Flexible monitoring in the management of patient care processes: a pilot study

This article describes a study conducted on the internal medicine, general surgical, and vascular wards of a large metropolitan hospital to assess the impact of a networked monitoring system and portable patient monitors. This pilot study was developed to address the need of hospital patients who require continuous noninvasive vital signs monitoring (including heart rate, noninvasive blood pressure, pulse oximetry, cardiac waveform monitoring) with the addition of surveillance from a cardiac intensive care area. Data were collected from 114 patients over a 3-month period to identify a patient group that could be managed appropriately under the new system and to determine the effect that flexible monitoring had on patient care management. Findings include identification of a specific patient group that can be managed successfully outside the cardiac intensive care area using this system. Other findings suggest a way to improve the management of patient monitoring in the general ward areas.     

Hemodynamic monitoring modalities in pediatric cardiac surgical patients

Transthoracic monitoring lines yield vital information in the care of the pediatric postoperative cardiovascular surgical patient. It is the critical care nurse, in the holistic care of the patient, who integrates this data into the daily plan of care. Invasive monitoring carries risks; therefore, guidelines for care must be followed. The care of these critically ill infants requires a multifactoral approach. Hemodynamic monitoring is one of many avenues that we follow in the intensive care unit.     

Haemodynamic changes in circulatory function following cardiac surgery that requires urgent intervention

Appropriate and effective postoperative care of the patient following cardiac surgery requires a thorough assessment of the haemodynamic profile based on accurate measurement, skilled nursing observation and correct interpretation of the data. Abnormal haemodynamic variables reflect underlying complications which can be life threatening.Left and/or right ventricular failure and cardiogenic shock usually become manifest in the operating theatre after bypass. The management of these problems is usually well established by the time the patient is returned to the Critical Care Unit. In addition, there are a number of other acute circulatory disturbances which become manifest for the first time after the patient's return to the Critical Care Unit. The nurse's role in the early recognition and management of these problems is crucial.This paper highlights the importance of measurement and interpretation of haemodynamic parameters by the nurse in a post-operative cardiac critical care unit. Accurate haemodynamic monitoring leads to the early recognition of potential problems and facilitates appropriate clinical decisions.Central venous pressure (CVP), arterial blood pressure, cardiac output, left atrial pressure (LAP), and/or pulmonary capillary wedge pressure (PCWP) are the major variables which reflect the patient's cardiovascular status. Not all of these variables are measured in any one patient, but the accurate measurement of arterial blood pressure, and at least one filling pressure (e.g. CVP) is mandatory.Abnormal haemodynamic parameters are commonly associated with hypotension or hypertension of various causes. These will be discussed.     

Case management of the anemic patient. Focus on blood pressure and rHuEPO therapy

As the use of Epoetin alfa to treat the anemia of chronic renal failure (CRF) expands, nurses play an ever-increasing role in patient monitoring and control. One area that relies heavily on nurses is blood pressure monitoring. Clinical trials with Epoetin alfa in hemodialysis patients indicate that its use may be associated with the onset or aggravation of elevated blood pressure as the hematocrit level increases. Because high blood pressure is a risk factor for left ventricular hypertrophy and cardiovascular mortality in this patient population, use of an agent that may cause high blood pressure requires careful monitoring. As the following two cases reports illustrate, sufficient data to provide better insight into the clinical aspects of this potential problem have now been accumulated.     

Absent right superior vena cava

A patient is presented in whom pulmonary artery catheter insertion fortutiously demonstrated persistent left superior vena cava on two separate occasions. Further studies with venogram and a first pass nuclear scan demonstrated total absence of the right superior vena cava. Although this anomaly is commonly associated with intracardiac defects and rhythm disturbances only the latter was seen in our patient. Invasive hemodynamic monitoring is frequently performed in the majority of modern intensive care units. The bedside technique used for insertion of a Swan-Ganz catheter using only pressure monitoring for advancing the catheter has relatively few complications. One such complication is misplacement along an anomalous route where the catheter may take to the heart. We have recently treated a patient on two separate occasions who had a persistent left superior vena cava with absent right superior vena cava.     

