Visitation policies in the ICU: a time for change

The belief that visitation restrictions in the ICU are for the patient's good is not fully supported by research. However, there are no firm conclusions regarding how visitation decisions should be made. This paper suggests that decisional control over visitation be given to the patient and that, with the nurse functioning as a patient advocate, individualization of visitation be practiced. It is up to nursing to institute changes in visitation of the critical care patient.     

The post anesthesia care unit experience: a family-centered approach

The Post Anesthesia Care Unit (PACU) visitation program of Memorial Sloan-Kettering Cancer Center needed revision. The process was disorganized, visits were unescorted, and nurses and physicians were resistant. A committee was formed with the goal of developing a new unit philosophy and improving the overall process. Committee steps included reviewing the literature, educating staff about the benefits of visitation, empowering nurses to incorporate family visitation into patient care, and providing family education. As a result, staff attitudes changed, and nurses now contact the family within 90 minutes of the patient's arrival to the PACU to develop an individualized visitation plan. Morale is high, and nurses take pride in meeting the needs of patients and families.     

Promoting family-centered visitation makes a difference

Promoting parental and sibling visitation of the critically ill child can positively influence the resolution of a crisis when a child is admitted to the pediatric intensive care unit. There are many benefits as well as barriers to incorporating family-centered visitation into the plan of care. Understanding the needs, stressors, and coping styles of the entire family will help the nurse provide a positive experience when parents or siblings visit the critically ill child.     

Sleep deprivation in critical care units

Sleep deprivation is a significant problem for patients in critical care units. Sleep is a complex, active process that is divided into 4 stages of non-rapid eye movement (NREM) sleep, and rapid eye movement (REM) sleep. Noise, lights, discomfort, pain, medications, and stress all contribute to a patient's inability to sleep. Lack of knowledge about the sleep stages, nursing routines, and frequent nursing assessment and interventions also impact the critically ill patient's ability to sleep. Education about sleep deprivation needs to be integrated into critical care courses and orientation programs. Sleep deprivation should be addressed on the multidisciplinary care plan and in health team conference, and nursing care planned accordingly. Sleep medications and their effects should be evaluated for each patient, as well as identifying medications that might be preventing or disturbing sleep.     

Caring for people with carotid artery rupture

In the second of three articles, the authors discuss the care of people with carotid artery rupture. Carotid artery rupture is a potentially fatal condition that requires swift action on the part of the nurse who is present. The size of the rupture and the prognosis for the individual patient determines whether or not active resuscitation is undertaken. The multi-professional team should decide, in advance of an impending rupture, on the optimum plan of care. Calm, careful explanations should be given to patients and relatives and the decision regarding resuscitation should be recorded in the patient's notes. In the event of unforeseen circumstances where a rupture occurs, an active nursing care plan should be instituted and care taken to keep relatives well informed. The patient's airway should be kept clear through the use of suctioning, inflation of tracheostomy tube cuff and correct positioning. Sedative drugs and palliative care may subsequently be necessary. Support and help should be given to all who witness or are involved in the care of these patients.     

A family-centered critical care unit

Although care of the family has long been a focus of nursing, there has been an increased emphasis in recent years to provide opportunities for families to be an integral part of the hospitalization experience. This has been difficult for many nurses who perceive themselves as competent to care for a patient in "medical crisis" but feel unqualified to provide family care. This article will address issues related to implementing a family-centered philosophy of care in a critical care unit. Implementation strategies that will be discussed include: formulating a staff-led family support group and family committee, instituting a family visitation contract within open visitation parameters, and developing clinicians with expertise in family care. Tools such as a performance plan for a Clinical Nurse II specializing in family care and the family visitation contract will be shared.     

General principals of management: education

Asthma education is an essential part of the treatment of this disease. Health care professionals must establish a partnership with the patient with asthma and the patient's family to devise a plan of care with which the patient voluntarily will comply. The partnership with the patient begins at the first encounter and continues throughout the therapeutic relationship. Each member of the health care team can be instrumental in reinforcing the crucial information the patient must know to be an informed participant in his or her care. Nursing professionals are in a particularly advantageous position to foster this partnership because of their patient-focused outlook and the quality of time spent with patients. When the partnership is based on mutual trust and cooperation, the clinician can direct asthma care that is consistent with current expert guidelines. Educational interventions should be meaningful to the patient, learner centered to incorporate the patient's needs, and sensitive to the patient's cultural influences. The patient and his or her significant social and family support should be actively involved. The clinician should be alert to the patient's readiness to learn and tailor the message to suit the setting in which it is delivered. The patient should receive information that allows his or her participation in goal setting for treatment. Essentials to be included are the significance of the diagnosis, basics about inflammation as the primary cause of symptoms, the difference between controllers and relievers, how to use the medications and monitoring devices, how to reach the provider, and the need for continuous ongoing interaction with the clinician. Goals set in the partnership are objectified in the asthma action plan or guided self-management plan. The success of the treatment can be assessed from the patient's improved asthma control and reduced reliance on emergency treatment. Every health care provider is a potential wealth of patient education. Every patient encounter is an opportunity to reinforce knowledge and proficiency in asthma management. Nursing professionals can play a fundamental and crucial role in asthma education by maintaining the focus of the medical treatment on the priorities in asthma care--the learning needs and goals of the patient.     

