Hospital staff registered nurses' perception of horizontal violence, peer relationships, and the quality and safety of patient care.

OBJECTIVE: To test hypotheses from a horizontal violence and quality and safety of patient care model: horizontal violence (negative behavior among peers) is inversely related to peer relations, quality of care and it is positively related to errors and adverse events. Additionally, the association between horizontal violence, peer relations, quality of care, errors and adverse events, and nurse and work characteristics were determined. PARTICIPANTS: A random sample (n= 175) of hospital staff Registered Nurses working in California. METHODS: Nurses participated via survey. Bivariate and multivariate analyses tested the study hypotheses. RESULTS: Hypotheses were supported. Horizontal violence was inversely related to peer relations and quality of care, and positively related to errors and adverse events. Including peer relations in the analyses altered the relationship between horizontal violence and quality of care but not between horizontal violence, errors and adverse events. Nurse and hospital characteristics were not related to other variables. Clinical area contributed significantly in predicting the quality of care, errors and adverse events but not peer relationships. CONCLUSIONS: Horizontal violence affects peer relationships and the quality and safety of patient care as perceived by participating nurses. Supportive peer relationships are important to mitigate the impact of horizontal violence on quality of care.

Knowledge and beliefs about smoking and goals for smoking cessation in hospitalized men with cardiovascular disease.

OBJECTIVES: To describe perceptions of smoking in men hospitalized with cardiovascular disease (CVD). BACKGROUND: Smoking is a major risk factor and associated with the high prevalence of CVD in Jordan. METHODS: The study design was cross-sectional with a convenience sample. A structured interview was conducted in 112 men who were hospitalized with CVD. RESULTS: The study showed that 91% of men hospitalized with CVD smoked daily. The majority (83%) had attempted to quit smoking in the past without help from others, and intended to quit in the future using the same previously unsuccessful method. They were unaware of the hazards of smoking such as stroke; or the long term health benefits of quitting smoking. Logistic regressions showed that men were more confident in quitting smoking if they had a high income (OR: 7.7; 95% CI: 2.7, 22.3), longer hospitalizations (OR: 2.6; 95% CI: 1.3, 5.3), or were hospitalized in acute cardiac settings (OR: 3.9; 95% CI: 1.2, 12.7), and admitted with a diagnosis of MI or angina (OR: 3.0; 95% CI: 1.1, 8.3). CONCLUSION: Assessment of smoking status with smoking cessation counseling is paramount in hospitalized men with CVD who smoke.

Changes in heel skin temperature under pressure in hip surgery patients.

OBJECTIVE: The aim of the study was to examine the effect of external pressure of the bed surface on heel skin temperature in adults in the first 3 days after hip surgery. DESIGN: A quasi-experimental study in a prospective, within-subjects, repeated-measures design. SETTING: This study was performed at 2 acute-care hospitals. PARTICIPANTS: Eighteen subjects (9 men and 9 women) with a mean age of 58.3 (±16.1) years were recruited after hip surgery at the 2 hospitals. METHODS: Temperature sensors were placed on the plantar surface of each foot, close to the heels. Measures were taken when the heels were (1) suspended above the bed surface for 20 minutes (preload), (2) on the bed surface for 15 minutes (loading), and (3) suspended again above the bed surface for 15 minutes (unloading). MAIN OUTCOME MEASURES: Heel skin temperature and demographic data. RESULTS: Heel temperature increased during loading and unloading in both legs on postoperative days 1 (P = .003) and 3 (P = .04) but not on postoperative day 2. Heel temperature in the nonoperative leg decreased in the first 3 minutes of unloading on postoperative days 2 (P = .02) and 3 (P = .01). CONCLUSION: Heel temperature increased with loading and unloading on postoperative days 1 and 3. Upon immediate unloading, hyperemic response was present only in the nonoperative leg. Keeping the heels off the bed surface at all times may avoid heel skin temperature changes and prevent tissue damage. Further research is needed to identify the mechanisms that explain the effect of external pressure on heel temperature.

