[Resuscitative Endovascular Balloon Occlusion of the Aorta: Implementation and Nursing Care].

Uncontrolled hemorrhagic shock is the main cause of death in patients with traumatic injuries. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a rapidly performed and less-invasive treatment to stop bleeding. The REBOA balloon may be placed at the location of bleeding to achieve hemostasis. Prior to balloon placement, the indications for placement must be evaluated, including non-thoracic aortic trauma and non-traumatic patients with postpartum hemorrhage, and the appropriate sheath size (from 5 to 8 French) must be selected based on the bleeding site. As vascular injury of aortic dissection, rupture, or perforation may occur during the procedure, changes in hemodynamic parameters should be monitored. After balloon placement, ischemic complications due to blood flow occlusion such as lower extremity ischemia and acute renal failure should be tracked. After balloon removal, reperfusion injuries may occur, which can result in multiple organ failure, and should be observed closely. When caring for patients receiving REBOA, physicians should explain the procedure to their families to obtain informed consent. Also, nurses should prepare supplies and closely monitor changes in critical life signs to minimize the risks of hypotension, arrhythmia, and changes in consciousness during the procedure. After placement, the neurovascular and peripheral limbs "5P" (pain, pallor, paresthesia, pulselessness and paralysis) condition should be evaluated and recorded in detail. This treatment approach requires further study and research to assess the long-term impacts of placement and improve quality of care in these patients.

[Project to Reduce Cases of Drug-Resistant Strain Colonization in the Intensive Care Unit Using a Chlorhexidine Gluconate Bath].

BACKGROUND: Drug-resistant strains of bacteria are associated with severe consequences such as bacteremia, shock, and death, and increase hospital stay durations and medical health expenses. Therefore, reducing the spread of drug-resistant strains is a priority concern. PURPOSE: This project was developed to reduce the number of colonization cases of drug-resistant strains and subsequently increase the quality of care provided in our intensive care unit. RESOLUTIONS: In this project, a chlorhexidine gluconate (CHG) bath standard protocol and CHG bath skill checklist were established, education and training courses were planned, a regular bed curtain replacement schedule and sink cleaning protocols were implemented, and regular audits were conducted. RESULTS: Immediately following project implementation (October - December 2018), the average monthly cases of Vancomycin-resistant enterococci colonization decreased from 6.08 to 4.33, and the average monthly cases of multi-drug resistant Acinebacter baumannii colonization decreased from 4.08 to 1.33. Furthermore, between January and July 2019, the average monthly cases of colonization for the abovementioned bacteria numbered 4 and 0.86, respectively, which met the level of reduction targeted in this project. CONCLUSIONS: The results of this project indicate that implementing CHG bed baths is effective in reducing the incidence of drug resistant strain colonization and rate of related infections in patients. CHG bed baths should be applied clinically to improve the quality of intensive care.

[Prone Position and Nursing Care].

Acute respiratory distress syndrome (ARDS) is a life-threatening disease, as acute inflammation in the lungs typically leads to hypoxia and symptoms of dyspnea. The treatment modalities of ARDS include mechanical ventilation, corticosteroid, extracorporeal membranous oxygenation, inhaled nitrogen oxide, and the prone position. Among these, the prone position is supported by evidence showing significantly reduced mortality in patients that adopt this modality. Lying in the prone position reduces atelectatic lung volumes by recruitment of dependent parts and facilitates normal regulation of alveolar ventilation, giving better-matched ventilation perfusion and, thus, improved oxygenation. Lying in the prone position should be initiated as early as possible and may be implemented when there is limited improvement after 12-24 hours under mechanical ventilation and when the PaO2/FiO2 ratio is less than 150 mmHg. However, the prone position may not be appropriate for patients with increased intracranial pressure, hemodynamic instability, an open abdominal wound, or pregnancy. Prior to setting a patient in the prone position, fixation of tubings should be affirmed, and all tubings should be reexamined after each adjustment in position in order to ensure that they are free of twists and function well. In addition, caution should be given to the skin at pressure points to avoid pressure sores and foam dressings may be applied in advance for protection. This article summarizes the pathophysiology of ARDS, the principle of applying the prone position, and related indications, complications, and nursing care in order to give nurses more confidence in caring for patients using the prone position.

[New Treatment for Vascular Thrombosis Prevention in Patients With Atrial Fibrillation: Left Atrial Appendage Occlusion].

Atrial fibrillation (AF) is a common type of arrhythmia that increases significantly the risk of blood clots in the heart and of stroke. Therefore, stroke prevention is a key goal of AF treatment. In the past, patients were required to take anticoagulants for the remainder of their life, to regularly the monitor international normalized ratio (INR) of prothrombin time (PT), and to avoid possible negative interactions with various drugs and foods. Left atrial appendage occlusion (LAAO), a novel device and technique, was thus developed for AF patients with contraindications to anticoagulants and a high risk of bleeding. When using this technique, the occluder is placed on the left atrial appendage in order to effectively prevent blood stasis and thrombi accumulation. Transesophageal echocardiogram and computed tomography are conducted prior to the LAAO procedure, which is similar to the procedure used for cardiac catheterization. After the LAAO procedure, the patient remains in the intensive care unit (ICU), where vital signs, bleeding at the puncture site, and pericardial tamponade complications are monitored. Health education on daily activities, anticoagulant use, and regular follow-up should be given prior to hospital discharge. While LAAO may not reduce the incidence of stroke, the benefits of this procedure include a significant reduction in bleeding complications as compared to procedures that use oral anticoagulants. Further studies including long-term follow up and in-depth examinations of this procedure are necessary. The present article offers a reference for clinical staffs who are responsible for the care of patients treated using the LAAO procedure.

