Revisión de conocimientos sobre el síndrome confusional agudo en el paciente crítico / Review of the knowledge on the acute confusional syndrome in the critical patient

Incorpora un sistema anual de autoevaluación y acreditación dentro de un Programa de Formación Continuada sobre la revisión de conocimientos para la atención de enfermería al paciente adulto en estado crítico. Uno de los objetivos de Enfermería Intensiva es que sirva como instrumento educativo y formativo en esta área y estimule el estudio continuado.Las personas interesadas en acceder a la obtención de los créditos de Formación Continuada, que a través de la SEEIUC otorga la Comisión Nacional de Formación Continuada, deberán remitir cumplimentada la hoja de respuestas adjunta (no se admiten fotocopias), dentro de los 2 meses siguientes a la aparición de cada número, a la Secretaría de la SEEIUC. Vicente Caballero, 17. 28007 Madrid (AU)

[Physical restraint use in critical care units. Perceptions of patients and their families]. / Restricciones físicas en UCI: su utilización y percepción de pacientes y familiares.

INTRODUCTION: The use of physical restraints in Intensive Care Units (ICU) is common although little is known about patients' and relatives' perceptions of this use. OBJECTIVES: 1) To analyze the prevalence and use of physical restraints in a general adult ICU; 2) to know the perceptions of patients who experienced use of physical restraints and; 3) to know the perceptions of relatives of patients who used physical restraints. METHODS: This descriptive study, which used both quantitative and qualitative methods, was carried out in an adult ICU. For the first objective, all the patients (101) who had used any kind of physical restraint were analysed. For the second and third objectives, 30 patients and 30 relatives were interviewed using the guidelines of Strumpf & Evans as modified by Hardin (1993). All interviews were recorded, fully transcribed and then submitted to a language content analysis using the method of Hsieh & Shannon. RESULTS: The only physical restraint used was the wrist restraint with a prevalence of 43.47%. Seventy-two percent of patients wore the restraint ≤12h and 28%>12h. Analysis of the patient interviews revealed 4 main themes: acceptance of the restraint conditioned by beliefs and information provided; feelings and sensations caused by the use of the restraint; alternatives proposed and future repercussions. Three themes emerged from the interviews with relatives: impressions caused by the use of the restrictions; reasons for accepting or rejecting them; alternatives to the use of restraints. CONCLUSIONS: Most patients used physical restraints for a short period of time and only the wrist restraint was used. Patients using physical restraints and their relatives expressed a wide range of feelings and sensations, with no negative future repercussions. In general, they agreed with the use of restraints although more precise information would lead to greater acceptance.

Revisión de conocimientos sobre alteraciones del ritmo intestinal y de eliminación fecal en el paciente crítico / Review of the knowledge on gastrointestinal motility disorders and stool elimination in the critical patient

Incorpora un sistema anual de autoevaluación y acreditación dentro de un Programa de Formación Continuada sobre la revisión de conocimientos para la atención de enfermería al paciente adulto en estado crítico. Uno de los objetivos de ENFERMERÍA INTENSIVA es que sirva como instrumento educativo y formativo en esta área y estimule el estudio continuado. Las personas interesadas en acceder a la obtención de los créditos de Formación Continuada, que a través de la SEEIUC otorga la Comisión Nacional de Formación Continuada, deberán remitir cumplimentada la hoja de respuestas adjunta (no se admiten fotocopias), dentro de los 2 meses siguientes a la aparición de cada número, a la Secretaría de la SEEIUC. Vicente Caballero, 17. 28007 Madrid (AU)

[Nursing care in the prevention of ventilator-associated pneumonia]. / Valoración de los cuidados de enfermería en la prevención de la neumonía asociada a ventilación mecánica.

