Barriers and facilitators to children's use of speech-generating devices: a descriptive qualitative study of mothers' perspectives.

PURPOSE: The purpose of this study was to identify barriers and facilitators to children's use of speech-generating devices (SGD). DESIGN AND METHODS: Interviews with 14 mothers were analyzed with content analysis to identify barriers and facilitators to SGD use. RESULTS: This study identified a number of specific barriers and facilitators to successful and sustained SGD use by children with complex communication disorders. PRACTICE IMPLICATIONS: Nurses can use the list of barriers and facilitators provided here as a springboard to discuss the families' experiences with device use.

Psychometric evaluation of the ostomy complication severity index.

PURPOSE: The purpose of this study was to evaluate the psychometric properties of a new instrument to measure incidence and severity of ostomy complications early in the postoperative period. SUBJECTS AND SETTINGS: 71 participants were enrolled, most were men (52%), white (96%), and married or partnered (55%). The mean age of participants was 57 ± 15.09 years (mean ± SD). Fifty-two participants (84%) experienced at least 1 ostomy complication in the 60-day postoperative period. The research setting was 3 acute care settings within a large healthcare system in the Midwestern United States. INSTRUMENT: We developed an evidence-based conceptual model to guide development and evaluation of a new instrument, the Pittman Ostomy Complication Severity Index (OCSI). The OCSI format includes Likert-like scale with 9 individual items scored 0 to 3 and a total score computed by summing the individual items. Higher scores indicate more severe ostomy complications. METHOD: This study consisted of 2 phases: (1) an expert review, conducted to establish content validity; and (2) a prospective, longitudinal study design, to examine psychometric properties of the instrument. A convenience sample of 71 adult patients who underwent surgery to create a new fecal ostomy was recruited from 3 hospitals. Descriptive analyses, content validity indices, interrater reliability testing, and construct validity testing were employed. RESULTS: Common complications included leakage (60%), peristomal moisture-associated dermatitis (50%), stomal pain (42%), retraction (39%), and bleeding (32%). The OCSI demonstrated acceptable evidence of content validity index (CVI = 0.9) and interrater reliability for individual items (k = 0.71-1.0), as well as almost perfect agreement for total scores among raters (ICC = 0.991, P ≤ .001). Construct validity of the OCSI was supported by significant correlations among variables in the conceptual model (complications, risk factors, stoma care self-efficacy, and ostomy adjustment). CONCLUSION: OCSI demonstrated acceptable validity and reliability and can be used to assess incidence and severity of ostomy complications in the early postoperative period. We found the OCSI to be brief, easy-to-use, and clinically practical. It can be used to (a) identify priority areas for nursing intervention related to the ostomy, (b) determine appropriate interventions to prevent or treat complications, and (c) evaluate the effects of nursing interventions designed to improve outcomes for patients with ostomies.

Comparing bedside methods of determining placement of gastric tubes in children.

PURPOSE: The purpose of this study was to compare the accuracy and predictive validity of pH, bilirubin, and CO2 in identifying gastric tube placement errors in children. DESIGN AND METHODS: After the tube was inserted into 276 children, the CO2 monitor reading was obtained. Fluid was then aspirated to test pH and bilirubin. RESULTS: Lack of ability to obtain tube aspirate was the best predictor of NG/OG placement errors with a sensitivity of 34.9% and a positive predictive value of 66.7%. Measuring pH, bilirubin, and CO2 of tube aspirate was less helpful. PRACTICE IMPLICATIONS: Healthcare providers should suspect NG/OG tube misplacement when no fluid is aspirated.

Systematic review of health-related quality of life models.

