Evaluation of portable bladder ultrasound: accuracy and effect on nursing practice in an acute care neuroscience unit.

The purpose of this evaluation was to determine the accuracy of a portable ultrasound instrument in assessing bladder volume in an acute care neuroscience population and the effect of ultrasound assessment on nursing practice in an acute care neuroscience unit. In a 6-week prospective evaluation, 105 paired ultrasound measurements were performed by 45 nurses on 30 patients suspected to be retaining urine. Sixty-seven catheterizations were performed, and volumes were compared with corresponding ultrasound readings. The first ultrasound volume readings slightly underestimated the catheterized volumes, but the volumes from the first ultrasound readings and the catheterized volumes were highly correlated. Volume readings from a second ultrasound, the average of the first and second ultrasound readings, and the higher of the two ultrasound readings did not add to the ability of the ultrasound instrument to predict catheterized volumes. Patient age and gender did not change the relationship between ultrasound and catheterized volumes. The ultrasound assessment changed nursing practice in 51% of the instances; the most common change (32%) was that nurses did not catheterize the patient. The ultrasound assessment did not change nursing practice in 49% of the instances; the most common reason (41%) was that the ultrasound confirmed the need to catheterize the patient. The instrument was therefore judged to be an accurate and reliable tool that changed nursing practice in an acute care neuroscience unit.

Accuracy of leveling hemodynamic transducer systems.

Critically ill patients frequently have invasive catheters placed to monitor hemodynamic pressures and to calculate hemodynamic indices. Correct leveling to the appropriate anatomical structure is critical as the pressure readings guide management of fluids, drug administration, and other interventions. The authors of this study investigated the accuracy with which registered nurses and respiratory technologists were able to level hemodynamic transducers to the phlebostatic axis using visual checks, a carpenter's level, and a laser leveling device. The results indicate that both groups were unable to accurately level transducers with visual checks alone. Use of a leveling tool improved accuracy. The laser level was superior for accuracy and speed and preferred for dexterity required, ease of use and patient safety. The data supports the need for a tool to accurately level hemodynamic transducer systems and suggests that the laser leveling device is the tool of choice.

Bridging the gap: medical directives for acute care nurse practitioners.

The following article describes the process by which a group of acute care nurse practitioners sought to address the legal challenges of working beyond the traditional scope of nursing practice. It was necessary to establish mechanisms for communicating a diagnosis, as well as for ordering diagnostic tests, treatments and procedures. Medical directives were viewed as an approach to address components of practice involving controlled acts not authorized to nursing. The process of developing medical directives began with a description of the components of a medical directive. Algorithms were then developed based on the College of Nurses of Ontario's decision tree (Purvis, 1995) for the performance of procedures. These algorithms were broad and applicable across all clinical programs. The final step, required each nurse practitioner/clinical nurse specialist in collaboration with physician colleagues, to develop individual appendices specific to each clinical program. Health care administrators may find the information provided of assistance in addressing legal concerns that arise when new opportunities for nursing involve movement beyond traditional boundaries.

Nursing research in stroke. A review.

Nurses have demonstrated an interest in research in stroke. Studies encompass a broad variety of subjects; some clearly within the traditional realm of nursing and others that are common to multiple disciplines. Studies are limited in number and most lack the necessary numbers or controls that make data meaningful. Important beginnings are evident. Research about nurses who care for stroke survivors attempts to find correlations between attitudes and knowledge or outcome measures. Care delivery systems and models of nursing practice may impact on a variety of outcome measures, both those which are patient centred (functional status, quality of life) and those which are system driven (length of stay, recidivism). Information regarding the experience of stroke is rich in detail but limited in quantity. Much more information must be gained from a broader segment of the population to provide a baseline of understanding. Similarly, caregiver research begins to touch on the experience but considerable variation must exist between spouse caregivers and adult children or others, and between cultures. Finally, our interventions and their effect on outcomes are only just beginning to be studied. We remain a great distance from our ideal "evidence based practice". On a positive note, the research that nurses have conducted within the field of stroke is indicative of the broad interests that exist. To provide the care that is needed for our aging population while resources shift and shrink, it is essential that we not only test our interventions and their impact on outcomes but that we also are prepared to blur the traditional professional boundaries. Nurses do not have a monopoly on family centred care and care for the caregivers, nor do we act in isolation when we implement strategies to normalize bowel function post stroke. Collaborative research between disciplines and across cultural and political barriers is essential; resources for funding are available but have not been successfully accessed. The time is now for research by nurses and colleagues to begin to bridge the many knowledge gaps that persist.

Accuracy of levelling intraventricular collection drainage systems.

In neuroscience critical care units, patients may have ventricular drains placed to aid management of acutely elevated intracranial pressure from a variety of causes. Correct placement of the ventricular drainage collection system, a nursing responsibility, is key to the process, and has the potential to influence patient outcome. A two-part study investigated the accuracy with which registered nurses levelled a ventricular drainage collection system. Part 1 found that nurses (N = 33) were unable to accurately level using visual means only. Part 2 found that nurses' (N = 31) use of a tool (a carpenter's level or a newly developed laser levelling device) dramatically improved accuracy. However, demographic differences between nurses in Part 1 and Part 2 may have contributed to this outcome. While both tools were accurate, the laser levelling device was superior to the carpenter's level for speed of use, nurses' rating of ease of use and patient safety.

Cardiac function in aneurysmal subarachnoid haemorrhage: a study of electrocardiographic and echocardiographic abnormalities.

Electrocardiographic (ECG) changes are reported frequently after subarachnoid haemorrhage (SAH). The aim of this study was to investigate the functional significance of ECG changes by echocardiographic assessment of cardiac function. Forty-five patients with intracranial aneurysms were studied. All patients had a 12-lead ECG and a two-dimensional echocardiogram. After patients with an history of chronic cardiac disease (n = 4) were excluded, only four patients were found to have wall motion abnormalities. These patients had only minor ECG abnormalities, but severe neurological dysfunction. Conversely, patients with other ECG abnormalities including the deep inverted T waves associated usually with SAH, had normal echocardiograms. We conclude that the ECG is not an accurate predictor of myocardial function after SAH and that myocardial dysfunction is related more closely to severity of neurological condition.

Syringomyelia and syringobulbia: pathophysiology, surgical treatment and nursing implications.

Syringomyelia (central cavitation of the spinal cord) and syringobulbia (cavitation of the medulla) are relatively rare disorders. These conditions are often found in association with congenital abnormalities such as Chiari malformations, with neoplasms or as sequelae to spinal cord trauma. The pathology progresses from minor sensory changes to weakness and wasting and, in the case of syringobulbia, to respiratory compromise and even death. Surgical treatment involves drainage or decompression of the syrinx cavity with diversion of fluid to the subarachnoid space or peritoneal cavity. Posterior fossa decompression may also be used. These procedures attempt to halt destruction of the nervous system, but will not reverse damage that has already occurred. A case presentation and associated nursing diagnoses are discussed to illustrate current medical and nursing interventions.

Carotid cavernous fistulas.

Carotid cavernous fistulas treated by endovascular means provide nurses with an excellent opportunity to use their skills in assessment. With knowledge of the local anatomy, that assessment must include evaluation of cranial nerves II through VI, to establish a neurological baseline and monitor changes. The patient problems attributed to pathology are multiple, and require active nursing intervention to optimize recovery and return to independent function.