experiência foi fruto da vivência de acadêmicos de enfermagem do sexto semestre da Universidade Estadual de Feira de Santana. Foram respeitados os aspectos éticos da Resolução 466/2012. Resultados: Foi aplicada a Sistematização da Assistência de Enfermagem no Perioperatório a paciente idoso com fratura de colo de fêmur, conforme cinco fases do processo de enfermagem: Histórico, Diagnóstico, Planejamento, Implementação e Avaliação. Ressalta-se que o referido caso foi analisado de acordo com as Diretrizes Terapêuticas para Fratura de Colo de Fêmur, que demostraram a importância da aplicação da sistematização para um cuidado diferenciado ao paciente idoso com diagnóstico de fratura de fêmur, considerando que a população idosa cada vez mais vem alcançando a longevidade e as quedas são um dos eventos adversos que mais acometem essa população, seguido pela fratura. Conclusão: Este estudo pretende contribuir como instrumento gerencial e de cuidado relevante para a instituição no centro cirúrgico que visem acelerar o tempo de alta, minimizar o risco de complicações, reduzir os custos e favorecer a qualidade de vida dos pacientes idosos com fratura de fêmur a partir da sistematização da assistência de enfermagem perioperatória.

Objective: Describe the application of Nursing Care Systematization to a patient with a femoral neck fracture during the perioperative period. Methodology: Report of an experience carried out in the operating room of a general hospital, which cares for the spontaneous demand of the capital city and the interior of the state of Bahia. The study was held in August 2019 in the city of Feira de Santana, in the state of Bahia. This was the result of the academic experience of nursing students in the sixth semester at the State University of Feira de Santana. The ethical aspects of Resolution 466/2012 were respected. Results: Perioperative Nursing Care Systematization was applied to an elderly patient with a femoral neck fracture, according to five phases of the nursing process: History, Diagnosis, Planning, Implementation, and Evaluation. It emphasizes whether the case was analyzed according to the Therapeutic Guidelines for Femoral Neck Fractures, which demonstrated the importance of applying systematization for differentiated care for elderly patients diagnosed with femoral fractures, considering that the elderly population is living longer, and falls are one of the adverse events most frequently affecting such population, followed by fracture. Conclusion: This study aims at contributing as a relevant management and care instrument for the institution of any surgical center that aims at speeding up discharge time, minimizing the risk of complications, reducing costs, and favoring the quality of life of elderly patients with femur fracture from the systematization of perioperative nursing care.

Exploring Production Pressure and Normalization of Deviance and Their Relationship to Poor Patient Outcomes.

Production pressure and/or normalization of deviance contribute to poor patient outcomes. The purpose of this study was to explore the relationship between production pressure and normalization of deviance to poor patient outcomes. A team of experienced qualitative researchers conducted a metasynthesis of all qualitative closed claims studies that used the American Association of Nurse Anesthetists (AANA) Foundation Closed Claims database and were accepted for publication at the time of the study. Three central concepts emerged from the analysis: (1) impaired culture of safety, (2) violations of standards of care, and (3) impaired patient safety and outcomes. It is imperative that anesthesia providers support a culture of safety and follow AANA Standards for Nurse Anesthesia Practice.

Adult patients' wellbeing and disturbances during early recovery in the post anaesthesia care unit. A cross-sectional study.

OBJECTIVES: Assessment of patients' wellbeing in the post anaesthesia care unit and how much each disturbance influences it. Furthermore, assessment of the incidence of the correlated disturbances and whether there are gender-specific aspects. DESIGN/SETTING: Observational anonymised survey with a validated questionnaire in a university hospital in central Europe. MAIN OUTCOME MEASURES: Incidence rates of wellbeing and disturbances in the post anaesthesia care unit. RESULTS: The patients' most frequently reported early postsurgical disturbances (n = 349) were i) dry mouth (35.4%), ii) pain in the surgical area (12.7%) and iii) hunger (12.2%). Every other disturbance was below 10% (e.g. nausea). Subjective wellbeing was reported by 57.2% of our patients. There were weak correlations between wellbeing and physical discomfort, pain in the surgical area, sleepiness and nausea. The strongest correlation was with physical discomfort. Female patients showed more feelings of cold, nausea and headache. CONCLUSION: Even in hospitals repeatedly certified in pain management, a high percentage of patients still claim early postoperative discomfort. We see the necessity for an increased focus on this topic and the need for investigations regarding patients' perception. The most frequent claims were related to pain in the surgical area and a dry mouth.