Neurologic monitoring in the ICU

While structure of the central nervous system (CNS) is evaluated through diagnostic tests such as computed tomography or magnetic resonance imaging, CNS function requires special monitoring techniques. These techniques are particularly useful adjuncts to the clinical examination, especially in the critically ill patient. Monitoring techniques include intracranial pressure monitoring, cerebral blood flow monitoring, cerebral hemodynamic assessment, and electrophysiologic monitoring. Rationale and specific applications are unique to each technique. Nursing considerations focus on knowledge of rationale for monitoring, providing safe patient care, validating appropriateness of interventions based on monitoring, and investigating the relationship of monitoring to outcome.     

Intracranial pressure monitoring: why monitor?

Evidence suggests that the mortality and morbidity of acquired brain injury could be reduced if clinicians used an aggressive intracranial pressure guided approach to care. Despite nearly 50 years of evidence that intracranial pressure monitoring benefits patient care, only about half of the patients who could benefit are monitored. Some clinicians express concerns regarding risks such as bleeding, infections, and inaccuracy of the technology. Others cite cost as the reason. This article discusses the risks and benefits of intracranial pressure monitoring and the current state of evidence of why patients should be monitored.     

Prone positioning in the patient who has acute respiratory distress syndrome: the art and science

Acute respiratory distress syndrome (ARDS) remains a significant contributor to the morbidity and mortality of patients in the ICU. A variety of treatments are used to support the lung of the patient who has ARDS and improve gas exchange during the acute injury phase. It seems, however, that the simple, safe, and noninvasive act of prone positioning of the critically ill patient who has ARDS may improve gas exchange while preventing potential complications of high positive end-expiratory pressure, volutrauma, and oxygen toxicity. This article provides the critical care nurse with the physiologic rationale for use of the prone position, indications and contraindications for use, safe strategies for prone positioning, and care techniques and monitoring methods of the patient who is in the prone position.     

Perioperative Care of the Morbidly Obese Patient in the Lithotomy Position

The lithotomy position is used daily in the OR to position patients for vaginal, rectal, and urologic procedures. Use of this position requires a careful nursing assessment to ensure that the patient can tolerate having his or her legs placed in the stirrups and to ensure that no pressure points exist for the duration of the surgery. Caring for a patient who is morbidly obese and who requires surgery in the lithotomy position can be especially challenging, and the possibility of injury to the patient or staff members should be considered. A case study involving the care of a patient who weighed almost 600 lb undergoing surgery in the lithotomy position demonstrates ways to provide safe care for this type of challenging patient.     

Exploring the guidelines for the management of severe head injury.

A significant improvement in patient outcomes can be achieved by in-hospital interventions aimed at the prevention of secondary brain injury. The Guidelines for the Management of Severe Head Injury is a scientific, evidence-based document that evaluates the current evidence for practice and interventions to reduce secondary brain injury and improve outcome for traumatic brain injury (TBI) patients. The Guidelines covers a wide range of topics including trauma systems, oxygenation and blood pressure resuscitation, intracranial pressure monitoring, intracranial hypertension, nutrition, and pharmacological interventions for the severe TBI patient in the intensive care environment. Head injury care requires an interdisciplinary approach involving emergency room personnel, trauma nurses, and critical care nurses. Critical care nurses will find this document especially applicable because secondary brain injuries are often the result of events that occur in the ICU setting: hypoxemia, hypotension, and intracranial hypertension.     

The hospital transfer of a patient with gastrointestinal bleeding from oesophageal varices

The care of patients with gastrointestinal bleeding from oesophageal varices during inter-hospital transfer is a complex procedure to different causes. Some of these include, the high number of parameters to take into account, the monitoring of the electro-medical equipment, the instability of the patient and their needs or the short time available to know the patient and obtain the maximum information in order to plan a safe and proper transfer. The main role of the nurse in the transfer of critically ill patients focuses on the control and monitoring of all these aspects and the maintenance of the continuity of the caring initiated in the hospital. This requires a personalized care plan to be prepared for the patient who has to be transferred to avoid putting the individual at risk due to their high vulnerability. This should minimise the risk of possible complications or accidental incidents related to the high number of instruments used for monitoring the patients during their transfer. The case presented below describes the transfer of a patient by ambulance from a level 2 hospital to a level 3 hospital of a person who had an urgent condition that reflected all this complexity. It highlights the indications and basic care that has to be taken into account in this type of transfer and the transfer of the patient once in the receiving hospital, especially in this case, where the condition of the patient is highly compromised.     

