The conceptualization of physical restraint as a nursing-sensitive adverse outcome in acute care psychiatric treatment settings

The occurrence of physical restraint episodes in psychiatric settings is a major public health issue because the therapeutic utility of this form of behavior control has not been substantiated empirically. The purpose of this article was to examine the extant literature to determine if evidence supports the conceptualization of a physical restraint episode as an adverse client outcome that is sensitive to the organization of nursing care in psychiatric settings. An adapted version of the Quality Health Outcomes Model (Mitchell, P. H., Ferketich, S., & Jennings, B. M. (1998). Quality Health Outcomes Model. Image Journal of Nursing Scholarship, 30, 43-46) was used as the conceptual model to guide this inquiry. The databases Cumulative Index to Nursing and Allied Health Literature, Health and Psychosocial Instruments, HealthSTAR/Ovid and Healthstar, Medline, and psychINFO were searched from 1990 to 2005. There are 101 sources in this review. Evidence strongly suggests that a physical restraint episode is an adverse outcome that is sensitive to the organization of nursing care. A systematic exploration of the specific structures and processes of the organization that affect adverse outcomes, such as physical restraint episodes, is lacking in the United States.     

Ultrafiltration rate as a nursing-sensitive quality indicator in haemodialysis

Nursing quality indicators are widely used to demonstrate nurses' contributions to health care. Some studies in nephrology settings have addressed nursing quality, but indicators reflecting the nursing process quality in haemodialysis are lacking. This paper argues for considering ultrafiltration rate as a nursing-sensitive quality indicator in haemodialysis. Strategies and qualifications for considering ultrafiltration rate as a nursing quality indicator are established and discussed. It is argued that the indicator is associated with nursing practice, linked to both morbidity and mortality, and is within the scope of the nurse's responsibility. It is also argued that the indicator could be influenced by other factors than nursing care. Thus, further studies are needed to investigate the association between ultrafiltration rate and patient safety. The introduction of the ultrafiltration rate as a duty specific quality indicator is a coveted measure of nursing care quality in haemodialysis settings.     

Survival and neurologic outcome after traumatic out-of-hospital cardiopulmonary arrest in a pediatric and adult population: a systematic review

ABSTRACT: INTRODUCTION: This systematic review is focused on the in-hospital mortality and neurological outcome of survivors after prehospital resuscitation following trauma. Data were analyzed for adults/pediatric patients and for blunt/penetrating trauma. METHODS: A systematic review was performed using the data available in Ovid Medline. 476 articles from 1/1964 - 5/2011 were identified by two independent investigators and 47 studies fulfilled the requirements (admission to hospital after prehospital resuscitation following trauma). Neurological outcome was evaluated using the Glasgow outcome scale. RESULTS: 34 studies/5391 patients with a potentially mixed population (no information was found in most studies if and how many children were included) and 13 paediatric studies/1243 children (age ≤ 18 years) were investigated. The overall mortality was 92.8% (mixed population: 238 survivors, lethality 96.7%; paediatric group: 237 survivors, lethality 86.4% = p < 0.001).Penetrating trauma was found in 19 studies/1891 patients in the mixed population (69 survivors, lethality: 96.4%) and in 3 pediatric studies/91 children (2 survivors lethality 97.8%).44.3% of the survivors in the mixed population and 38.3% in the group of children had a good neurological recovery. A moderate disability could be evaluated in 13.1% in the mixed population and in 12.8% in children. A severe disability was found in 29.5% of the survivors in the mixed patients and in 38.3% in the group of children. A persistent vegetative state was the neurological status in 9.8% in the mixed population and in 10.6% in children.For each year prior to 2010, the estimated log-odds for survival decreased by 0.022 (95%-CI: [0.038;0.006]). When jointly analyzing the studies on adults and children, the proportion of survivors for children is estimated to be 17.8% (95%-CI: [15.1%;20.8%]). The difference of the paediatric compared to the adult proportion is significant (p < 0.001). CONCLUSIONS: Children have a higher chance of survival after resuscitation of an out-of-hospital traumatic cardiac arrest compared to adults but tend to have a poorer neurological outcome at discharge.     