[Introduction of Hemodynamic Monitoring in Critical Care Units].

Hemodynamic monitoring is a very important treatment in intensive care units. Measurements taken during monitoring include pulmonary artery catheter (PAC), pulse-induced contour output (PiCCO), and non-invasive hemodynamic monitoring. PAC measures cardiopulmonary parameters using the thermodilution principle. PiCCO uses transpulmonary thermodilution and pulse contour analysis to measure cardiopulmonary parameters and extra-vascular lung water, to predict lung edema, and to differentiate between cardiogenic and non-cardiogenic respiratory failure. Non-invasive hemodynamic monitoring uses the thoracic electrical bioimpedance principle to measure electrical conductivity and then calculates stroke volume and cardiopulmonary parameters using the arrangement of red blood cells. The author is a nurse in an intensive care unit who is familiar with the various methods used in hemodynamic monitoring, with preparing the related devices, with briefing patients and family members prior to procedures, with related aseptic skills, with preventing complications during the insertion procedure, and with analyzing and interpreting those parameters accurately. The issues addressed in this paper are provided as a reference for nurses and other medical personnel to choose appropriate treatments when caring for critical patients.

[Transcatheter Aortic Valve Implantation: An Introduction and Patient Care].

Aortic stenosis has a high prevalence among individuals over 75 years of age. Transcatheter aortic valve implantation (TAVI) is a novel valve-replacement technique for patients with multiple chronic diseases who are at high risk of requiring aortic valve replacement surgery. Most of the time, the indicators of TAVI are detected during an echocardiographic exam. The femoral artery is the primary insertion site. The complications of TAVI include stroke, vascular dissection, bleeding, aortic valve regurgitation, and arrhythmia. In terms of clinical effectiveness, the mortality rate of TAVI is lower than percutaneous ballon valvuloplasty but similar to AVR. The unplanned cardiac-related re-admission rate within 30 days of discharge is lower for TAVI than for AVR. In terms of activity tolerance, TAVI is significantly better than both percutaneous ballon valvuloplasty and AVR. Comprehensive nursing care may reduce the incidence of complications associated with TAVI. Nursing care of TAVI includes explaining and providing instructions regarding TAVI prior to the procedure. After the TAVI procedure and while the patient is in the ICU, remove the endotracheal tube as soon as possible, monitor his / her neuro-cognitive status, monitor for early detection of a stroke event, record urine output to assess renal function, observe bleeding in the puncture site, and evaluate cardiac arrhythmia and pain. While in the general ward, resume early physical activities and educate the patient regarding the risks and the prevention of bleeding. This article provides references for clinical staff responsible to care for post-TAVI surgery patients.

Effectiveness of a self-care program in improving symptom distress and quality of life in congestive heart failure patients: a preliminary study.

BACKGROUND: Prevalence of heart failure is increasing among older adults. Most heart failure patients experience distressing symptoms that lead to decreased physical functioning, poor quality of life, and a high incidence of rehospitalization. Health education about heart failure self-care (HFSC) is very important during hospitalization for these patients. However, lack of ongoing follow-up after discharge makes evaluation and disease management difficult. This is a significant problem in Taiwan. PURPOSE: This study was undertaken to determine if participants with heart failure who were managed under the HFSC program had fewer distressing symptoms, better functional status, improved quality of life, and reduced hospital and emergency readmission rates compared with control group participants. METHODS: This study used a quasi-experimental design with a control group that received usual care and an intervention group that received usual care plus the HFSC program. Twenty-seven participants were recruited from 2 cardiac general wards at 1 medical center in Taipei City, Taiwan, and were randomized into intervention (n = 14) and control (n = 13) groups. RESULTS: : After 3 months, there were significant differences in symptom distress (p < .01), 6-minute walk test results (p < .01), and quality of life (using Short Form 36, Taiwan version, p < .05) between the HFSC and control groups but no significant differences in hospital readmission and emergency department visits. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: The HFSC program for patients with heart failure improved their heart failure symptoms and resulted in increased functional status and better quality of life. HFSC is a workable program in the clinical environment. Advanced nurse practitioners can use HFSC methods and principles to provide improved education and follow-up to heart failure patients.

[Nursing experience with reducing delirium in a hospitalized elderly patient].

This article describes an experience of providing nursing care to an eighty year-old patient with urinary tract infection (UTI). The author cared for this patient in the role of clinical geriatric nurse specialist from May 11 to 23 in 2005. Through comprehensive assessment, careful review of medical records, contact with family and nursing home healthcare workers, it was determined that the patient's cognition and physical function declines were due to delirium resulting from the last time the patient had been hospitalized in the intensive care unit (ICU). In order to prevent incidents of delirium, three nursing goals were set: controlling infection, avoidance of delirium recurrence, and recovery of prior levels of physical function and self-care ability. Nursing interventions used included UTI control, tube and catheter removal as early as possible, control of environmental factors, and muscle strength and exercise training. After two weeks of care, the patient could take food orally and the nasogastric (NG) tube had been successfully removed. Physical function and self-care ability improved from "dependent" to "partial assistance". Although UTI was controlled, removal of the foley tube failed due to prostate hypertrophy. No delirious event occurred during hospitalization and cognitive functions improved. From this experience, early assessment and intervention should be conducted for high-risk elderly patients in order to prevent delirious events and declines in cognitive and physical functions. The author hopes this case report will prove a useful reference to nurses charged with caring for elderly patients at risk for delirium.