INTRODUCTION: Certain nursing interventions reduce the incidence of ventilator-associated pneumonia (VAP). OBJECTIVES: a) to analyze in patients with more than 24 hours of invasive mechanical ventilation how frequently oral hygiene, oropharyngeal suction, turning and evaluation of the tolerance of enteral nutrition were performed according to established protocols; b) to record in these same patients endotracheal tube cuff pressures and the degrees of elevation of the head of the bed (HOB); c) to determine over the three months of the study the incidence density of VAP. METHOD: This descriptive study was carried out in 26 patients. The nursing interventions of interest were recorded daily. Furthermore, endotracheal tube cuff pressures and the degrees of elevation of HOB were measured 3 times a day. Compliance with the established protocols was considered good when it reached ≥80%. Cases of VAP were determined using CDC criteria. The incidence density was calculated including all the patients (122) with mechanical ventilation during the study period. RESULTS: Good compliance with the established protocols was achieved for oral hygiene in 23 patients, for oropharyngeal suction and for turning in 19 patients, and in all patients for the evaluation of the tolerance of enteral nutrition. In 214 measurements endotracheal tube cuff pressure was ≥ 20cm H20 and in 121 lower. In 79 measurements elevation of HOB was ≥30° and in 256 lower. The incidence density of VAP was 7.43/ 1.000 days of mechanical ventilation. CONCLUSIONS: : For these nurse interventions aimed at preventing VAP, levels of compliance with established protocols were satisfactory. The incidence density of VAP was low and well within internationally established ranges. Nevertheless, the incidence of VAP could be further reduced with a better control of cuff pressures and by elevating the HOB to between 30° and 45°.

La calidad asistencial en cuidados intensivos evaluada por los pacientes mediante la escala SERVQUAL / Care quality in intensive care evaluated by the patients using a service quality scale (SERVQUAL)

Introducción La evaluación realizada por los pacientes de la calidad del servicio que han recibido es importante para introducir estrategias de mejora en la calidad asistencial.Objetivos1. Evaluar la calidad asistencial mediante el análisis de las diferencias obtenidas entre las expectativas y las percepciones que los pacientes tienen del servicio recibido en la UCI.2. Analizar si existe relación entre la calidad asistencial evaluada por los pacientes y las variables sociodemográficas.MétodoSe estudió prospectivamente a 86 pacientes que durante su estancia en la UCI estuvieron conscientes y orientados. A las 24h del alta de la UCI se les pasó la escala SERVQUAL (Service Quality), adaptada para el ámbito hospitalario por Babakus y Mangold (1992); esta escala mide la calidad asistencial basada en la diferencia de puntuaciones obtenidas entre las expectativas y las percepciones de los pacientes; las puntuaciones positivas indican que las percepciones de los pacientes superan sus expectativas. La escala tiene 5 dimensiones: tangibilidad, fiabilidad, capacidad de respuesta, seguridad y empatía. Incluye 15 ítems para las percepciones y los mismos para las expectativas, con 5 grados de respuesta (1: totalmente en desacuerdo-5: totalmente de acuerdo).ResultadosLa puntuación media de las percepciones (66,92) superó la de las expectativas (62,30). La puntuación media de la diferencia entre percepciones y expectativas para el total de la escala SERVQUAL fue de (..) (AU)

Introduction The evaluation made by the patients on the quality of service received is important to introduce improvement strategies in the care quality.Objectives1. To evaluate the care quality through the analysis of the differences obtained between expectations and perceptions, that the patients have of the service received in the ICU2. To analyze if there is any relationship between care quality evaluated by the patients and the sociodemographic variables.MethodA total of 86 patients who were conscious and oriented during their stay in the ICU were studied prospectively. At 24h of the discharge from the ICU, the SERVQUAL (Service Quality) scale, adapted for the hospital setting by Babakus and Mangold (1992), was applied. This scale measures the care quality based on the difference in scores obtained between expectations and perceptions of the patients. The positive scores indicate that the perceptions of the patients exceed their expectations. The scale has 5 dimensions: Tangibility, Reliability, Responsiveness, Assurances and Empathy. It includes 15 items for perceptions and the same for expectations, with 5 grades of response (1 totally disagree – 5 totally agree).ResultsThe mean score of perceptions 66.92) exceeded that of the expectations (62.30). The mean score of the difference between perceptions and expectations for the total of the SERVQUAL scale was 4.62. It was also positive for each one of the dimensions: Tangibility=1.44, Reliability=0.53, Responsiveness=0.95, Assurances=0.99, Empathy=0.71. No statistically significant associations were found between care quality evaluated by the patients and the sociodemographic variables.ConclusionThe care quality perceived by the patients in the ICU exceeds their expectations, and had no relationship with the sociodemographic characteristics(AU)

