Improving care of HIV-infected patients in the outpatient setting with patient data flow sheets.

Medical management of pediatric/adolescent HIV has become increasingly complex, requiring a multidisciplinary approach to care. Close clinical monitoring is needed to minimize opportunistic infections, initiate appropriate antiretroviral therapy, and ensure optimal health care to the patient. Monitoring should include evaluation of efficacy and side effects of therapy, early detection and treatment of HIV-associated complications, and maintenance of current immunizations. Tracking clinical data in chronically ill patients is a difficult task without an effective monitoring system. A patient data flow sheet was created to assist in planning care and monitoring disease progression by consolidating clinical information into an organized, one-page summary for each patient. One year after the patient data flow sheets were instituted, there was a significant improvement in the consistency of obtaining and monitoring routine HIV labs as well as serologies, and other recommended tests. The flow sheets have increased effectiveness of patient care and have been used to assist with quality assurance monitoring and quality improvement in the clinic setting.     

Current issues related to home monitoring

Physiologic monitoring is no longer confined to the critical care unit. Home monitors connect patients with clinics, physician offices, disease management programs, and home care agencies for the purpose of streamlining care delivery, maintaining a close patient connection, and promoting early identification of patient status changes. The advent of telehealth technologies offers a wide range of options for home monitoring. The goal of home monitoring is to promote patient comfort and avoid disruption of daily activities. To accomplish this, however, nurses must address issues such as, technology compatibility with patient capabilities, compatibility with nurses' practice beliefs, cost of home monitoring of overall care, and the physiologic parameters that will measure early decompensation.     

Troubleshooting the ECG

Improper ECG monitoring is dangerous to patient care. Artifact in ECG monitoring can be annoying, costly and produce delays in proper care. Understanding the technical sources of artifact and care in the application of monitoring electrodes can significantly reduce or even eliminate the problem. Critical to the success of ECG monitoring are the technical aspects of proper equipment selection, preventive maintenance, and timely and rapid application to the patient, all to deliver the highest quality patient care. Just as critical is the prehospital clinician's understanding of equipment capabilities and limitations. Take time to read and understand the operator's manual for the ECG monitor/defibrillator in use in your ambulance. The ECG offers invaluable diagnostic information to EMS clinicians. With recent technological advances, today's ECG monitors provide even greater ease and versatility, which results in enhanced patient monitoring. Many factors can affect the quality of the ECG trace and therefore must be controlled in order to gain the most accurate and meaningful reading. Electrode placement and selection, as well as site preparation, are key considerations when applying and monitoring a patient's ECG.     

Monitoring and evaluation in the special care unit: the JCAHO ten-step process

Monitoring and evaluating the quality and appropriateness of patient care in the special care unit is the basis for quality assurance activities. To make the monitoring and evaluation process helpful, health care professionals in special care units must be involved in each step of the process. The focus must be on patient care, specifically on clinical aspects of care rather than on structural specifications or technical processes. In addition to assisting the special care unit to meet accreditation requirements, ongoing monitoring and evaluation assist that unit to assure high-quality care. Monitoring and evaluation activities also assist the special care unit manager in responding to demands of state and federal regulators by providing an objective assessment of the care provided to Medicare and Medicaid patients. These activities also can provide assistance in responding to concerns about lawsuits involving alleged negligence in provision of special care; and in meeting pressures from third-party payers to reduce costs associated with unnecessary treatment in special care units. This chapter describes how the ten-step monitoring and evaluation process can be used to help assure high-quality patient care in the special care unit.     

Introduction to hemodynamic monitoring

This article discusses nursing care of the patient who requires hemodynamic monitoring. This will include care of the patient who requires intra-arterial pressure monitoring, central venous pressure (CVP) monitoring, left atrial pressure (LAP) monitoring, and monitoring of left heart pressures, cardiac output, and systemic vascular resistance using a pulmonary artery (PA) catheter.     

