Amy Miner Ross

Spiraling evidence-based practice and outcomes management concepts in an undergraduate curriculum: a systematic approach.

Preparing undergraduate nursing students to practice nursing in the 21st century requires a focus on the development of evidence-based practice and outcomes management knowledge and skills throughout the nursing curriculum. To this end, seven learning activities were created that spiral and increase in complexity while building on previously acquired skills. Working in teams and practicing team-building techniques, students learned how to develop a clinical question, search the literature, synthesize the current knowledge, identify the significance of the issue in an ecological model, decipher existing quality data and compare that data to national benchmarks, investigate a health care quality issue using quality improvement methods, and draft a proposal for implementation of a continuous quality improvement initiative. Work was presented in both written and oral presentation formats, with emphasis on engaging various audiences in a compelling health care issue.

Candesartan cilexetil in cardiovascular disease.

Hypertension is a major cardiovascular risk factor, but most patients remain asymptomatic for many years. Successful therapy not only needs to be effective, it also needs to be well tolerated. Angiotensin receptor blockers have emerged as a major therapeutic class because they meet both of these requirements. Numerous studies indicate that all approved angiotensin receptor blockers are highly selective for angiotensin-1 receptors, lower blood pressure as monotherapies, and work well in combination with other drugs – particularly diuretics. The side-effect profile of angiotensin receptor blockers is similar to that of placebo and they have not been associated with known side effects of angiotensin-converting enzyme inhibitors such as cough and angioneurotic edema. Candesartan cilexetil is an angiotensin receptor blocker with insurmountable binding properties to the angiotensin-1 receptor, long duration of action and improved efficacy. In patients with hypertension, candesartan monotherapy has been shown to be safe and effective. Comparative data have shown similar or better results to other monotherapies in blood-pressure control, and in combination with hydrochlorothiazide it has been shown to have additive or synergistic effects. More recent data demonstrate that candesartan cilexetil is useful in the treatment of patients with heart failure and may protect against diabetic nephropathy. Studies have also shown protection from stroke, particularly in patients with isolated systolic hypertension.

International classification of functioning, disability and health categories for spinal cord injury nursing in China

Abstract Purpose: To explore a set of International Classification of Functioning, Disability and Health (ICF) categories that cover the spinal cord injury (SCI) nursing practice in China through a national expert survey. Methods: An internet-based email survey was used. An original set of ICF categories specifically for SCI nursing has been developed from the preliminary studies based on an international perspective. For cultural adaptation in China, a national expert survey was conducted with Chinese experts on SCI nursing to identify the ICF categories that were specifically for SCI nursing in China. The ICF categories which received more than 80% support from the experts would be reported. Results: Twenty-nine Chinese experts on SCI nursing participated. There were 81 ICF categories which received more than 80% agreement among the experts, including 33 Body Functions categories, eight Body Structures, 24 Activities and Participation, six Environmental Factors and 10 Personal Factors items. Conclusions: A set of ICF categories that cover the SCI nursing practice in China was identified. It reflects the main issues that Chinese nurses focus on in caring SCI patients. These categories can facilitate Chinese nurses to use the ICF in multidisciplinary teamwork and improve the participation of nurses in the team. Implications for Rehabilitation In China, nurses lack of an effective model or tool to communicate with the other health professionals in the rehabilitation team for spinal cord injury (SCI) patients. International Classification of Functioning, Disability and Health (ICF) is a tool for multidisciplinary use, which can promote the communication and collaboration in the healthcare team by establishing a common language across different disciplines and sectors. This set of ICF categories developed from this study can serve as a roadmap for important items for use in clinical practice of Chinese SCI nursing.

Surgical exploration before computed tomography scanning in children with traumatic tentorial herniation

Seventeen consecutive children with early clinical signs of tentorial herniation after head injury underwent immediate burr-hole exploration before computed tomography scanning. In nine children (53%), a subdural hematoma was discovered and immediately evacuated. In one, a small intracerebral hemorrhage was diagnosed by intraoperative ultrasonography. Postoperative studies showed that no intraaxial or extraaxial hematoma was missed by surgical exploration. Nine children (53%) survived; eight (47%) died. The survival rate was higher among patients with a mass lesion than among those without. Seven children had a good recovery, and two were moderately disabled (mean follow-up, 15.2 months). We conclude that a significant proportion of head-injured children with clinical signs of tentorial herniation have extraaxial hematomas that can be readily identified and evacuated by immediate surgical exploration. The survival rate and extent of recovery in children appear to be better than in similarly injured adults.

Creation of a virtual health system for leadership clinical experiences.

Students had difficulty integrating leadership and outcomes management skills into their burgeoning novice practice. Further, the Baccalaureate Completion Program for RNs, an online program, expanded student enrollment, which created difficulty in finding enough clinical placements in agencies with staff experienced in leading teams and conducting performance improvement projects. The Leadership and Outcomes Management course was changed from a live clinical agency placement course to a virtual clinical agency experience. Students worked in teams on a virtual quality care delivery case within a virtual health care system. Students selected the case and where they worked within our full-service virtual health system. The virtual health system required interactions with staff, and faculty assumed several roles within the virtual health system as they guided the students through leadership skill development and the creation of a performance improvement system process. It also eliminated the need for live clinical agency placements.