MDS-Med Guide. Assessing medication effects using resident assessment data

The MDS-Med Guide is a unique new clinical tool developed to integrate patient assessment data with medication monitoring in the federally mandated resident assessment process. The guide correlates medication effects with a patient's physical, functional, and psychosocial status; identifies medications that may cause or aggravate common geriatric problems; and facilitates incorporation of medication information into the patient's care plan. The information provided in the guide is applicable to all geriatric patients receiving medication therapy to treat chronic diseases and conditions and should be of benefit to geriatric nurses in all practice settings.     

Incorporating advance care planning into family practice [see comment

Despite widespread support for the concept of advance care planning, few Americans have a living will or a health care proxy. Advance care planning offers the patient the opportunity to have an ongoing dialog with his or her relatives and family physician regarding choices for care at the end of life. Ultimately, advance care planning is designed to clarify the patient's questions, fears and values, and thus improve the patient's well-being by reducing the frequency and magnitude of overtreatment and undertreatment as defined by the patient. An advance directive consists of oral and written instructions about a person's future medical care in the event he or she becomes unable to communicate. There are two types of advance directives: a living will and a health care power of attorney. Family physicians are in an ideal position to discuss advance care plans with their patients. By introducing the subject during a routine office visit, physicians can facilitate a structured discussion of the patient's wishes for end-of-life care. At the next visit, further discussion can include the patient and his or her proxy. A document that clearly delineates the patient's wishes is then developed. The patient should be assured that the directive can be changed at any time according to the patient's wishes. The advance care plan should be reviewed periodically to make sure the specifications continue to be in line with the patient's wishes.     

Implementation and sustainment strategies for open visitation in the intensive care unit: A multicentre qualitative study

ObjectiveOpen visitation in adult intensive care units has been associated with improved family and patient outcomes. However, worldwide adoption of this practice has been slow and reasons for this are unclear. This study documents barriers and strategies for implementing and sustaining open visitation in adult intensive care units in the United States experienced by nursing leadership.Research designQualitative approach using grounded theory.ParticipantsNurse leaders in adult intensive care units with open visitation.SettingMagnet® or Pathway to Excellence® designated hospitals in the United States.MethodsSemi structured interviews were conducted with 19 nurse leaders from 15 geographically dispersed hospitals. Interviews were recorded, transcribed and imported into Atlas.ti qualitative software for analysis. Grounded theory constant comparison analysis was used for coding and category development.FindingsThe analysis revealed three barriers; nursing attitudes and clinical and nonclinical barriers. Strategies to overcome these barriers were empathy, evidence-based practice, models of care, shared governance, nurse discretion, security and family spaces.ConclusionIntensive care nursing leadership experienced distinct barriers and strategies during pre-implementation, implementation and sustainment of open visitation. Other nursing leaders interested in open visitation can use these findings as they plan this transition in their intensive care units.     

The perfectionistic patient.

Family members, residents, and care givers often react negatively when perfection is demanded by the geriatric patient. This type of reaction presents a challenge to the nurse providing care. When a geriatric patient is perfectionistic, it is important to step back, to observe and assess, and to plan appropriate strategies that will facilitate the patient's adjustment. When the behavior is related to situational stressors, it may be appropriate to respond to the stressors and ignore the behavior. When the behavior results from a feeling of loss of control and powerlessness, intervention should be directed in that direction. In any case, actions of the nurse should respond to the patient's need for self-esteem and improved ability to cope with the environment. Responding to the perfectionistic geriatric patient presents a particular challenge to the nurse in long-term care, and the nurse's strategic intervention can significantly increase the patient's ability to adjust to the ongoing changes that accompany the aging process.     

How to Develop a Tele-ICU Model?

The concept of the tele-ICU (intensive care unit) is about 30 years old and more hospitals are utilizing it to cover multiple hospitals in their system or for hospitals that lack on-site critical care coverage such as in the rural setting. Doing a needs analysis, picking the appropriate committee to oversee development of the correct model, choosing quality metrics to measure, and designing an implementation plan that has a timeline is how the process should begin. Research including visitation to established programs and connecting with professional societies are helpful. Developing both a business and financial plan will optimize the value of a tele-ICU program. The innovative ICU nursing director will help to integrate a telemedicine program seamlessly with the on-site program to insure a successful program that benefits patients, their families, the ICU staff, and the hospital.     