[Care quality in intensive care evaluated by the patients using a service quality scale (SERVQUAL)]. / La calidad asistencial en cuidados intensivos evaluada por los pacientes mediante la escala SERVQUAL.

INTRODUCTION: The evaluation made by the patients on the quality of service received is important to introduce improvement strategies in the care quality. OBJECTIVES: 1. To evaluate the care quality through the analysis of the differences obtained between expectations and perceptions, that the patients have of the service received in the ICU. 2. To analyze if there is any relationship between care quality evaluated by the patients and the sociodemographic variables. METHOD: A total of 86 patients who were conscious and oriented during their stay in the ICU were studied prospectively. At 24h of the discharge from the ICU, the SERVQUAL (Service Quality) scale, adapted for the hospital setting by Babakus and Mangold (1992), was applied. This scale measures the care quality based on the difference in scores obtained between expectations and perceptions of the patients. The positive scores indicate that the perceptions of the patients exceed their expectations. The scale has 5 dimensions: Tangibility, Reliability, Responsiveness, Assurances and Empathy. It includes 15 items for perceptions and the same for expectations, with 5 grades of response (1 totally disagree - 5 totally agree). RESULTS: The mean score of perceptions 66.92) exceeded that of the expectations (62.30). The mean score of the difference between perceptions and expectations for the total of the SERVQUAL scale was 4.62. It was also positive for each one of the dimensions: Tangibility=1.44, Reliability=0.53, Responsiveness=0.95, Assurances=0.99, Empathy=0.71. No statistically significant associations were found between care quality evaluated by the patients and the sociodemographic variables. CONCLUSION: The care quality perceived by the patients in the ICU exceeds their expectations, and had no relationship with the sociodemographic characteristics.

[Evaluation of pain during posture change in patients with invasive mechanical ventilation]. / Valoración del dolor durante el cambio postural en pacientes con ventilación mecánica invasiva.

INTRODUCTION: The evaluation of pain poses special difficulties in critical patients who have altered verbal communication. OBJECTIVES: Compare the behaviour responses to pain, measured with the Critical-Care Pain Observation Tool (CPOT) scale and the physiological responses before, during and after the posture change procedure in patients with invasive mechanical ventilation. Analyze if there are any differences in the COPT score between medical and surgical patients and between the conscious and unconscious patients in the posture change procedure. Describe the analgesia/sedation administered to the patients 1 hour before and during the posture change procedure. MATERIAL AND METHODS: This descriptive, prospective study evaluated pain during turning/postural changes in 201 observations performed in 56 patients. Data collection was made 1 minute before, during, and 10 minutes after the procedure using the COPT scale that includes four indicators: facial expression, body movements, muscle tension and adaptation to the ventilator. In the same way, the physiological variables were recorded: mean arterial pressure, heart rate, respiratory rate and arterial oxygen saturation. RESULTS: Total mean score of the CPOT scale before the procedure of turning was 0.30, during it 2.06 and after the procedure 0.15 with statistically significant differences. Facial expression was the indicator that increased the greatest in relationship with the baseline condition, since it occurred in 55% of the observations body movements increased in more than 40%; adaptation to the ventilator, occurred in 33% and muscular tension had an increase of 22% of the observations. There were also slight variations in the physiological variables during the postural change regarding baseline with statistically significant differences. Total mean score of the CPOT scale during turning of the surgical patients was higher than medical patients (p = 0.018). Patients received analgesia/sedation one hour prior to the procedure in 99.5% of the observation and additional analgesia for the postural change was only administered in 13% of the observations. CONCLUSIONS: Observation of the patient's behavior during posture change and the physiological changes produced allows the professionals to objectify the pain in the critical patients who can verbal communication problems.