Non-pharmacological strategies to obtain usable magnetic resonance images in non-sedated infants: Systematic review and meta-analysis.

BACKGROUND: Although the use of sedation is commonly practiced to keep infants still while receiving magnetic resonance imaging, non-pharmacological strategies are a potential alternative. OBJECTIVES: The purpose of this study was to determine the success rate of obtaining usable magnetic resonance images in infants with the sole use of non-pharmacological strategies. DESIGN: Systematic literature review and meta-analysis SETTING: A search was conducted in PubMed, CINAHL and Cochrane Library. PARTICIPANTS: Human infants from birth to 24 months of age who did not receive any sedation or anesthesia during magnetic resonance imaging METHOD: Articles that reported the success rate of obtaining usable images were included. RESULTS: Of the 521 non-duplicate articles found, 58 articles were included in the systematic review with sample sizes ranging from 2-457, an average success rate of 87.8%, and an average scan time of 30 min. The most common non-pharmacological technique included feeding and swaddling infants before imaging to encourage infants to sleep during the scan. Meta-analysis performed on 53 articles comprising 3,410 infants found a success rate of 87%, but significant heterogeneity was found (I2 = 98.30%). It was more difficult to obtain usable images solely with non-pharmacological techniques if infants were critically ill or a structural magnetic resonance imaging of the brain was required. CONCLUSION: Non-pharmacological techniques are effective for obtaining usable magnetic resonance imaging scans in most but not all infants. Tweetable abstract: Non-pharmacological techniques are effective for obtaining usable magnetic resonance imaging scans in most infants.

Anesthetic Management of Elderly Patients With Down Syndrome: A Case Report.

In 1930, the life expectancy of patients with Down syndrome was about 10 years; today, their life expectancy is more than 60 years. With aging, there is an increased need for anesthesia and surgery. There is, however, no published information regarding the anesthetic management of older adults with Down syndrome. In this report, we described the anesthetic management of a 50-year-old woman with Down syndrome undergoing major cervical spine surgery. Components of the anesthetic that we thought would be difficult such as intravenous line placement and endotracheal intubation were accomplished without difficulty. Despite our best efforts, our patient nevertheless experienced both emergence delirium and postoperative vomiting. We advocate that physicians, advanced practice providers, and registered nurses be aware of the unique perianesthesia needs of older patients with Down syndrome.

Description of practices and complications in the French centres that participated to APRICOT: A secondary analysis.

INTRODUCTION: Analysing national patients' profile and organisation of human resources are important for improving the perioperative quality of care. The aim of the current study was to achieve these goals using the French data from the APRICOT study. MATERIAL AND METHODS: Data from the French centres that participated to the APRICOT study were extracted and analysed. The primary goal of the study was to describe patients' characteristics, procedures and perioperative anaesthetic management in France, and compare them to the results of the European APRICOT trial. Secondary outcomes were the description of major perioperative complications and the determination of human resources organisation possibly associated with these perioperative complications. RESULTS: Overall 3535 procedures collected in 20 facilities (17 teaching hospitals, one community hospital and two private institutions) were analysed. Comparison between the French and European APRICOT cohorts found differences related to the more specialised French centres participating to the study. Overall complications (respiratory complications, haemodynamic instability, cardiac arrest, drug errors, and anaphylactic reactions) were observed in 6.4% [95% CI: 5.6; 6.3] of cases. Multivariate analysis identified the anaesthesiologist's experience of<15 years and the absence of an anaesthetic nurse as human factors independently associated with an increased risk for perioperative complications. DISCUSSION: The current study identified some important differences between the French and the whole APRICOT cohort in terms of preoperative evaluation, surgical specialties involved, and monitoring of neuromuscular blockade. It confirms that, in France, the presence of an anaesthetic nurse and an experienced anaesthesiologist prevents anaesthetic complications.