BACKGROUND: A systematic literature review was conducted to (a) identify the most frequently used health-related quality of life (HRQOL) models and (b) critique those models. METHODS: Online search engines were queried using pre-determined inclusion and exclusion criteria. We reviewed titles, abstracts, and then full-text articles for their relevance to this review. Then the most commonly used models were identified, reviewed in tables, and critiqued using published criteria. RESULTS: Of 1,602 titles identified, 100 articles from 21 countries met the inclusion criteria. The most frequently used HRQOL models were: Wilson and Cleary (16%), Ferrans and colleagues (4%), or World Health Organization (WHO) (5%). Ferrans and colleagues' model was a revision of Wilson and Cleary's model and appeared to have the greatest potential to guide future HRQOL research and practice. CONCLUSIONS: Recommendations are for researchers to use one of the three common HRQOL models unless there are compelling and clearly delineated reasons for creating new models. Disease-specific models can be derived from one of the three commonly used HRQOL models. We recommend Ferrans and colleagues' model because they added individual and environmental characteristics to the popular Wilson and Cleary model to better explain HRQOL. Using a common HRQOL model across studies will promote a coherent body of evidence that will more quickly advance the science in the area of HRQOL.

Quality of communication: different patterns of reporting the location of the tip of a nasogastric tube.

PURPOSE: This investigation is part of a prospective National Institutes of Health-funded study evaluating three different methods for estimating the optimal length for placement of a new nasogastric (NG) tube. Abdomen radiographs were required to determine the location of the tube tip. Our objective was to analyze different methods by which the tube location was described in the radiology report of the abdominal radiographs, and the influence of the presence or absence of a relevant clinical history. METHODS: We reviewed the imaging reports obtained following placement of a new nasogastric tube in patients enrolled in the study. RESULTS: There were 188 studies. The x-ray report contained separate description and impression sections in 154. In 24 they were combined. When the history on the requisition indicated "tube placement" as the reason for the study, the location of the tube tip was given in the impression on 134/141 (95%). When the requisition failed to mention "tube placement" as the study indication, the impression only mentioned the tube tip location 4/13 (31%). The report provided a specific location for the tube tip in 115 of the 188 cases; in 73 of the 188 cases, the report stated that the tube tip "overlies/is in the region of" the stomach. On 29 occasions the report stated that the tube, not the tube tip, was in the stomach. CONCLUSIONS: There is variation in the manner of reporting the location of NG tube tips. When the requisition fails to indicate "tube placement" as the study indication, the report impression often fails to mention the tube location.

Comparing methods of determining insertion length for placing gastric tubes in children 1 month to 17 years of age.

PURPOSE: The purpose was to compare three methods of predicting the gastric tube insertion length in children 1 month to 17 years of age: age-related, height-based (ARHB); nose-ear-xiphoid (NEX); and nose-ear-mid-umbilicus (NEMU). DESIGN AND METHODS: The design was a randomized controlled trial. Children were randomly assigned to the ARHB, NEX, or NEMU groups. Tubes placed high were considered to be misplaced. RESULTS: There were significant differences in percentages of correctly placed tubes, with ARHB and NEMU being more accurate than NEX. PRACTICE IMPLICATIONS: NEX should no longer be used as a gastric tube insertion-length predictor. Either ARHB or NEMU should be used.

Predicting the insertion length for gastric tube placement in neonates.

OBJECTIVE: To compare error rates of three existing methods of predicting the gastric tube insertion length in a group of neonates <1 month corrected age: age-related, height-based (ARHB); direct distance nose-ear-xiphoid (NEX); and direct distance nose-ear-mid-umbilicus (NEMU). DESIGN: Randomized controlled trial. SETTING: Five neonatal care units in a large midwestern city. PARTICIPANTS: One hundred and seventy-three hospitalized neonates. METHODS: Neonates were randomly assigned to one of three groups: ARHB, NEX, or NEMU. For primary analysis, only tubes placed too high with the tube tip in the esophagus or at the gastroesophageal junction were considered to be misplaced. For secondary analysis, a stricter definition was used, and low placements (pylorus or duodenum) were also considered to be misplaced. All radiographs were blinded and read by a pediatric radiologist. RESULTS: For the primary analysis, the differences in percentages of correctly placed tubes among the three methods was statistically significant (χ(2) =34.45; p<.0001), with NEMU and ARHB more accurate than NEX (NEMU χ(2) =18.59, p<.0001; ARHB χ(2) =21.34, p<.0001). Using the stricter definition for placement, ARHB was not significantly different from NEX (p=.0615). A new ARHB equation was developed specific for neonates <1 month corrected age. CONCLUSIONS: Direct distance nose-ear-xiphoid should no longer be used as an nasogastric/orogastric (NG/OG) tube insertion-length predictor in neonates. Either NEMU for NG/OG tubes or the new ARHB equation for NG tubes should be used.