Health-seeking behavior as an outcome of a homeless population

Health care is an ever-present concern for homeless individuals. Health-Seeking Behaviors within this population are examined from a nursing perspective. Complex Relationship Building, considered essential in addressing Health-seeking Behaviors for the homeless, is examined in regard to access, trust, and follow-up. It is believed that access and follow-up are related to convenience of site and the matter of trust. A pilot study of how to measure the concept of trust was conducted. Factor analysis for the Gibson Trust Instrument shows two factors: (1) interpersonal attributes and (2) behavior attributes. The Gibson Trust Instrument can be used to measure trust, which is crucial for Complex Relationship Building.     

Surgery in the patient with neurologic disease

Patients with neurologic disease who require surgery present distinct issues and challenges for the medical consultant. Although it is not possible to offer a unified approach to neurologic patients, the primary care consultant should understand the clinical issues that are common to these patients, and the individual considerations necessitated by the nature of the neurologic disorder and the clinical characteristics of the patient. The preoperative evaluation combines elements of literature evidence on risk assessment with a thorough understanding of the planned procedure and local practice patterns, and clinical judgment as to the estimated risk-benefit ratio. Perioperative management necessitates attention to many general principles of perioperative care, such as awareness of the potential for cardiopulmonary complications and the need for DVT prophylaxis. In addition, there are management issues for neurologic patients, such as blood pressure control and evaluation of hyponatremia, which may differ from other surgical patients. In these circumstances, the interaction of the neurologic condition with the medical condition and the implications of treatment on the underlying neurologic process also need to be considered.     

Serum lactate as a predictor of neurologic outcome in ED patients with acute carbon monoxide poisoning

Background

This study was conducted to assess and clarify the predictive risk factor of neurologic outcome in patients with acute carbon monoxide (CO) poisoning.

The impact of intensive patient education on clinical outcome in a clinic-based migraine population

OBJECTIVE: To determine whether the addition of patient education to routine medical management improves the clinical status of migraine patients and reduces their utilization of healthcare resources. BACKGROUND: Optimal migraine management typically requires effective patient education. Such education often is difficult to accomplish in the busy clinic setting. METHODS: One hundred consecutive patients with migraine presenting to an university-based headache clinic were randomized to receive or not receive a standardized course of didactic instruction regarding migraine biogenesis and management. The course consisted of 3 classes taught by lay migraineurs who themselves previously had undergone intensive training. All patients were evaluated initially and at 1, 3, and 6 months by a neurologist blinded as to the results of randomization. Clinical variables examined included headache frequency/severity, migraine disability assessment (MIDAS) scores, patient compliance, presence versus absence of analgesic use/overuse, and headache-related unscheduled visits or phone calls. Comparisons were made between baseline findings and findings at the 6-month follow-up visit, with the change in mean MIDAS score serving as the primary outcome variable. RESULTS: At 6 months the group randomized to receive intensive education exhibited a significantly greater reduction in mean MIDAS score than the group randomized to routine medical management only (24 vs. 14 points; P < .05). Those patients also experienced a reduction in mean headache days per month and a greater reduction in functionally incapacitating headache days per month, exhibited less analgesic overuse and need for abortive therapy, were more compliant with prophylactic therapy prescribed, and made fewer headache-related calls to the clinic or unscheduled visits. CONCLUSION: Intensive education of migraine patients by trained lay instructors may convey significant benefit to those patients and reduce their utilization of healthcare resources.     