The common meanings and shared practices of sedation assessment in the context of managing patients with an opioid: A phenomenological study.

AIMS AND OBJECTIVES: To examine the common meanings of opioid-induced sedation and shared practices in the context of post-operative pain management in expert Post-Anesthesia Care Unit nurses during patient's pain management with opioids. BACKGROUND: Within the clinical setting, linear pain and sedation scales are not enough to support clinical judgement with acute pain management. Because sedation measurement rests along a fluctuating continuum, it is possible for a patient to be sedated and then shift to increasing alertness, and then to drift back to a sedated state. This potential for acute clinical transition can be challenging to nurses of all levels, even for expert nurses. DESIGN: Interpretive phenomenology. METHODS: Twenty expert Post-Anesthetic Care Unit nurses, with more than 7 years of nursing experience, participated in qualitative interviews regarding their lived experiences. Interviews were analysed using a modified seven-stage process for interpretation by Diekelmann, Allen and Tanner. The manuscript was developed utilising the COREQ guidelines for reporting qualitative studies. RESULTS: Four themes identified through the participant's stories were recognising every patient is different, engaging in iterative knowing, walking a fine line, and looking beyond and anticipating. This study identified a constitutive pattern of interpreting sedation by integrating practical understanding and anticipating beyond. CONCLUSIONS: This study indicates a deeper complexity in the way opioid-induced sedation is assessed and balanced with pain management by nurses in the Post-Anesthetic Care Unit. RELEVANCE TO PRACTICE: Nurses in the study adapted their practices around pain management with opioids, in response to their patient's level of sedation; incorporating practices such as giving small, incremental doses and changing the drug. Nurses valued the importance of having "eyeballs on everybody" and being ready to meet the needs of their patient. They appreciate the time to watch and wait for their patient to respond, to better judge the result of their interventions.

Nurse-led extubation in the post-anaesthesia care unit.

Weaning of mechanical ventilation occurs in intensive care units by nurses, which stimulates the prospect of nurse-led extubation extending into the PACU environment for improved patient outcomes and reduced demand of hospital resources. Nurse-led patient extubation in the PACU, would involve specially trained nurses weaning mechanical ventilation via an established protocol for a specific patient group, prior to the patient being extubated by an anaesthetist or intensivist.

Developing an e-learning resource for nurse airway assistants in the emergency department.

The aims of this project were to determine the required competencies for a nurse in the emergency department assisting with a rapid sequence induction of anaesthesia (RSI), and to produce a relevant e-learning resource. A three-round multidisciplinary Delphi process produced the following competencies: ability to describe the steps and sequence of events of an RSI, familiarity with the equipment used during an RSI, ability to recognise and help manage problems occurring during an RSI, ability to prepare for an RSI, ability to apply cricoid pressure, and understanding the modification of an RSI in special circumstances. An interactive e-learning package was produced and made available online. Twelve emergency department nurses took part in an evaluation of the e-learning package. All either agreed or strongly agreed that they had increased their knowledge and found the learning useful, and 11 out of 12 nurses reported being somewhat or very confident in the role of airway assistant following completion of the learning.

The Role of Documentation Quality in Anesthesia-Related Closed Claims: A Descriptive Qualitative Study.

Clinical documentation is a critical tool in supporting care provided to patients. Sound documentation provides a picture of clinical events that can be used to improve patient care. However, many other uses for clinical documentation are equally important. Such documentation informs clinical decision support tools, creates a legal record of patient care, assists in financial reimbursement of services, and serves as a repository for secondary data analysis. Conversely, poor documentation can impair patient safety and increase malpractice risk exposure by reflecting poor or inaccurate information that ultimately may guide patient care decisions.Through an examination of anesthesia-related closed claims, a descriptive qualitative study emerged, which explored the antecedents and consequences of documentation quality in the claims reviewed. A secondary data analysis utilized a database generated by the American Association of Nurse Anesthetists Foundation closed claim review team. Four major themes emerged from the analysis. Themes 1, 2, and 4 primarily describe how poor documentation quality can have negative consequences for clinicians. The third theme primarily describes how poor documentation quality that can negatively affect patient safety.