Peripheral immune response and infection in first-time and recurrent ischemic stroke or transient ischemic attack.

ABSTRACT Goals: The aims of this study were to determine if the infection rate differs between the first and recurrent ischemic stroke/transient ischemic attack (TIA), if the pattern of the peripheral immune response (PIR) differs between the first and recurrent ischemic stroke/TIA and if infection further influenced the pattern of the PIR. Methods: Retrospective review of 500 stroke cases with strict exclusion criteria (e.g., hemorrhagic stroke, subarachnoid hemorrhage, or spontaneous intracerebral hemorrhage; history of cancer; on steroids or immune suppressive drugs; recent invasive procedure) resulted in inclusion of 198 cases. Independent variables were first stroke or recurrent stroke and not infected or infected cases. Main-effect dependent variables were the white blood cell (WBC) and differential leukocyte counts (percentages of 100 cell counts for neutrophils, lymphocytes, and monocytes and absolute counts of neutrophils, lymphocytes, and monocytes). Findings: Infection rate was not different between the first versus recurrent stroke (p = .279). The pattern of WBC and differential counts were not different between groups, but addition of the covariate of infection showed group differences (p = .05). A four-group comparison of the dependent variables with the laboratory normal ranges showed lymphocyte percentages below the lower range limit in all four groups. Generalized linear modeling showed a modest rise (15%) in WBC counts in both groups with concomitant infection, a modestly low (−18%) lymphocyte percentage in recurrent stroke with infection, and a more substantial rise (22%–26%) in absolute neutrophil count in both groups with concomitant infection. Conclusions: Infection influences the pattern of the PIR in the first and recurrent stroke/TIA, and this difference can be quantified.

Effects of Work Environment on Quality of Care in ICUs: A Multisite Survey in China.

This study estimated the effects of the work environment on the quality of care in intensive care units (ICUs). Nurses in ICUs with good work environments or high nurse staffing were significantly less likely to report poor or fair quality of care (odds ratio [OR] = 0.37-0.47), rationing of nursing care (OR = 0.38-0.76), and health care–associated infections (OR = 0.28-0.68). Favorable ICU work environments and adequate nurse staffing can predict better quality of care.

Description and Identification of the Peripheral Immune Response Trajectories Over Time in First-Time and Recurrent Stroke/Transient Ischemic Attack.

ABSTRACT A unique extant database to explain heterogeneity in peripheral immune response (PIR) over time in response to stroke/transient ischemic attack (TIA) was used to compare changes in PIR between first-time and recurrent stroke/TIA and to identify distinct and common trajectories of change in the PIR in stroke/TIA. Associations between risk factors for stroke (hypertension, smoking, diabetes, hypercholesterolemia, infection) and PIR trajectory were quantified using multivariate random effects modeling. With comparable admission values, patients with recurrent stroke/TIA had a persistent elevation in lymphocyte percentage as opposed to the significant decline in lymphocyte percentages over time observed in those with first-time stroke/TIA. Two naturally occurring trajectories of the PIR to stroke/TIA were observed, one indicative of a primed PIR and one indicative of an unprimed PIR. A large proportion of the sample, 80%, was classified as having persistently higher lymphocyte percentages and lower neutrophil percentages over time compared with the remainder of the sample. When controlling for risk factors for stroke, adults admitted with recurrent stroke/TIA without infection were more than three times as likely to have a primed PIR (i.e., the high lymphocyte–low neutrophil trajectory) than those with first-time stroke with infection. Interventions for reduction of neurological deficits require tight implementation windows early after stroke occurs. The outlined classification of cases in these primed and unprimed trajectories of the PIR adds to the knowledge of optimal clinical timing for de novo immune-based interventions.

Prognosticators of Outcome After Major Head Injury in the Elderly

&NA; In 195 elderly head‐injured patients. Glasgow Coma Scale (GCS) scores (admission and 72 hours) and intracranial pressure (ICP) 0–12 days after injury were compared to 6 month Glasgow Outcome Scores. All patients remaining comatose at least 72 hours after injury died within 6 months The mortality rate among patients with ICP greater than 20 mm Hg was higher both at 72 hours and at 6 months after injury. The 6 month mortality rate was 75% overall and 90% among patients with elevated ICP. This increased mortality in elderly patients with initially elevated ICP indicates that nurses and other health professionals should consider ICP as well as level of consciousness when counseling patients and families regarding the likely outcome after major head injuries.

Influence of Gender and Age on the Peripheral Immune Response in Stroke

Background:Women and men have unique stroke risk factors and can experience different poststroke infections. Objective:The aim of this study is to determine the influence of gender, age, and risk factors on the peripheral immune response in stroke/transient ischemic attack (TIA). Method:A total of 192 adult acute stroke/TIA cases were analyzed for age, gender, risk factors for stroke/TIA, and white blood cell with differential count. &khgr;2 Test and analysis of variance were conducted to test for differences between genders and age groups related to stroke risk factors and the immune response. Growth modeling was used to test for trended differences in the immune response. Results:Women were 4 years older than men; fewer women had strokes in the younger age group (<79 years) and more men currently smoked. Trended lymphocyte percentages for the young and old (slope, P = .04; pattern, P = .02) and admission monocyte percentages by gender were significantly different (P = .01). Conclusions:Age influenced trended lymphocyte numbers and gender influenced monocyte percentage on admission.