Accurate localization of the position of the tip of a naso/orogastric tube in children; where is the location of the gastro-esophageal junction?

BACKGROUND: Abdominal radiographs are used to determine the location of the tip of a newly placed nasogastric tube. The precise location of the gastroesophageal junction has not been well described in the radiology literature. OBJECTIVE: To improve interpretation of radiographs taken to evaluate the location of the tip of a nasogastric tube. Using UGI barium studies, we determined the anatomical location and variability of the position of the gastroesophageal (GE) junction and the pylorus MATERIALS AND METHODS: We reviewed 200 upper gastrointestinal barium studies (50 in each of 4 age groups). We measured the vertebral levels and distance of the gastroesophageal junction and the pylorus from the spine, the vertical distance of the gastroesophageal junction from the dome of the diaphragm and the distance from the gastroesophageal junction to the pylorus. RESULTS: There is a constant location of the GE junction with no significant variation between age groups. There is a moderately constant location of the pylorus. The other measurements were very variable. CONCLUSION: The location of the GE junction is very constant, irrespective of age. Tube tips below the level of the vertebral disc between the 11th and 12th thoracic vertebra and/or more than 16 mm from the left side of the spine lie in the stomach and not the lower esophagus. Our results should help in accurate radiographic description of the location of the tip of an NG tube.

Evidence-based practices of gastroenterology nurses.

Evidence-based practice (EBP) incorporates use of the best scientific knowledge, expert opinion, clinician experience, and patient preferences to facilitate the best patient outcomes in healthcare. Recent studies have suggested that nurses lack the skills and expertise to facilitate EBP in a meaningful way. This replication study (n = 225) investigated the EBPs of gastroenterology nurses in the United States. Findings generally support the previous studies that suggest nurses do not yet possess the skills or resources to implement EBP. Recommendations for addressing this deficit in the specialty of gastroenterology nursing are discussed.

Review of propofol and auxiliary medications used for sedation.

The sedative-hypnotic propofol (2,6-diisopropylphenol) is being increasingly used for sedation during painful diagnostic and therapeutic procedures in adults and children. The purpose of this article is to present a general overview of the use of propofol for endoscopic sedation. Advantages and disadvantages of using propofol for sedation, as well as its pharmacokinetics, preparation for use, dosing for endoscopic sedation, auxiliary sedative and analgesic medication options, methods of administering, adverse effects with interventions, recovery, and patient-physician satisfaction are discussed. Finally, next steps necessary to optimize future use of propofol are suggested.

Infant crying among recent African immigrants.

Studies in non-Western cultures have shown that infants cry very little, probably because they are carried constantly by caregivers. Western literature suggests that the bouts of persistent crying found in infants at least in part result from Western caregiving practices. This study was conducted to describe crying patterns of a small sample (n = 8) of infants born to recent African immigrants to the United States. Audio-recorded interviews were analyzed using content analysis and descriptive statistics. Some infant crying occurred but less than for typical Western babies. Mothers provided reasons why increased crying occurred. Nursing implications of the findings are discussed.

A literature review of the safety and efficacy of using propofol for sedation in endoscopy.

A 2007 survey of members of the Society of Gastroenterology Nurses and Associates identified a need for more evidence regarding sedation medications including propofol. Therefore, the Cochrane Database of Systematic Reviews, Cochrane Database of Randomized Clinical Trials, MEDLINE, CINAHL, EMBASE, and the National Guideline Clearinghouse (http://www.guideline.gov) databases were individually searched using the term propofol, limited to human, English, 2000-2009, review articles, and randomized clinical trials. A total of 46 resources contributed to this review, with emphasis on 16 studies ranging from retrospective chart reviews to double-blind, randomized controlled trials. Nonanesthesia personnel-administered propofol, including that administered by specially trained nurses under the supervision of an endoscopist, appears to be safe with minor, easily resolved, adverse events occurring in less than 1% of patients. These minor adverse events included four studies reporting hypoxemia requiring occasional intervention, three studies reporting hypotension, and two studies reporting bradycardia. No patients required tracheal intubation, and no deaths were reported.