Professionals' Perceptions about the Need for Pain Management Interventions for Children with Cerebral Palsy in South African School Settings.

Pain is common in children with cerebral palsy (CP) and may have negative consequences for children's success in their studies. Research has shown that pain in childhood negatively influences individuals' participation and quality of life in later years. This study investigated how professionals in South African school settings respond to children's need for pain management in an attempt to enable the children to be active participants in school activities, despite their pain. The study was descriptive and followed a qualitative design (i.e., focus group interviews with semistructured questions and a conventional content analysis). Five government schools for children with special education needs in South Africa's Gauteng province participated. Participants/Subjects: Thirty-eight professionals who represented eight professions. Professional statements on the topic were collected from five focus group sessions conducted during one week. Qualitative content analysis of the data was performed. Similar statements were combined, coded, and sorted into main categories and subcategories. The analysis identified three main categories for pain management: environmental, treatment, and support strategies. In addition, four groups of statements emerged on how contextual factors might affect pain in children with CP and their participation in school settings. It is important to train professionals in pain management and to implement structured models for pain prevention and management to ensure that best practices are adhered to for children with CP who suffer from acute or chronic pain.

Scope of Practice Laws and Anesthesia Complications: No Measurable Impact of Certified Registered Nurse Anesthetist Expanded Scope of Practice on Anesthesia-related Complications.

BACKGROUND: Scope of practice (SOP) laws governing Certified Registered Nurse Anesthetists (CRNAs) vary by state and drive CRNA practice and reimbursement. OBJECTIVE: To test whether the odds of an anesthesia complication vary by SOP and delivery model (CRNA only, anesthesiologist only, or mixed anesthesiologist and CRNAs team). METHODS: Anesthesia claims and related complications were identified in a large commercial payor database, including inpatient and ambulatory settings. Logit regression models were estimated by setting to determine the impact of SOP and delivery model on the odds of an anesthesia-related complication, while controlling for patient characteristics, patient comorbidities, procedure and procedure complexity, and local area economic factors. RESULTS: Overall, 8 in every 10,000 anesthesia-related procedures had a complication. However, complications were 4 times more likely in the inpatient setting (20 per 10,000) than the outpatient setting (4 per 10,000). In both settings, the odds of a complication were found to differ significantly with patient characteristics, patient comorbidities, and the procedures being administered. The odds of an anesthesia-elated complication are particularly high for procedures related to childbirth. However, complication odds were not found to differ by SOP or delivery model. CONCLUSIONS: Our research results suggest that there is strong evidence of differences in the likelihood of anesthesia complications by patient characteristics, patient comorbidities, and the procedures being administered, but virtually no evidence that the odds of a complication differ by SOP or delivery model.

[Anesthesiological care in orthogeriatric co-management. Perioperative treatment of geriatric trauma patients]. / Anästhesiologische Betreuung im orthogeriatrischen Co­Management. Perioperative Versorgung des geriatrischen Traumapatienten.

Elderly patients increasingly need to undergo surgery under anesthesia, especially following trauma. A timely interdisciplinary approach to the perioperative management of these patients is decisive for the long-term outcome. Orthogeriatric co-management, which includes geriatricians and anesthesiologists from an early stage, is of great benefit for geriatric patients. Patient age, comorbidities and self-sufficiency in activities of daily life are decisive for an anesthesiological assessment of the state of health and preoperative risk stratification. If necessary additional investigations, such as echocardiography must be carried out, in order to guarantee optimal perioperative anesthesiological management. Certain medical factors can delay the initiation of anesthesia and it is absolutely necessary that these are taken into consideration for surgical management. Not every form of anesthesia is equally suitable for every geriatric patient.

[Nursing care in the anesthetic procedure: an integrative review]. / Assistência de enfermagem no procedimento anestésico: revisão integrative.