Doctors' perceptions of laboratory monitoring in office practice

Background Laboratory monitoring has been increasingly recognized as an important area for improving patient safety in ambulatory care. Little is known about doctors' attitudes towards laboratory monitoring and potential ways to improve it. Methods Six focus groups and one individual interview with 20 primary care doctors and nine specialists from three Massachusetts communities. Results Participants viewed laboratory monitoring as a critical, time‐consuming task integral to their practice of medicine. Most believed they commit few laboratory monitoring errors and were surprised at the error rates reported in the literature. They listed various barriers to monitoring, including not knowing which doctor was responsible for ensuring the completion of laboratory monitoring, uncertainty regarding the necessity of monitoring, lack of alerts/reminders and patient non‐adherence with recommended monitoring. The primary facilitator of monitoring was ordering laboratory tests while the patient is in the office. Primary care doctors felt more strongly than specialists that computerized alerts could improve laboratory monitoring. Participants wanted to individualize alerts for their practices and warned that alerts must not interrupt work flow or require too many clicks. Conclusions Doctors in community practice recognized the potential of computerized alerts to enhance their monitoring protocols for some medications. They viewed patient non‐adherence as a barrier to optimal monitoring. Interventions to improve laboratory monitoring should address doctor workflow issues, in addition to patients' awareness of the importance of fulfilling recommended therapeutic monitoring to prevent adverse drug events.     

Noninvasive blood gas monitoring

In the clinical setting, noninvasive blood gas monitoring has become the standard of care over arterial punctures. Technology has provided ways to measure both arterial oxygen (PaO2) and arterial Carbon Dioxide (PaCO2). With the availability of noninvasive blood gas monitoring, patient care and comfort is improving, and cost savings are being implemented. Overall noninvasive monitoring can aid in the diagnosis of some pulmonary diseases and monitor patient progress.     

Quality assurance: monitors in special care

Special care units need to establish economically feasible and meaningful monitors to evaluate patient care needs. High-cost areas, such as special care, monitor appropriate use of resources in high-risk, high-volume, and problem-prone areas. The monitoring process needs to provide information regarding the quality of care in the special care unit without greatly decreasing time spent by staff in direct patient care. This chapter discusses development of efficient monitoring tools for quality assurance indicators in the special care unit.     

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.     

1例心脏移植术后突发脑出血患者的护理

总结1例心脏移植术后突发脑出血患者的护理经验。从神经系统监测，术后容量管理，积极预防和应对感染，多学科协作呼吸道管理，密切监测出血征象，抗排异药物管理，多种方式加强皮肤护理，早期唤醒结合目标导向个体化康复共8个方面制定针对性的护理计划并实施。患者术后44天顺利出院，恢复良好。     

Facilitating cancer pain control in the home: Opioid-related issues

The basic principles of pain management are the same whether the patient is in an acute care setting, their home, or a long-term care facility. Wherever the setting, pain management is part of the comprehensive care for the cancer patient. Successful therapy depends on a clear definition of treatment goals, an informed patient and family, collaboration and effective communication between the physician, home care nurse, patient and family, and ongoing monitoring to ensure effectiveness of pain relief measures. Careful discharge planning to ensure appropriate home care for the patient with pain and their family is critical.     

Hyperosmolar non-ketotic hyperglycaemia.

Thorough assessment of the patient and good understanding of potential complications enhance patient care and safety. Correction of volume depletion and maintenance of a strict fluid balance chart is essential to avoid complications of congestive cardiac failure, cerebral or pulmonary oedema, renal failure and further dehydration. Careful monitoring of electrolytes and administration of supplements should be undertaken to prevent instability. Regular monitoring of blood glucose levels and careful insulin administration should be undertaken to prevent fluctuations in blood glucose levels. Any possible source of infection should be identified and treated as prescribed. Good basic nursing care for the patient and support and counselling for the patient and his family are essential components of holistic care.     