Out of the abyss of colic: a view through the fathers' eyes.

PURPOSE: To elucidate the experience of fathers living with a colicky infant. STUDY DESIGN AND METHODS: Interpretive phenomenology using in-depth interviews with 10 fathers of colicky infants. Reiterative interview reading, repeated meaning unit sorting, going back to the literature, and discussions gave way to emerging themes. FINDINGS: The overall experience is one of "falling into and arising from the crying abyss together as a family." Four themes emerged: (a) falling in, (b) hitting bottom, (c) weaving strands to make a rope, and (d) climbing out. CLINICAL IMPLICATIONS: From their stories, fathers provide insight useful to nurses assisting families of colicky infants through a very difficult time. Nurses should talk to fathers directly about the possibility of colic, and teach both parents what it is, how long it usually lasts, and what can be done about it. Anticipatory guidance as well as discussion about colic during newborn health visits can help parents to vocalize their feelings, and learn what actions to take when the stress of colic becomes overwhelming.

The use of carbon dioxide monitoring to determine orogastric tube placement in premature infants: a pilot study.

Enteral nutrition, frequently given through gastric tubes inserted through the nose or mouth, is an important part of supportive care for children unable to maintain adequate nutrition orally. To provide safe enteral nutrition, however, correct tube position must be achieved. Capnography, a noninvasive monitoring technique designed to measure expired carbon dioxide (CO2) levels, has been used previously to identify respiratory placement of nasogastric tubes in adults; however, its use in children is understudied. The purpose of this pilot study was to determine the potential of CO2 monitoring to differentiate respiratory from gastric placement of nasogastric/orogastric (NG/OG) tubes in the youngest, most fragile children-premature infants. Immediately prior to chest radiograph, CO2 levels in 7 premature infants were measured at the open ends of both the endotracheal and NG/OG tubes by using a bedside capnography monitor. The 14 CO2 readings from the correctly placed endotracheal tubes ranged from 32 to 61 mmHg (M = 47.6 mmHg, SD = 10.0). CO2 readings were zero in all 14 correctly placed NG/OG tubes. The results of this pilot study provide evidence that capnography may be useful in differentiating respiratory from gastrointestinal tube placement in premature infants.

Predicting internal distance to the stomach for positioning nasogastric and orogastric feeding tubes in children.

AIM: This paper is a report of a study to examine how well direct morphological distances commonly used for nasogastric or orogastric tube insertion and other methods perform as predictors of the internal distance to the targeted position for the tube pores in the stomach. BACKGROUND: Previous studies with very small samples have indicated that commonly used distances give malplacements, either above the oesophagogastric junction or below the body of the stomach, perhaps as much as 33% of the time. METHODS: We compared the predicted distances to the endoscopic and manometric distances to the oesophagogastric junction and to the body of the stomach in a prospective study of 494 children, 2 weeks to 19 years (231 months) of age. Data were collected from 1991 to 1998 and in 2005. RESULTS: The nose-ear-xiphoid distance commonly used in nursing, and other morphological distances, often gave estimates that were either shorter than that to the oesophagogastric junction or longer than that to the distal margin of the body of the stomach. Age-specific methods for predicting the distance to the body of the stomach based on height gave highly accurate predictions of the internal distances. CONCLUSION: Age-specific methods have the potential to predict accurately the distances to the body of the stomach in 98.8% of children from 0.5 to 100 months of age and in 96.5% of children over 100 months of age. Where age-specific prediction methods cannot be used, the next best choice is the nose or mouth to ear-mid-xiphoid-umbilicus span.

Measuring nausea and vomiting in adolescents: a feasibility study.

Several instruments have been developed over the years to assess nausea and vomiting in adults, yet their validity and reliability with children are unknown. It would be useful to have an instrument simple enough for use with the vast majority of children (regardless of age and developmental level) to provide a consistent way to measure nausea and vomiting throughout the pediatric population. The purpose of this study was to test the feasibility of using one or more adult instruments with adolescents. A feasibility study was conducted using three existing instruments designed to measure nausea and vomiting. A convenience sample of 10 adolescents between the ages of 13 and 18 years receiving chemotherapy was recruited at a Midwestern children's hospital oncology unit. The adolescents were assessed using instruments starting before and continuing after one individual round of chemotherapy. A qualitative analysis demonstrated significant problems in implementing all three instruments with adolescents. Future research should concentrate on original instrument development based on qualitative studies that seek to understand the unique experience of a child with cancer.