OBJECTIVE: To search for the scientific evidence available on nursing professional actions during the anesthetic procedure. METHOD: An integrative review of articles in Portuguese, English and Spanish, indexed in MEDLINE/PubMed, CINAHL, LILACS, National Cochrane, SciELO databases and the VHL portal. RESULTS: Seven studies were analyzed, showing nurse anesthetists' work in countries such as the United States and parts of Europe, with the formulation of a plan for anesthesia and patient care regarding the verification of materials and intraoperative controls. The barriers to their performance involved working in conjunction with or supervised by anesthesiologists, the lack of government guidelines and policies for the legal exercise of the profession, and the conflict between nursing and the health system for maintenance of the performance in places with legislation and defined protocols for the specialty. CONCLUSION: Despite the methodological weaknesses found, the studies indicated a wide diversity of nursing work. Furthermore, in countries absent of the specialty, like Brazil, the need to develop guidelines for care during the anesthetic procedure was observed.

Nursing care in the anesthetic procedure: an integrative review / Asistencia de enfermería en el procedimiento anestésico: revisión integradora / Assistência de enfermagem no procedimento anestésico: revisão integrativa

Abstract OBJECTIVE To search for the scientific evidence available on nursing professional actions during the anesthetic procedure. METHOD An integrative review of articles in Portuguese, English and Spanish, indexed in MEDLINE/PubMed, CINAHL, LILACS, National Cochrane, SciELO databases and the VHL portal. RESULTS Seven studies were analyzed, showing nurse anesthetists' work in countries such as the United States and parts of Europe, with the formulation of a plan for anesthesia and patient care regarding the verification of materials and intraoperative controls. The barriers to their performance involved working in conjunction with or supervised by anesthesiologists, the lack of government guidelines and policies for the legal exercise of the profession, and the conflict between nursing and the health system for maintenance of the performance in places with legislation and defined protocols for the specialty. Conclusion Despite the methodological weaknesses found, the studies indicated a wide diversity of nursing work. Furthermore, in countries absent of the specialty, like Brazil, the need to develop guidelines for care during the anesthetic procedure was observed.

Resumen OBJETIVO Buscar evidencias científicas disponibles acerca de las acciones del profesional de enfermería durante el procedimiento anestésico. MÉTODO Revisión integradora de artículos en portugués, inglés o español, indexados en las bases de datos MEDLINE/PubMed, CINAHL, LILACS, Cochrane Nacional, SciELO y en el Portal BVS. RESULTADOS Fueron analizados siete estudios que evidenciaron el trabajo del enfermero anestesista en países como Estados Unidos y regiones de Europa, con el diseño del plan de anestesia y asistencia al paciente en lo que se refiere al chequeo de los materiales y controles intraoperatorios. Las barreras para la actuación del enfermero involucraron el trabajo conjunto o supervisado por anestesiólogos, la ausencia de directrices y políticas gubernamentales para el ejercicio legal de la profesión, el conflicto entre el enfermero y el sistema de salud para el mantenimiento de la actuación en sitios en donde la especialidad tiene legislación y protocolos definidos. CONCLUSIÓN Aun con la fragilidad metodológica encontrada, los estudios señalaron gran diversidad de actuación del enfermero. Además, en países que carecen de la especialidad, como Brasil, se advirtió la necesidad de elaboración de directrices para la asistencia durante el procedimiento anestésico.

Resumo OBJETIVO Buscar evidências científicas disponíveis sobre as ações do profissional de enfermagem durante o procedimento anestésico. MÉTODO Revisão integrativa de artigos em português, inglês ou espanhol, indexados nas bases de dados MEDLINE/PubMed, CINAHL, LILACS, Cochrane Nacional, SciELO e no Portal BVS. RESULTADOS Foram analisados sete estudos que evidenciaram o trabalho do enfermeiro anestesista em países como Estados Unidos e regiões da Europa, com a elaboração do plano de anestesia e assistência ao paciente no que se refere à conferência de materiais e controles intraoperatórios. As barreiras para atuação do enfermeiro envolveram o trabalho conjunto ou supervisionado por anestesiologistas, a falta de diretrizes e políticas governamentais para o exercício legal da profissão, o conflito entre o enfermeiro e o sistema de saúde para manutenção da atuação em locais nos quais a especialidade possui legislação e protocolos definidos. CONCLUSÃO Mesmo com a fragilidade metodológica encontrada, os estudos indicaram grande diversidade de atuação do enfermeiro. Além disso, em países com a ausência da especialidade, como no Brasil, observou-se a necessidade de elaboração de diretrizes para assistência durante o procedimento anestésico.