Ambulatory blood pressure monitoring and the primary care physician

The primary care physician welcomes technology that will reduce overlabelling and overtreatment of hypertension. Three concerns with respect to ambulatory blood pressure monitoring are: the clear identification of those patients who will benefit from monitoring; the potential for labelling patients prematurely as having technical abnormalities (i.e., 'hypervariability'), which may have little clinical significance; and the inaccessibility of ambulatory monitoring. To determine patient acceptance of ambulatory monitoring, a follow-up survey of 37 patients who used the Spacelab 5200 device was conducted. Twenty-four percent said they would not be agreeable to further monitoring. While newer devices may be less disruptive, the point is made that it is important to include patient assessments in the evaluation of these devices. A comparison is undertaken between ambulatory monitors and the more accessible self-monitoring devices which involve the patient to a greater degree in his/her own care.     

Bridging the gap between hemodynamics and monitoring

Hurst states that "hemodynamic monitoring is a complement of, rather than a replacement for, clinical judgment." Holder explains that "hemodynamic parameters add sufficient clarity for physicians to a difficult patient management problem." However, it is nursing which must bring clarity to the parameters. It is the nurse who must be ever-vigilant and strive for excellence in invasive hemodynamic monitoring of critically ill patients--as the caregiver who is with the patient 24 hours a day, 7 days a week. Effective hemodynamic monitoring starts with an understanding of the hemodynamic mechanisms that monitoring aims to measure. Then, measuring the hemodynamic mechanisms requires technical expertise to provide accurate parameters from the monitoring equipment. Lastly, an appreciation for the risks and benefits, together with patient responses to being monitored, helps the nurse evaluate the contribution invasive hemodynamic monitoring has on patient outcomes. Nurses who couple knowledge of cardiovascular physiology, technical expertise, and thorough assessment and diagnosis of patient responses to hemodynamic instability and invasive monitoring bring the essence of holistic nursing care to hemodynamic monitoring.     

Work environmental factors and retention of nurses

Perceptions of the work environment were studied among acute care nurses working in a large county hospital who left their units during an 18-month period, compared to those who stayed. Analysis using Moos' work environment subscales suggests that the nurses who remained in their units perceived less work pressure and had greater perception of peer cohesion, supervisor support, and autonomy than nurses who left. Moos' Work Environment Scale suggests that a supportive work environment enables nurses to provide quality patient care, enhance their own self-esteem, increase job satisfaction, and provide cost savings to their employers. Such an environment promotes retention of skilled, caring, knowledgeable, and experienced nurses who provide better patient care with fewer complications, and reduces the economic and social costs of healthcare for both providers and consumers.     

Monitoring nasal conductance by bilateral nasal cannula pressure transducers

Nasal obstruction is common and may disturb well-being during daytime and sleep. Its objective assessment by standard methods requires patient cooperation and inconvenient instrumentation. Therefore, the purpose of this study was to develop a novel, unobtrusive technique for continuous monitoring of changes in nasal conductance during natural breathing based on pressure recordings at the left and right nares. In ten volunteers, pressure swings derived independently from left and right nasal cannula were recorded at baseline, and after topical application of histamine and xylomethazoline. Nasal conductance was measured by means of epipharyngeal pressure recordings and face-mask pneumotachography as the reference standard. Decreases in nasal conductance were associated with changes in relative timing and shape of left and right nasal cannula derived pressure swings during breathing. This was reflected in decreases in the coefficient of cross-correlation between left and right nasal pressure signals. Diagnostic accuracy in detecting a fall in nasal conductance to <80% baseline by the maximal coefficient of determination from cross-correlation of left versus right nasal pressure was evaluated by receiver operator characteristics. The area under the curve was 0.88, 95% confidence interval 0.76 to 0.99, n = 40, P < 0.05 versus 0.5. We conclude that patterns of pressure swings derived from left and right nasal cannula may serve as a noninvasive means to detect changes in nasal conductance without requirement of patient cooperation.     