Acute coronary syndromes in deployed military personnel.

PURPOSE: The purpose of this study was to describe the cardiovascular (CV) risk profile of deployed military men who experience acute coronary syndrome (ACS). DATA SOURCES: A retrospective record review of deployed military men who experienced ACS while deployed and were treated at an overseas military medical center between 2001 and 2007 was conducted to obtain the information for this descriptive study (N= 100). CONCLUSIONS: Acute myocardial infarction was diagnosed in 82% of the sample, and 18% experienced unstable angina. Subjects' mean age was 44.7 years (SD± 7.6; range 29-60) and most were enlisted and reservists. Risk factors included a family history of premature coronary artery disease (41%) and smoking (47%) as well as a history of hyperlipidemia (48%), hypertension (28%), and glucose abnormalities (6%). The group was overweight (BMI 27.77 kg/m(2) ± 3.2) and low risk for CV events (Framingham risk score 7.8%[± 4.4]). IMPLICATIONS FOR PRACTICE: Young military men are regarded as the epitome of health and fitness; however, findings from this study suggest that this generally low-risk group do indeed have multiple CV risk factors and experience ACS. Early risk factor assessment and modification, including smoking cessation, weight management, and improving dyslipidemia, is essential.

Efficacy of small doses of ketamine with morphine to decrease procedural pain responses during open wound care.

OBJECTIVE: The purpose of this study was to evaluate differences in pain intensity, pain quality, physiological measures, and adverse effects when patients received morphine with saline (MS) compared with morphine and a small dose of ketamine (MK) before an open wound care procedure (WCP). METHODS: A randomized, cross-over design was used to determine whether the addition of a small dose of ketamine would potentiate morphine's analgesic effects and decrease WCP pain intensity. Patients were randomized to receive either 0.1 mg/kg of morphine (8 mg maximum) plus saline intravenously (IV) or 0.05 mg/kg of morphine (4 mg maximum) plus ketamine 0.25 mg/kg IV before the WCP. Patients were crossed-over to receive the alternate treatment during the next WCP. RESULTS: Eleven male patients participated in the study. Mean rank of pain intensity during WCP-MK was significantly less than during WCP-MS (P=0.005). Mean±standard error of mean pain intensity during the WCP-MK was 3.09±0.99, whereas it was 6.82±0.92 during the WCP-MS. However, 91% of the patients had adverse effects (eg, strange sensations, hallucinations, blurred vision) with MK versus 0% with MS. Diastolic blood pressure was significantly higher during the WCP-MK. DISCUSSION: Ketamine with morphine significantly reduced procedural wound pain intensity during WCP. Adverse effects and higher diastolic BP occurred with MK. Further research is warranted to determine the optimal analgesic dose of ketamine or if the addition of a benzodiazepine would mitigate the psychotomimetic effects of ketamine.

A review of cardiovascular risk factors in US military personnel.

As the civilian population exhibits increasing trends in major cardiovascular (CV) risk factors in younger age groups, the US military is observing similar trends. These worrisome developments are seen even in young adulthood. Despite the need for a fit, combat-ready force, increases in CV risk are increasingly evident in the military population. This review provides an overview of coronary artery disease in the young and the prevalence of risk factors in the military population. With increases in current military operations in an acutely stressful environment, the role of stress and the manifestation of CV disease are also examined.

The Women's Initiative for Nonsmoking (WINS) XI: age-related differences in smoking cessation responses among women with cardiovascular disease.

Smoking cessation has immediate health benefits; however, the efficacy of smoking cessation interventions among older adults and women has received limited research attention. The original Women's Initiative for Nonsmoking (WINS) study was a randomized controlled trial that tested the efficacy of a smoking cessation intervention for Bay Area women hospitalized with cardiovascular disease. The current study, which used the WINS dataset, compares participants 62 and older with those younger than 62 years. The sample (n=277) contained 136 older smokers and 141 younger smokers. At the 6-month follow-up, 52.1% of older smokers had quit smoking compared with 40.6% of younger smokers. At the 12-month follow-up, 52.0% of older smokers had quit smoking compared with 38.1% of younger smokers. The difference at 12 months was statistically significant, and a Kaplan-Meier survival analysis further supported these findings. Clinicians should be sure to also include older smokers in smoking assessments and smoking cessation interventions.