Paediatric anaesthesia: an overview.

This article provides an overview of the nursing considerations for paediatric anaesthesia. It is aimed at newly qualified operating department practitioners and anaesthetic nurses, and those with limited experience in the care of paediatric patients. It explores the ways in which paediatric anatomy and physiology differ from those of adults and looks at the implications for treatment in the anaesthetic environment. It also discusses the equipment required and the rationale for its use.

Identification of a Very High Cuff Pressure by Manual Palpation of the External Cuff Balloon on an Endotracheal Tube.

The most common complication due to intubation is a high cuff pressure. A high cuff pressure can cause postanesthetic tracheal mucosal injuries in patients undergoing surgery. The aim of this cross-sectional study was to describe whether anesthetic nurses and anesthesiologists identified a very high cuff pressure by manual palpation of the external cuff balloon on an endotracheal tube. An airway device was intubated with an endotracheal tube cuffed to 95 cm H2O. Each participant palpated the external cuff balloon and then filled out a questionnaire, including estimation of the cuff pressure and user frequency of the cuff pressure manometer. The results showed that 89.1% estimated that the cuff pressure was high. Among the participants who rated the cuff pressure as high, 44.8% rated the pressure as quite high and 60.6% rated the pressure as very high. There was no significant relationship between profession and skill in identifying a very high cuff pressure (P = .843) or between work experience and skill in terms of identifying a very high cuff pressure (P = .816). These findings indicate that 10% of patients are at risk of tracheal erosion because of a high cuff pressure.

The preoperative anesthesia evaluation--revisited.

This article discusses the importance of individualizing the preoperative anesthesia assessment. Establishing trust between the interviewer and patient results in a positive, calming effect from preoperative period through to PACU. An interviewing technique can eas- ily be developed to alleviate anxiety and still make patients aware of risks and potential outcomes.

Development of a nurse-assisted preanesthesia evaluation program for pediatric outpatient anesthesia.

BACKGROUND: Historically, anesthesiologists have conducted preanesthesia evaluation, but more recently, nurse practitioners (NPs) are increasingly assisting with the preanesthesia evaluation of children. In the current economic environment for healthcare, strategies to provide superior outcomes and exceptional patient experience at the lowest possible cost are constantly being explored. We examined whether well trained nurses, working alongside NPs, could safely and effectively assist in preanesthesia evaluation. The aim of this quality improvement project was to implement a new model for preanesthesia evaluation for healthy outpatient pediatric patients: nurse-assisted preanesthesia evaluation (NAPE). METHODS: Using quality improvement methods, Key Driver Diagrams and SMART aims gave direction for the training and clinical implementation of this new process. Using small tests of change and Plan-Do-Study-Act cycles, we developed a training process and a stepwise process to integrate them into the clinical work flow. The primary outcome measure was the proportion of the total preanesthesia evaluations in which the Anesthesia Nurses assisted. To ensure quality and safety, data on balancing measures and quality metrics were collected. RESULTS: The weekly percentage of outpatients evaluated by Anesthesia Nurses increased from 0% to 55% within the first 4 months and was then sustained. The remaining patients were evaluated by the Anesthesia NPs. The balancing measures did not show any significant negative effect. Our perioperative quality metrics were also not changed significantly. CONCLUSION: Using quality improvement methods, we successfully improved the utilization of staff resources by adding an Anesthesia Nurse-assisted preanesthesia evaluation program alongside our NPs to provide outstanding preanesthesia care at the lowest possible cost.