[Effect of the do-not-resuscitate orders on the critical patient care plan]. / El efecto de la orden de no reanimación cardiopulmonar en el plan de atención al paciente crítico.

BACKGROUND: Do-not-resuscitate (DNR) orders are physician orders that refer to not initiating cardiopulmonary resuscitation in a patient who is in cardiac or respiratory arrest. However, these orders often imply other treatment modifications. AIMS: To analyze the effect that do-not-resuscitate orders have on the care plan of the critically ill patient; and to analyze if differences exist in the nursing workload (NEMS), before and after DNR prescription. METHOD: This descriptive study analyzed the care plan of 50 critically ill adult patients, before and after an electronic DNR order. RESULTS: After the DNR order was written the following variations were found: treatment was withdrawn in 30 patients; initiated in 6; both withdrawn and initiated in 12 patients; and there were no changes in their treatment in 2 patients. Specific modifications were: respiratory support: invasive mechanical ventilation was withdrawn in 7 patients, and non-invasive ventilation in 3, and the FiO(2) of the ventilator was reduced in 15 patients on the day of death; circulatory support: in 10 patients vasoconstrictor drugs were withdrawn and in one patient this therapy was initiated; inotropic drugs were withdrawn in 3 patients and initiated in 2 patients; extrarenal depuration hemofiltration was withdrawn in 4 patients and initiated in 2. The NEMS scores decreased on the patients after the order was written (36.20-34.62; p = 0.03). CONCLUSIONS: Do-not-resuscitate orders have an effect on the care plan of the critically ill adult patient. Also, although the NEMS scores decrease after the order, the nursing workload remains the same due to an increase in the psychosocial intervention with patient and family.

El efecto de la orden de no reanimación cardiopulmonar en el plan de atención al paciente crítico / Effect of the do-not-resuscitate orders on the critical patient care plan

Introducción. La orden de no resucitación es una medida referida estrictamente a la no realización de maniobras de reanimación cardiopulmonar (RCP), sin embargo se observa que habitualmente implica modificaciones en el tratamiento. Objetivos. Analizar el efecto que tiene la orden de no RCP en el plan de atención al paciente crítico y analizar si existen diferencias en la carga de trabajo de enfermería (Nine Equivalents of Nursing Manpower Use Score [NEMS]) antes y después de la orden de no RCP. Método. Este estudio descriptivo analizó el plan de atención de 50 pacientes críticos antes y después de la orden electrónica de no RCP. Resultados. Las variaciones encontradas después de la firma de la orden de no RCP fueron la retirada de tratamientos en 30 pacientes, la instauración en 6, en 12 tanto se retiraron como se iniciaron tratamientos y en 2 no hubo cambios. Se encontraron modificaciones en el soporte ventilatorio, en la administración de fármacos vasoactivos y en la depuración extrarrenal. Soporte ventilatorio: a 7 pacientes se les retiró la ventilación invasiva, a 3 la ventilación no invasiva y a 15 se les disminuyó la fracción inspiratoria de oxígeno del respirador el día del exitus. Fármacos vasoactivos: en 10 pacientes se retiró el tratamiento vasoconstrictor y en uno se instauró, los inotrópicos se retiraron en 3 pacientes y se instauraron en 2. Depuración extrarrenal: en 4 pacientes se retiró y en 2 se inició. La puntuación NEMS disminuyó después de la orden (36,20-34,62; p = 0,030). Conclusiones. La orden de no RCP tiene un efecto en el plan de atención al paciente crítico. Por otro lado, aunque la puntuación NEMS disminuye ligeramente después de la firma, la carga de trabajo de enfermería se mantiene al incrementarse la atención psicosocial al paciente y a la familia

