Where do you insert a drain tube during breast reconstruction?

PURPOSE: A drain tube is commonly inserted during breast reconstruction surgery. This leads to a scar in addition to the scar on the breast. This study was performed to investigate how patients feel about the drain scar and to clarify its ideal location. METHODS: A questionnaire survey about the drain scar was distributed to 38 consecutive breast reconstruction patients and a total of 104 female doctors and nurses engaged in breast reconstruction. The drain scars were evaluated using the Japan Scar Workshop (JSW) Scar Scale. RESULTS: A total of 32% of the patients expressed some anxiety about the drain scar. Patients who were anxious about the drain scar had higher scores on the JSW Scar Scale than those who were not anxious. Younger doctors and nurses preferred the drain scar to be on the side of the chest, while older doctors and nurses preferred the drain scars to be at the axilla. CONCLUSIONS: About a third of the patients had some anxiety associated with their drain scar after breast reconstruction surgery, and this anxiety level was correlated with objective assessment of the scar. Thus, more patient involvement or the provision of more information regarding drain placement is required.

Validation of the behavioral pain scale to assess pain intensity in adult, intubated postcardiac surgery patients: A cohort observational study - POL-BPS.

Patients after cardiac surgery experience significant pain, but cannot communicate effectively due to opioid analgesia and sedation. Identification of pain with validated behavioral observation tool in patients with limited abilities to self-report pain improves quality of care and prevents suffering. Aim of this study was to validate Polish version of behavioral pain scale (BPS) in intubated, mechanically ventilated patients sedated with dexmedetomidine and morphine after cardiac surgery.Prospective observational cohort study included postoperative cardiac surgery patients, both sedated with dexmedetomidine and unsedated, observed at rest, during a nociceptive procedure (position change) and 10 minutes after intervention. Pain control was achieved using morphine infusion and nonopioid coanalgesia. Pain intensity evaluation included self-report by patient using numeric rating scale (NRS) and BPS assessments carried out by 2 blinded observers.A total of 708 assessments were performed in 59 patients (mean age 68 years), predominantly men (44/59, 75%). Results showed very good interrater correlation between raters (interrater correlation scores >0.87). Self-report NRS scores were obtained from all patients. Correlation between NRS and BPS was relatively strong during nociceptive procedures in all patients for rater A and rater B (Spearman R > 0.65, P < .001). Both mean NRS and BPS scores were significantly higher during nociceptive procedures as compared to assessments at rest, in both sedated and unsedated patients (P < .001).The results of this observational study show that the Polish translation of BPS can be regarded as a useful and validated tool for pain assessment in adult intubated patients. This instrument can be used in both unsedated and sedated cardiac surgery patients with limited communication abilities.

The Use of Life-Sustaining Procedures in the Last Month of Life Is Associated With More Depressive Symptoms in Surviving Spouses.

CONTEXT: Family caregivers of individuals with serious illness who undergo intensive life-sustaining medical procedures at the end of life may be at risk of negative consequences including depression. OBJECTIVES: The objective of this study was to determine the association between patients' use of life-sustaining procedures at the end of life and depressive symptoms in their surviving spouses. METHODS: We used data from the Health and Retirement Study, a longitudinal survey of U.S. residents, linked to Medicare claims data. We included married Medicare beneficiaries aged 65 years and older who died between 2000 and 2011 (n = 1258) and their surviving spouses. The use of life-sustaining procedures (i.e., intubation/mechanical ventilation, tracheostomy, gastrostomy tube insertion, enteral/parenteral nutrition, and cardiopulmonary resuscitation) in the last month of life was measured via claims data. Using propensity score matching, we compared change in depressive symptoms of surviving spouses. RESULTS: Eighteen percent of decedents underwent one or more life-sustaining procedures in the last month of life. Those whose spouses underwent life-sustaining procedures had a 0.32-point increase in depressive symptoms after death (scale range = 0-8) and a greater likelihood of clinically significant depression (odds ratio = 1.51) compared with a matched sample of spouses of those who did not have procedures (P < 0.05). CONCLUSION: Surviving spouses of those who undergo intensive life-sustaining procedures at the end of life experience a greater magnitude of increase in depressive symptoms than those whose spouses do not undergo such procedures. Further study of the circumstances and decision making surrounding these procedures is needed to understand their relationship with survivors' negative mental health consequences and how best to provide appropriate support.

Preferences for resuscitation and intubation among patients with do-not-resuscitate/do-not-intubate orders.