Agitation in closed head injury: haloperidol effects on rehabilitation outcome

The role of agitation as a prognostic indicator of outcome in 26 patients with severe traumatic closed head injury was studied to explore haloperidol effects on the outcome of rehabilitation treatment. The incidence and degree of agitation and post-traumatic amnesia (PTA) in brain-injured patients undergoing comprehensive inpatient rehabilitation were also studied. Variables measured included length of coma, PTA, rehabilitation admission and discharge functional status, and CT scan results. Of the 26 patients, 25 were agitated after emerging from coma and 11 required intervention with haloperidol. Treated and nontreated patients were compared statistically. No differences were found between groups as to demographics, length of coma, and most importantly, in success of rehabilitation outcome. The duration of PTA was significantly longer in the treated group.     

Family-centered care of the critically III neurologic patient

To determine the immediate needs of families of neurological/neurosurgical patients during the critical care period, family members were interviewed, using a 45 needs statement inventory and an open-ended questionnaire. Each participant addressed all the needs statements and 70% answered the open-ended questions. The participants ranked "to be assured that the best care is being given to the patient" as their number one need. Sixty percent of the participants ranked the physician as the most likely person to meet their needs. When compared, no significant difference was found between the families of neurological/neurosurgical and cardiac/MI patients. Although ranked slightly differently, 13 of the top 15 needs for both groups were the same. The two top needs were ranked in reverse order, "to be assured that the best possible care is being given to the patient," and "to have questions answered honestly," respectively. Nurses caring for the neurological/neurosurgical patients need to be aware that, for the most part, the top needs for families of this group have centered around communication, honesty, and reassurance. Participants do not want to hear false hopes. The family perceived the nurses as giving information regarding transfer and day-to-day occurrences with the patient care.     

The Johnson Behavioral Systems Model as a framework for patient outcome evaluation

Background: Although there is a great deal of interest in the outcome of the nursing care of psychiatric patients, there is little empirical research about the effectiveness of nursing care.Methods: This study evaluated the medical record documentation by nurses as an important database (N = 380 patients). The predicted patient outcome instrument developed by the authors was used to collect the data related to patient demographics, acuity, nursing diagnosis, short-and long-term goals, and nursing interventions. The Johnson Behavioral System Model was the nursing conceptual framework used.Findings: Overall, 80% of the predicted patient outcomes were achieved by the time of discharge, with increased length of stay being a factor in increasing the likelihood of achievement of goals. A positive link was found between achievement of outcomes at time of discharge and nursing interventions. A nursing theoretical framework made it possible to prescribe nursing care as a distinction from medical care.Conclusion: This study showed the importance of the nursing database in the medical records and the effectiveness of nursing interventions on predicted patient outcomes achieved by the time of discharge.     

Premonitory neurologic signs in a patient with an acute vertex epidural hematoma

A case of an acute vertex epidural hematoma with delayed neurologic deterioration is presented. Prior to the onset of signs of midbrain compression, the patient developed an excrutiating headache, a movement disorder, and upper motor neuron signs. A review of the literature and this case suggest that the presence of a severe, unrelenting headache and upper motor neuron signs in a victim of head trauma may be secondary to compression of the parasagittal brain region by a vertex hematoma.     

Preoperative management of the surgical patient with neurologic disease

This article reviews neurologic problems that have been categorized into two groups: parenchymal and vascular disease. Each disease has a brief summary of key clinical points, followed by recommended management strategies. The neurologic diseases most frequently encountered by the medical consultant are presented.     

Effects of hyperglycemia on neurologic outcome in stroke patients.

Hyperglycemia in acute stroke patients increases cerebral infarct size and worsens neurologic outcome with and without preexisting diabetes mellitus. Hyperglycemia results from metabolic alterations in glucose metabolism, and is most common in patients with acute illness such as stroke. Strict control of hyperglycemia with intensive insulin therapy has been shown to dramatically decrease hospital morbidity and mortality, inpatient stays, hospital costs, and, most importantly, neurologic injury. Insulin treatment protocols developed and implemented by multidisciplinary teams allow for rapid and effective control of hyperglycemia. Nurses who know about hyperglycemia's often-neglected and detrimental effects can play a vital role in influencing outcomes in stroke patients.