How heel oxygenation changes under pressure.

The mechanism of heel pressure ulcers after hip surgery is not entirely understood. The purpose of this one-group, prospective, repeated-measures design study was to examine how the external pressure of the bed surface affects heel skin oxygen tension in adults on the first 3 days after hip surgery. Transcutaneous oxygen sensors were placed on the plantar surface of each foot, close to the heels. Measures were taken on room air and with an oxygen challenge with the heels (1) suspended above the bed surface (preload), (2) on the bed surface for 15 minutes (loading), and (3) again suspended above the bed surface for 15 minutes (unloading). Eighteen hip surgery patients (mean age 58.3+/-16.1 years) from two hospitals participated. When compared with preload on room air, both loading and unloading on all 3 days resulted in a reduction in heel oxygen tension bilaterally (p<0.001). Heel oxygenation decreased without the anticipated hyperemic response, raising the question of whether this is a sign of increased pressure ulcer risk. Further work is needed to understand why this short period of external pressure results in decreased oxygenation and why oxygen tension does not return to baseline when pressure is removed.

Beliefs about health, smoking, and future smoking cessation among South Korean men hospitalized for cardiovascular disease.

BACKGROUND: A particularly high rate of smoking among South Korean men corresponds to high rates of cardiovascular disease. OBJECTIVES: This study evaluated South Korean men hospitalized with cardiovascular disease to explore beliefs about the health benefits of smoking cessation, to determine smoking cessation intentions, and to identify factors associated with confidence in quitting smoking. METHODS: This was a cross-sectional, descriptive study. RESULTS: Of the study's 97 participants, only 78% believed that smoking cessation avoids or decreases the chance of developing heart disease; 93% reported their intention to quit; 74% had moderate to high confidence about quitting within the month after hospital discharge; and 88% preferred to quit by themselves without help. Significant predictors of low confidence in quitting were being married (odds ratio: 5.54, 95% confidence interval: 1.33-23.08); being alcohol dependent (odds ratio: 3.25, confidence interval: 1.20-8.80); and starting to smoke at or before 20 years of age (odds ratio: 2.96, confidence interval: 1.14-7.68). CONCLUSION: The study's participants were motivated to quit smoking for their health, but they must be educated to understand that smoking is addictive and that special intervention is needed.

Skin disease in HIV-positive persons living in Puerto Rico.

OBJECTIVES: To determine the frequency of skin disease in persons infected with the human immunodeficiency virus (HIV), to validate the agreement of self-reported skin condition(s) versus objective data obtained by physical examination, and to describe the characteristics of HIV-positive persons with skin disease in Puerto Rico. DESIGN: Descriptive correlational design. SETTING AND PARTICIPANTS: Ninety-five HIV-positive adults in San Juan, Puerto Rico. Ninety-five adults who were HIV-positive participated. RESULTS: Ninety (94.7%) participants had skin disease and/or signs or symptoms suggestive of disease. Diseases most often reported were onychomycosis (n=16; 17.8%) and nongenital warts (n=11; 12.2%). Signs and symptoms reported were dryness (n=59; 65.6%), itch (n=58; 64.4%), erythema (n=30; 33.3%), induration (n=13; 14.4%), postinflammatory hyperpigmentation (n=9; 10.0%), and excoriation (n=9; 10.0%). Kappa index confirmed the relationship between self-reported skin condition or signs and symptoms and the diagnosis of a skin disease by the physician (k=.42). Positive predictive value was 97.7% (95% confidence interval [CI], 94.7%-100%). Condyloma acuminata was associated with male gender (chi2=4.09, P=.043). Tinea pedis (P=.0215), excoriations (P=.002), and prurigo nodularis (P=.0096) were associated with having a low CD4 cell count. CONCLUSIONS: This study shows that persons infected with HIV can identify significant skin manifestations that are associated with the diagnosis of a skin disease. This validates the use of self-reporting of skin conditions in these patients and points to the importance of educating patients and providers to report patient skin problems. Although the high prevalence of skin disease found in this study population supports a need for improving dermatologic care in HIV-infected patients, the findings of such prevalent cutaneous disease can also provide caretakers with ample evidence to suspect and, therefore, test for HIV infection.