Admission and discharge guidelines for the pediatric patient requiring intermediate care

During the past three decades, the specialty of pediatric critical care medicine has grown rapidly, leading to a number of pediatric intensive care units being opened across the country. Many patients who are admitted to the hospital require a higher level of care than the routine inpatient general pediatric care, yet not to the degree of intensity as pediatric critical care; therefore, an intermediate care level has been developed in institutions providing multiple disciplinary subspecialty pediatric care. These patients may require frequent monitoring of vital signs and nursing interventions but usually do not require invasive monitoring. The admission of the pediatric intermediate care patient is guided by physiologic parameters depending on the respective organ system involved relative to the institution's resources and capacity in caring for a patient in a general care environment. This report provides admission and discharge guidelines for intermediate pediatric care. Intermediate care promotes greater flexibility in patient triage and provides a cost-effective alternative to admission to a pediatric intensive care unit. This level of care may enhance the efficiency of care and improve the healthcare affordability for patients receiving intermediate care.     

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.     

A systems approach to asthma care

This two-year asthma intervention focuses on provider education emphasizing early diagnosis of asthma, early use of oral steroids, proper use of inhalation devices, objective monitoring of patient status, and use of daily preventive treatment. Patient education is an integral part of treatment. This approach supports the primary care physician as the provider and coordinator of care by supplying monitoring and treatment devices, books, diaries, home care services, and allergy consultation. It also manifests a systems approach to asthma care in its reliance on a nurse case manager who oversees patient and family support network.     

Best practices in orthopaedic inpatient care

Most patients admitted in the hospital requiring skilled nursing care are at risk for adverse events or complications from their conditions and treatments. They require close observation during their hospital stays, and care providers must be prepared to detect and intervene quickly when complications occur. Orthopaedic patients are a unique surgical patient population in that their underlying physical conditions, operative locations, and comorbidities can place them at higher risk for complications or adverse events than many other surgical patients. Orthopaedic patients are usually admitted to general acute care surgical units where there are no monitoring devices and the staffing ratios are less intense. In the event that a higher level of surveillance is needed, current practice is to transfer the patient to a care area with telemetry or hardwired monitoring capability, which can result in deviation from the orthopaedic care pathway. In this article, we describe the implementation of best care practices that combine lower nurse to patient ratios, innovative and effective patient education, and continuous surveillance using novel technology in an orthopaedic unit. Data demonstrate that this multifaceted approach to high-quality orthopaedic care has contributed to better patient outcomes.     

End-tidal carbon dioxide monitoring: a VITAL sign worth watching

Capnography is the monitoring of end-tidal carbon dioxide in waveform and numeric display. For this technology to be useful, the critical care nurse must have a clear understanding of the normal capnography waveform and what the alterations in this waveform represent. The critical care nurse can use this information to plan patient care interventions with other critical care team members and to adjust care based on the patient's response. End-tidal carbon dioxide physiology, normal waveforms, abnormal waveforms, and clinical aspects of capnography monitoring are included.     

Noninvasive respiratory monitoring

Advances in technology now permit a variety of noninvasive respiratory monitoring options for clinicians. Perhaps a more complex issue is determining how much monitoring is needed as part of routine patient care. Often, practitioners take a "more is better" approach. This reasoning is justified in critical care, because, in theory, the more information clinicians have available to them, the more likely they are to make accurate assessments and proper therapeutic interventions. If one fails to properly understand the physiologic significance and clinical limitations of the numbers or waveforms from the monitor, however, patient care may not improve and, even worse, may be compromised. Therefore, proper training in all aspects of respiratory monitoring should be a basic and fundamental component of any critical care nurse training program. There are important cost considerations to be taken into account with continuous respiratory monitoring. The financial impact as it relates to care of the critically ill patient is often difficult to assess. Issues of cost-effectiveness are often justified because of the complex nature of caring for these patients and their need for intensive clinical observation and evaluation. The fact that many aspects of cardiopulmonary assessment can now be determined noninvasively is an important advantage over more invasive technologies and their associated risks. Clearly, monitoring techniques such as pulse oximetry and capnography do not eliminate the need for arterial blood gases and other invasive cardiopulmonary monitoring techniques. Rather, when appropriately applied, noninvasive monitoring has the potential to reduce the frequency of certain invasive procedures and still provide valuable information to nurses and other health care practitioners.