OBJECTIVE: To determine the accuracy of do-not-resuscitate/do-not-intubate (DNR/DNI) orders in representing patient preferences regarding cardiopulmonary resuscitation (CPR) and intubation. PATIENTS AND METHODS: We conducted a prospective survey study of patients with documented DNR/DNI code status at an urban academic tertiary care center that serves approximately 250,000 patients per year. From October 1, 2010, to October 1, 2011, research staff enrolled a convenience sample of patients from the inpatient medical service, providing them with a series of emergency scenarios for which they related their treatment preference. We used the Kendall τ rank correlation coefficient to examine correlation between degree of illness reversibility and willingness to be resuscitated. Using bivariate statistical analysis and multivariate logistic regression analysis, we examined predictors of discrepancies between code status and patient preferences. Our main outcome measure was the percentage of patients with DNR/DNI orders wanting CPR and/or intubation in each scenario. We hypothesized that patients with DNR/DNI orders would frequently want CPR and/or intubation. RESULTS: We enrolled 100 patients (mean ± SD age, 78 ± 13.7 years). A total of 58% (95% CI, 48%-67%) wanted intubation for angioedema, 28% (95% CI, 20%-3.07%) wanted intubation for severe pneumonia, and 20% (95% CI, 13%-29%) wanted a trial resuscitation for cardiac arrest. The desire for intubation decreased as potential reversibility of the acute disease process decreased (Kendall τ correlation coefficient, 0.45; P<.0002). CONCLUSION: Most patients with DNR/DNI orders want CPR and/or intubation in hypothetical clinical scenarios, directly conflicting with their documented DNR/DNI status. Further research is needed to better understand the discrepancy and limitations of DNR/DNI orders.

A nurse's experience being intubated and receiving mechanical ventilation.

A nurse with a history of childhood asthma describes her experiences with intubation and mechanical ventilation. It is important for nurses to recognize that mechanical ventilation is very stressful for patients and for the patients' families. It is essential for nurses to keep the patient as the focus of their care. A key part of that focus is to reorient patients who are receiving mechanical ventilation frequently.

Medical staff attitudes toward family presence during pediatric procedures.

OBJECTIVE: Investigate health care providers' perceived advantages and disadvantages of family member presence (FMP) for a wide spectrum of procedures in the pediatric emergency department. SETTING: Urban tertiary care children's hospital. PARTICIPANTS: Pediatric emergency department faculty and nurses, pediatric residents. METHODS: In a written survey, participants rated approval of FMP for 9 procedures: intravenous (IV) placement, urinary catheterization, suturing, lumbar puncture, fracture reduction, chest tube placement, endotracheal intubation, medical resuscitation, and trauma resuscitation. Respondents listed advantages and disadvantages of FMP for patients, families, and staff. RESULTS: 71% (104/146) of the surveys were completed. Attending physicians and nurses provided similarly high approval rating for less invasive procedures, with a decrement in approval for more invasive or life-threatening situations. Attending physicians and nurses were more likely than residents to approve FMP for all procedures except IV placement, suturing, and urinary catheterization, which had similar approval rates for all respondents. Commonly expressed potential advantages were ability to calm the patient, decreased parental "helplessness," and increased parental knowledge that everything was done. Disadvantages included higher anxiety in room, disturbing parental memories, and detriment to success of the procedure. Medical-legal concerns, mistrust of providers, and more difficult teaching environment were uncommonly listed as disadvantages. CONCLUSIONS: Emergency department staff support FMP for minor procedures, yet express concern regarding the effects of this practice on the family and the success of the procedure. Most attending physicians and nurses support FMP during highly invasive procedures and resuscitations, whereas residents do not. This information provides insight into the educational and systematic requirements of implementation of FMP.

Family presence during invasive procedures in the pediatric intensive care unit: a prospective study.

OBJECTIVES: To determine if allowing 1 or both parents to be present during invasive procedures reduces the anxiety that parents experience while their child is in the pediatric intensive care unit; to evaluate if the parent's presence was helpful to the child and parent; and to determine whether this presence was harmful to the nurses or physicians. DESIGN: A prospective study using surveys (5-point Likert scale) of parents of children requiring intubation, placement of central lines, or chest tubes. Additional surveys were completed by bedside nurses to evaluate the effects of parental presence. SETTING: A 12-bed pediatric intensive care unit in upstate New York. PARTICIPANTS: The study population consisted of the parents of 16 children undergoing 1 or more procedures; 7 had undergone intubation, 11 had central lines placed, and 2 had chest tubes placed. The control population consisted of the parents of 7 children undergoing 1 or more procedures; 7 had undergone intubation, 5 had central lines placed, and 3 had chest tubes placed. RESULTS: Parental presence significantly reduced the parental anxiety related to the procedure (P = .005; Mann-Whitney test), but did not change condition-related anxiety (P = 0.9; Mann-Whitney test). Thirteen of 16 parents found their presence helpful to themselves (10 very, 3 somewhat) and the medical staff (11 very); 14 of 16 found their presence helpful to their child (11 very). Fifteen (94%) of 16 parents would repeat their choice to watch. Fifteen (94%) of 16 nurses found parents' presence helpful to the child (9 very) and to the parents (10 very). One nurse found a parent's presence somewhat harmful to nurses and very harmful to the parent. Thirteen (72%) of 18 nurses indicated that allowing parents to observe procedures was an appropriate policy. There were no significant differences noted in response of nurses based on years of experience. CONCLUSIONS: Allowing parental presence during procedures decreases procedure-related anxiety. The implications of such a policy change on physicians and other aspects of pediatric intensive care, including medical education, need further evaluation.