Attitudes of critically ill Filipino patients and their families toward advance directives.

BACKGROUND: Advance directives are important but often underused tools in critical care. Healthcare professionals' understanding of how culture influences attitudes toward advance directives can improve knowledge and completion of these documents. OBJECTIVE: To understand the attitudes of critically ill Filipino American patients and their families toward advance directives. METHODS: A descriptive, correlational, cross-sectional study with a convenience sample of 22 Filipino American patients and 22 Filipino American family members at a West Coast medical center. All patients were admitted for cardiac surgery or cardiac interventions. Participants were interviewed with the Advance Directive Attitude Survey and A Short Acculturation Scale for Filipino Americans. RESULTS: Family members' scores were significantly more positive than patients' scores on the attitude survey (P = .01). Family members were more American acculturated than were patients (P = .001). Family members with more education had more positive attitudes toward advance directives (P = .02). Only 2 patients (and no family members) had completed an advance directive before the study. Only 27.3% of family members had prior knowledge of advance directives. CONCLUSION: Overall attitudes toward advance directives were positive; however, the completion rate and knowledge of advance directives were low. Participants may have been saying what they thought the researcher wanted to hear in order to avoid disagreement. Such behavior could partly explain the positive attitudes of the Filipino Americans toward advance directives. Further research is warranted to understand how to increase completion rates for advance directives among Filipino Americans.

Mechanisms for radiation-induced oral mucositis and the consequences.

Radiation therapy remains the primary method of treatment for patients with head and neck cancer. The tissue destruction and functional alterations in the oral cavity lead to the development of oral mucositis. The purpose of this review is to describe the mechanisms, risk factors, prevalence, and magnitude of radiation therapy-related oral mucositis and its morbidities in patients with head and neck cancer. The review concludes with a discussion of the implications for clinical practice. This review provides cancer nurses with the information necessary to identify patients with head and neck cancer who are at high risk for oral mucositis and the significant comorbidities associated with this complication of radiation therapy.

A research review of the current treatments for radiation-induced oral mucositis in patients with head and neck cancer.

PURPOSE/OBJECTIVES: To review the research studies on the current treatments for radiation therapy-(RT-) induced mucositis in patients with head and neck cancer. DATA SOURCES: MEDLINE search of the literature from 1966-2001. DATA SYNTHESIS: Four types of agents (i.e., antimicrobial, coating, anti-inflammatory, and cytokine-like agents) have been evaluated for the management of RT-induced oral mucositis in patients with head and neck cancer. Most of the published studies had relatively small sample sizes and used inconsistent measures to evaluate the extent and severity of oral mucositis. Therefore, definitive conclusions regarding the effectiveness of any of the agents tested in the prevention and treatment of RT-induced oral mucositis cannot be drawn. CONCLUSIONS: Oral mucositis remains the most common complication among patients with head and neck cancer. Although a number of strategies and products are being investigated and new directions are promising, the therapies tested to date have not produced consistent results. IMPLICATIONS FOR NURSING: The most effective measure to treat RT-induced mucositis in patients with head and neck cancer is frequent oral rinsing with a bland mouthwash, such as saline or a sodium bicarbonate rinse, to reduce the amount of oral microbial flora. Dental care, consistent oral assessments, and the initiation of a standardized oral hygiene protocol before the initiation of cancer treatment are the most effective approaches for oral mucositis.