Background. Do-not-resuscitate (DNR) orders are physician orders that refer to not initiating cardiopulmonary resuscitation in a patient who is in cardiac or respiratory arrest. However, these orders often imply other treatment modifications. Aims. To analyze the effect that do-not-resuscitate orders have on the care plan of the critically ill patient; and to analyze if differences exist in the nursing workload (NEMS), before and after DNR prescription. Method. This descriptive study analyzed the care plan of 50 critically ill adult patients, before and after an electronic DNR order. Results. After the DNR order was written the following variations were found: treatment was withdrawn in 30 patients; initiated in 6; both withdrawn and initiated in 12 patients; and there were no changes in their treatment in 2 patients. Specific modifications were: respiratory support: invasive mechanical ventilation was withdrawn in 7 patients, and non-invasive ventilation in 3, and the FiO2 of the ventilator was reduced in 15 patients on the day of death; circulatory support: in 10 patients vasoconstrictor drugs were withdrawn and in one patient this therapy was initiated; inotropic drugs were withdrawn in 3 patients and initiated in 2 patients; extrarenal depuration hemofiltration was withdrawn in 4 patients and initiated in 2. The NEMS scores decreased on the patients after the order was written (36.20-34.62; p = 0.03). Conclusions. Do-not-resuscitate orders have an effect on the care plan of the critically ill adult patient. Also, although the NEMS scores decrease after the order, the nursing workload remains the same due to an increase in the psychosocial intervention with patient and family

Revisión de conocimientos para cuidar a pacientes con problemas cardiovasculares / Review of the knowledge on care of patients

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[Care to the end-stage patient: help and obstacles perceived by Intensive Care nurses]. / Cuidados del paciente al final de la vida: ayudas y obstáculos que perciben las enfermeras de Cuidados Intensivos.

BACKGROUND: The Intensive Care Unit (UCI) environment is not the most appropriate for the development of the end-of-life process, due to the fact that ICU is a hi-tech setting and its focus is on curing and giving life support, rather than delivering palliative care to patients. AIMS: To investigate supportive behaviours and obstacles, and the nurses' demographic characteristics. METHOD: A descriptive correlational design was used in five tertiary Spanish hospitals. A convenience sample included 151 critical care nurses. A self-administered anonymous questionnaire (Beckstrand and Kirchhoff, 2005) was used to investigate supportive behaviours and obstacles perceived by nurses providing end-of-life care, in a scale from 0 to 5 (O = not help/obstacle; 5 = main help/obstacle). Some demographic data of the sample were also collected. FINDINGS: Nurses mean age was 35 (min. 22-max. 57; SD = 7,6) and had an average of 9,2 (min. 1-max. 30; SD = 6,9) years of experience working in ICU. Physicians agreeing on direction of patient care was perceived as the most supportive item (x = 4.46); whereas ethics committee constantly involved in the unit as the least supportive one (x = 2.93). The main obstacle for nurses was patient having pain that is difficult to control or alleviate (x = 4.38), and nurses knowing poor prognosis before family was seen as the less important obstacle (x = 1.37) Statistically significant correlations were found between nurses age and years of experience in ICU and their perception of some helps/obstacles. Statistically significant differences were found between nurses with postgraduate education in intensive care and those without it and their perception of some helps/obstacles. CONCLUSIONS: Intensive care nurses perceive adequate patients' pain management, agreement between health professionals on decision-making, and facilitating a comfortable environment for patients and families, during the whole end-of-life process as a priority.

Cuidados del paciente al final de la vida: ayudas y obstáculos que perciben las enfermeras de Cuidados Intensivos / Care to the end-stage patient: help and obstacles perceived by Intensive Care nurses