Examination of the effect of Dr. Brown's Natural Flow Baby Bottles on infant colic.

Thirty-six parents of colicky infants participated in this randomized, placebo-controlled clinical trial conducted via the Internet. Parents recorded a baseline state-of-arousal diary for 3 days using their usual feeding methods, and then they used six study-provided bottles for 2 weeks while recording a second state-of-arousal diary. Infants being fed with placebo bottles significantly spent more time crying (rho=.010) and fussing (rho=.002) on average than infants using Dr. Brown's Natural Flow Baby Bottles. Because these bottles decreased the time the infants spent crying and fussing, use of these bottles may be recommended for colicky infants who receive any bottle feedings.

Important facts about intestinal feeding tube placement.

Enteral feeding is desirable when the gastrointestinal tract is functional because it allows better use of nutrients, is safer, and is more cost-effective than parenteral nutrition. Feeding through a gastric tube, however, is often not feasible in severely ill adults and children because of gastric paresis leading to recurrent episodes of gastroesophageal reflux with the risk of subsequent aspiration. Feeding into the small intestine (duodenum or jejunum) through a nasointestinal tube, therefore, is preferred. Unfortunately, no method of enteral feeding is risk free. This literature review addresses the following 10 topics: (a) the reasons why nasointestinal tube feeding is better tolerated by some patients, (b) candidates for nasointestinal tube feeding, (c) options for selecting nasointestinal tubes, (d) recommended methods for predicting the distance to insert nasointestinal tubes, (e) recommended methods for placing nasointestinal tubes, (f) how promotility medications work and whether they facilitate nasointestinal tube placement, (g) nasointestinal tube placement error rate, (h) methods of determining the internal location of nasointestinal tubes, (i) complications associated with nasointestinal tube use, and (j) other pertinent issues surrounding feeding through nasointestinal tubes. The available research evidence is summarized and recommendations for future work are suggested.

Gastric tube placement in young children.

In this study, the internal position of a nasogastric/orogastric tube was determined in 72 children, prior to an abdominal radiograph, by measuring CO2 and pH and bilirubin of tube aspirate. Fifteen of the 72 tubes (20.8%) were incorrectly placed on radiograph. Using the suggested adult cutoff of pH 5, pH of aspirate correctly predicted misplacement outside the stomach in 7/28 (25%) of children and correctly predicted correct placement in the stomach in 34 of 40 children (85%). Using the suggested adult cutoff of bilirubin > or = 5 mg/dL, bilirubin monitoring failed to identify either of two incorrectly placed tubes. In this study, using an algorithm of assuming stomach placement if the pH of aspirate is < or = 5 and obtaining an abdominal radiograph when either no aspirate is obtained or the pH is >5 would have resulted in 92% accuracy. Alternatively, obtaining an abdominal radiograph would result in nearly 100% accuracy.

Parental perceptions of the lasting effects of infant colic.

PURPOSE: To describe the experience of families with previously colicky infants. STUDY DESIGN: This qualitative, descriptive study explored parents' perspectives of the lasting effects of infant colic on their children's development and on their family relationships. METHODS: Through in-depth interviews, the parents had the opportunity to share what they remembered most about this experience. Participants volunteered by accessing the Infant Colic Study Web site advertised on numerous search engines. Forty-four participants, all of whom had an infant with colic at some time in the past, answered open-ended questions regarding their feelings about the colicky period and how their children developed later. Data were analyzed from a phenomenologic perspective. RESULTS: The majority of participants reported no later problems in their previously colicky children. Some did believe, however, that family relationships had been affected by the colic experience, and that communication and support had been impaired. Most described feelings about the colic experience that were negative. CLINICAL IMPLICATIONS: Continued support needs to be provided to families of colicky infants throughout their growth and development at a primary care level. Nurses need to recognize that the experience of infant colic may have residual effects on the entire family unit. These families need to be provided with the support and resources to enable them to successfully care for their children and to engage in nurturing relationships.