Refusal of emergency medical care: An analysis of patients who left without being seen,eloped, and left against medical advice

ObjectiveEmergency department (ED) patients may elect to refuse any aspect of medical care. They may leave prior to physician evaluation, elope during treatment, or leave against medical advice during treatment. This study was undertaken to identify patient perspectives and reasons for refusal of care.MethodsThis prospective study was conducted at an urban Level 1 Trauma Center. This study examined ED patients who left without being seen (LWBS), eloped during treatment, or left against medical advice during September to December 2018. This project included both chart review and a prospective patient survey.ResultsAmong 298 participants, the majority were female (54%). Most participants were White (61%) or African American (36%). Thirty-eight percent of participants left against medical advice, 23% eloped, and 39% left without being seen by a provider. When compared to the general ED population, patients who refused care were significantly younger (p < 0.001). When comparing by groups, patients who left AMA were significantly older than those who eloped or left without being seen (p < 0.001). Among 68 patients interviewed by telephone, the most common stated reasons for refusal of care included wait time (23%), unmet expectations (23%), and negative interactions with ED staff (15%).ConclusionED patients who refused care were significantly younger than the general ED population. Common reasons cited by patients for refusal of care included wait time, unmet expectations, and negative interactions with ED staff.     

Acute crack cocaine intoxication: a case study

The survival of a patient with acute crack intoxication requires the dynamic and ongoing collaboration of the nurse and physician to facilitate aggressive treatment. The prevention of ominous complications in the patient exhibiting multisystem failure requires advanced physical assessment skills. It is the integration of these physical findings along with the interpretation of laboratory data and invasive monitoring techniques that enables the critical care nurse to constantly evaluate the patient's response. This ongoing evaluation further directs care planning to potentiate optimum patient outcomes.     

Comparison of Pulmonary Artery Pressure Measurements in the Supine and 60° Lateral Positions Leanne is continuing this research in her doctoral studies

Pulmonary artery pressure monitoring, with the patient in both the supine and lateral positions, is an essential element in the assessment of critically ill patients. Previous work offers conflicting results regarding the accuracy of measurements obtained with the patient in the lateral position. The purpose of this study was to determine if accurate pulmonary artery pressure measurements can be obtained in the cardiac surgical patient. Thirty-five patients underwent repositioning between the supine and both the left and right 60° lateral position while being mechanically ventilated and then breathing spontaneously. Pulmonary artery pressure measurements were recorded prior to, two minutes following and ten minutes following repositioning. Despite some variation in results the pulmonary capillary wedge pressure measurement was reliable ten minutes after repositioning in both the spontaneously breathing and mechanically ventilated patient. Other pulmonary artery pressure measurements were not so reliable in the lateral position. This study concludes that clinical practitioners can obtain accurate pulmonary capillary wedge pressure measurements in post-operative cardiac surgical patients positioned in either the left or right 60° lateral position. Further research is however required, with larger numbers from all sub-groups of the critical care population. Physiological and pathophysiological characteristics which preclude reliable pulmonary artery pressure measurements need to be identified.     

The Swan-Ganz catheter: a review.

Right heart catheterization, first reported in 1905, is now used for bedside assessment and management of the critically ill patient. A Swan-Ganz catheter and pulmonary artery pressure monitoring are the tools employed. In spite of the complications cited, the occurrence of hazard to the patient is infrequent. The catheter is particularly valuable in the hemodynamic evaluation of cardiac function. Right and left heart pump performance can be assessed by pressure measurements. The ability of the left heart to provide an adequate cardiac output can be numerically calculated, and its adequacy at a cellular level can be evaluated by determining arterial-venous oxygen saturation difference. One of the more important and newest uses of the Swan-Ganz catheter is the preventive function it plays in anesthesia administration. Implications of the Swan-Ganz catheter for nursing practice are: (1) explanation and support to patient and family; (2) technical understanding and knowledge of set-up; (3) care and maintenance of the catheter after insertion; (4) the understanding of physiologic principles underlying the use of the catheter; and, most important, (5) ability to correlate clinical observations and physiologic changes occurring in the patient with pressure measurements.     

Education, training, and use of unlicensed assistive personnel in critical care

The integration of the role of UAP in critical care requires a long-term commitment to patient centered care by the professional nursing staff. Standardized education and training of professional nurses and UAP, support for nurses who orient UAP, support for the PCTs who precept, and a supporting infrastructure promote integration of UAP in critical care with positive outcomes. The education of UAP does not conclude with orientation. Education, training, and competency revalidation should be ongoing to broaden individuals' knowledge base and enhance skills. The monitoring and evaluation of programs with timely modifications will support or enhance effectiveness of the programs.