Introducción. La muerte es una realidad que con frecuencia ocurre en las Unidades de Cuidados Intensivos (UCI). El ambiente de la UCI por su alta tecnología, el enfoque de los cuidados, centrado en la curación y en medidas para salvar la vida, hacen que no sea el entorno más natural para que se dé el proceso del final de la vida. Actualmente, un objetivo de los profesionales que trabajan en estas Unidades es el de crear un clima que favorezca una «buena muerte». Objetivos. Los objetivos de esta investigación son: a) conocer las ayudas y obstáculos que perciben las enfermeras de Cuidados Intensivos en la atención del paciente al final de la vida y b) analizar si existe relación entre las ayudas y obstáculos percibidos por las enfermeras y las variables sociodemográficas. Método. Estudio descriptivo correlacional realizado en 5 hospitales terciarios de dos Comunidades Autónomas de España. La muestra de conveniencia estuvo formada por 151 enfermeras de Cuidados Intensivos. El cuestionario de Beckstrand y Kirchhoff de 2005, con 6 grados de respuesta (0 = no ayuda, no obstáculo; 5 = máxima ayuda, máximo obstáculo) se utilizó para conocer las ayudas y los obstáculos que perciben las enfermeras en la atención del paciente al final de la vida. Resultados. La edad media de las enfermeras fue de 35 años (mínimo 22 - máximo 57; DE = 7,6) con una experiencia en UCI de 9,2 años (mínimo 1-máximo 30; DE = 6,9). El ítem percibido como máxima ayuda para proporcionar un buen cuidado al paciente al final de la vida fue «que todos los médicos estén de acuerdo con el enfoque de los cuidados» (x­ = 4,46). La mínima ayuda corresponde al ítem «tener un miembro del comité de ética en los pases de visita diarios» (x­ = 2,93). El máximo obstáculo correspondió al ítem «que el paciente tenga dolor difícil de controlar» (x­ =4,38) y el mínimo, a «que la enfermera/o conozca el mal pronóstico del paciente antes de que lo sepa la familia» (x­ = 1,37). Al relacionar la edad y los años de experiencia en UCI con las variables de interés, ayudas y obstáculos, se han encontrado algunas correlaciones estadísticamente significativas. De igual modo, existen diferencias estadísticamente significativas entre las enfermeras que tienen formación postgrado y las que no la tienen con la percepción de ciertas ayudas y obstáculos. Con respecto al número de pacientes atendidos al final de la vida se han encontrado también diferencias estadísticamente significativas con algunas ayudas y obstáculos. Conclusiones. Las enfermeras perciben como prioritario el adecuado control del dolor, que entre el equipo médico haya unanimidad de criterios en la toma de decisiones y que se favorezca, tanto al paciente como a la familia, un entorno digno durante todo el proceso

Background. The Intensive Care Unit (UCI) environment is not the most appropriate for the development of the end-of-life process, due to the fact that ICU is a hi-tech setting and its focus is on curing and giving life support, rather than delivering palliative care to patients. Aims. To investigate supportive behaviours and obstacles, and the nurses' demographic characteristics. Method. A descriptive correlational design was used in five tertiary Spanish hospitals. A convenience sample included 151 critical care nurses. A self-administered anonymous questionnaire (Beckstrand & Kirchhoff, 2005) was used to investigate supportive behaviours and obstacles perceived by nurses providing end-of-life care, in a scale from 0 to 5 (O = not help/obstacle; 5 = main help/obstacle). Some demographic data of the sample were also collected. Findings. Nurses mean age was 35 (min. 22-max. 57; SD = 7,6) and had an average of 9,2 (min. 1-max. 30; SD = 6,9) years of experience working in ICU. Physicians agreeing on direction of patient care was perceived as the most supportive item (x­ = 4.46); whereas ethics committee constanly involved in the unit as the least supportive one (x­ = 2.93). The main obstacle for nurses was patient having pain that is difficult to control or alleviate (x­ = 4.38), and nurses knowing poor prognosis before family was seen as the less important obstacle (x­ = 1.37) Statistically significant correlations were found between nurses age and years of experience in ICU and their perception of some helps/obstacles. Statistically significant diferences were found between nurses with postgraduate education in intensive care and those without it and their perception of some helps/obstacles. Conclusions. Intensive care nurses perceive adequate patients' pain management, agreement between health professionals on decision-making, and facilitating a comfortable environment for patients and families, during the whole end-of-life process as a priority

Revisión de conocimientos para cuidar a pacientes con sepsis severa / Application for membership to the scociety

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Revisión de conocimientos para cuidar a pacientes con sepsis severa / Review of knowledge to care for patients with severe sepsis

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