Factors affecting patient tolerance of upper gastrointestinal endoscopy.

Doctors are optimistic in their perception of how acceptable endoscopy is for patients. We analyzed elements that contribute to a poor experience for the patient and the agreement between the perceptions of endoscopists and patients. Eighty-four out-patients who had undergone gastroscopy completed questionnaires (response rate of 73%) 48 to 96 hours after the procedure. The endoscopist completed a similar questionnaire. Questions concerned overall tolerance, swallowing, retching and vomiting, sedation, duration, diagnosis, age, and sex. Data from both doctor and patient were available in 84 cases. The type of sedation, administration of hyoscine or Xylocaine (Astra Pharmaceuticals Ltd., Kings Langley, UK), diagnosis, and expression of need for more sedation were not statistically significantly related to the overall patient score. The largest contribution to a poor overall tolerance score arose from difficulty in swallowing the endoscope, followed by the duration of the procedure. A total of 8.3% of patients reported some overall difficulty which was not recognized by the endoscopist. In relation to retching and vomiting, 11.9% of patients had difficulty with retching and vomiting, which went unrecognized by the doctor, and 18% had difficulty in swallowing the endoscope. There was fair agreement between the assessments of overall acceptability of both endoscopists and patients. Difficulty in intubation, however, is the major contributor to a poor tolerance of gastroscopy and also the issue on which doctors and patients disagreed the most.

[Communication with intubated patients].

For critically ill patients on assisted respiration caring behavior is particularly important. In this paper we review the literature on patient satisfaction with medical care and with their communication with the nursing staff. Communication skills of staff of intensive respiratory care units were studied by direct observation, debriefing of hospitalized patients and by interview of discharged patients. Direct observation showed that nurses spent only a small proportion of their time talking to patients. The interactions dealt with technical rather than emotional matters and consisted mostly of negative and discouraging comments rather than positive and supporting messages. Debriefing of hospitalized intubated patients revealed a high degree of overall satisfaction with care on the one hand, and complaints of communication problems, anxiety and anger on the other. Lastly, interviews with discharged patients revealed that as many as a quarter of those who could remember their hospitalization reported feelings of anxiety, anger, distrust in the staff and difficulty in communication. These findings suggest that the nursing staff needs improved communication skills. There is evidence that the judicious use of communication techniques may improve patient satisfaction, reduce anxiety and reduce duration of treatment.

A comparison of the stressors experienced by parents of intubated and non-intubated children.

When children are ill enough to require admission to paediatric intensive care, parents may become distressed about their child's medical condition and this distress may be compounded by the unfamiliar nature of the highly technological environment. Parents of children who are sick enough to warrant intubation are particularly likely to be exposed to a frightening array of technological equipment. Seventy-one parents of intubated and non-intubated children completed the Parental Stressor Scale: Paediatric Intensive Care Unit (PSS:PICU). Overall the findings suggest that parents were most distressed (a) by the painful procedures to which their children were subjected, (b) by the sights and sounds of the intensive care unit and (c) by their children's reactions to intensive care. The behaviour of staff towards parents and the way that staff communicated with them caused the least distress. When the levels of stress reported by parents of intubated children were compared with those reported by parents of non-intubated children, different patterns of stress were found. Painful procedures were a source of greater stress to parents of intubated children whereas the behaviour of staff and the children's reactions to the intensive care experience caused greater stress to the parents of the non-intubated children. In general the findings suggest that the needs of parents of non-intubated children are being overlooked, with staff focusing more of their attention on the parents of intubated children.

Nurse-patient interaction in the intensive care unit.

Patients in the ICU, especially those who are unable to communicate verbally, need sensitive and individualized communication to prevent feelings of isolation and alienation and to promote continued socialization throughout their hospitalization and return to the community. The results of this study indicate that the quality and effect of the interactions between nurses and intubated patients in the ICU require further study to delineate the factors that contribute to the effective or ineffective communication. We believe that the Categories of Nurse-Patient Interaction that was developed for this study is useful and practical measure of nurse-patient interaction in the ICU.