Nursing assessments in the inpatient geriatric population

Thorough assessment is essential in caring for the institutionalized elderly who have difficulty with urine control. The assessment should include a physical examination, a functional assessment, and an evaluation of the environment. The physical examination should be completed in a timely fashion after incontinence develops in order to rule out treatable causes of urine loss. The examination includes a health history and physical examination, with special attention being given to the genitourinary system. A urine specimen should be obtained during the examination to rule out bladder infection. The functional assessment of the patient is one of the most important aspects of the patient assessment. This is particularly true for elderly inpatients because much of the incontinence found in nursing homes is attributable to functional deficits. The functional assessment should address the history of the patient's incontinence, the patient's cognitive abilities and potential for participating in continence care, the patient's mobility, and the patient's abilities related to activities of daily living. Deficits in any of these areas may contribute to or cause urinary incontinence. In addition to the physical examination and functional assessment of the patient, the environment should be evaluated. The visibility, location, and structure of the toileting facilities can serve to either promote or impair urine control. In addition to the physical facilities provided, the overall nursing care approach may foster or hinder the patient's ability to maintain urinary continence. Nursing assessment that addresses these three areas will provide information that is needed to develop a nursing care plan that will maximize the patient's potential for urine control.     

Effective communication and delivery of culturally competent health care

Effective communication between patients and health care providers is a critical element to quality health care. Becoming aware of patients' attitudes, beliefs, biases, and behaviors that may influence patient care can help clinicians improve access to and quality of care. Health care providers should develop a strategic plan for improvement, then implement and evaluate the plan to include structured, continuously improving progress toward achieving cultural competency goals. In this challenging health care environment, health care providers need the skills to explore the meaning of illness, to determine patient's social and family context, and provide patient-centered and culturally competent care.     

Assessment of patient laboratory data in the acutely ill

Laboratory test results are a valuable source of information. Nurses need to assess laboratory test results as part of the physical assessment of their patients. Comparison of laboratory test results and changes with abnormal physical findings provides the basis for changes in the nursing care plan. Progressive monitoring of laboratory results and prompt interventions might lessen the seriousness of the health problem. In acute care units, the initial group of laboratory tests serves as a baseline for assessing additional test results. Several reference values should be remembered, particularly the electrolytes (potassium, sodium, and calcium), glucose, BUN, creatinine, and albumin. Specific group profiles assist in identifying and in monitoring the patient's health status. Incorporating laboratory test results into the plan and evaluation of care will result in safer and more effective patient care. Referring to laboratory test findings and comparing them with physical assessment findings are required for the delivery of professional nursing care.     

The nursing case management computerized system: meeting the challenge of health care delivery through technology.

Does nursing case management compute? In this article, the author attempts to explain how computerizing the team plan of care and critical pathways decreases paperwork, makes it easier to develop standardized team care plans, enhances quality improvement trending, and is flexible enough to update the plan of care according to the patient's changing needs. The Nurse Case Management Computerized System puts the patient care team plan into an interactive computer program. The computer does the work of presenting the nurse with care plan options and printing a hard copy ready to implement. Use of the computer program enhances the health care team's ability to individualize the team plan of care while maintaining patient care standards. The system is also used to collect patient care data automatically and to trend for quality improvement.     

Recommendations for preconception care

Every woman of reproductive age who is capable of becoming pregnant is a candidate for preconception care, regardless of whether she is planning to conceive. Preconception care is aimed at identifying and modifying biomedical, behavioral, and social risks through preventive and management interventions. Key components include risk assessment, health promotion, and medical and psychosocial interventions. Patients should formulate a reproductive life plan that outlines personal goals about becoming pregnant based on the patient's values and resources. Preconception care can be provided in the primary care setting and through activities linked to schools, workplaces, and the community.     

Outpatient management of chronic heart failure

Critical to the success of managing heart failure is appropriate outpatient follow up. Various models of care integrate medical care, pharmacologic intervention, and patient education and support. Key factors in any program are frequent patient assessment with rapid response to even subtle changes in the patient's condition. As the disease progresses, alternative care options such as palliative care and hospice should be integrated into the patient's care regimen.     

Visitation in the intensive care unit: impact on infection prevention and control

Evidence-based practice has shown that open visitation in the intensive care setting positively impacts patient outcomes. However, many intensive care units continue to strictly limit visitation hours. One concern for nurses is that open visitation will expose their vulnerable patients to an increased risk of infection. This fear is unfounded in professional literature as well as in the experience of a busy intensive care unit in San Antonio, Texas. Keeping our patients safe from hospital-acquired infections requires vigilant attention to infection prevention procedures. Meanwhile, what may actually be bugging our patients is a health care culture that is based on tradition and is blind to the many benefits provided by a more liberal visitation policy rooted in patient-centered care.     

A system for delivering care.

Despite partners and relatives providing care prior to a hospital admission, all too often they are not involved or informed about the treatment process during a patient's stay in hospital. The primary nurse system is an effective way of delivering care within the mental health framework. The primary nurse is responsible and accountable for the patient throughout his/her stay in hospital. Peplau's model of nursing care concentrates on the development of the nurse-patient relationship. Care plans should be negotiated with the patient. Care plan meetings are useful for discussing problems, receiving feedback and for supporting colleagues. Family meetings are essential so that the main carer's continuing involvement in care can be acknowledged.