Barbara J. Holtzclaw

Research Careers for American Indian/Alaska Native Nurses: Pathway to Elimination of Health Disparities

The health status of American Indians/Alaska Natives lags behind that of the US population. American Indian/Alaska Native (AIAN) nurses are on the front lines of health services for AIAN people. They have the potential to make scientific contributions as well, but are under-represented among researchers working to understand health disparities. The AIAN MS-to-PhD Nursing Science Bridge, at the University of Minnesota, in partnership with the Universities of North Dakota and Oklahoma, provides support for AIAN nurses during the critical training transition from masters of science to doctoral programs. Partner schools collaborate with AIAN elders, medicine people/spiritual leaders, and academic consultants to (1) foster academic success and strengthen the AIAN identity of students during their research training and (2) bring about institutional change to optimize student experiences. Future research programs developed by this cadre of AIAN nurse scientists will contribute scientifically sound, culturally acceptable knowledge to effectively improve the health of AIAN people.

Night sweats: a systematic review of the literature.

Background: Much of primary care involves helping patients manage symptoms. Nighttime sweating is a symptom linked to menopause, malignancies, autoimmune diseases, and infections. However, in primary care settings, night sweats are commonly reported by persons without these conditions. Methods: We conducted a literature review, focusing on questions about definition, mechanisms, incidence/prevalence, measurement, clinical causes, evaluation, treatment, and prognosis. We limited our search to English language studies of adult humans published since 1966. Because studies of estrogen and androgen deficiency states had been reviewed by others, we excluded them. Search criteria were developed for each question. Publications meeting criteria were reviewed by the first 2 authors and consensus was reached through discussion. Results: Prevalence estimates ranged from 10% among older primary care patients to 60% among women on an obstetrics inpatient unit. Life expectancy of primary care patients reporting night sweats did not appear to be reduced. Although many clinical causes have been suggested, most are not well supported. Algorithmic approaches to evaluation are not evidence-based. Alpha adrenergic blockers may reduce night sweats in patients taking serotonin reuptake inhibitors. Thalidomide and thioridazine may benefit some terminal cancer patients with night sweats. Conclusions: The symptom, night sweats, appears to be nonspecific. Many questions about causation, evaluation, and management remain unanswered.

Circadian Rhythmicity and Homeostatic Stability in Thermoregulation

Stability and circadian variation in core body temperature (Tc) were believed to be homeostatic responses until well into the 20th century. Defense of a narrow thermoneutral range was well documented, whereas circadian oscillations were attributed to episodic biochemical and environmental stimuli or chronological stressors in life routines. Research in thermal physiology has illuminated several of the “black boxes” in the understanding of temperature regulation, and advances in chronobiology have shattered old paradigms. While these discoveries are still evolving, existing information provides valuable clues about physiological responses to heat loss or overheating that could improve clinical assessment and intervention. Discoveries that circadian rhythm of Tc is regulated by an endogenous “clock” and is remarkably stable have helped to make it the most widely used circadian indicator. More recently, Tc was found to exert its own cyclic rhythm under free-running conditions. While some investigators claim that circadian and homeostatic processes are independent, there are conditions in which clinical distinctions are less clear. This overview reviews contemporary scientific findings about circadian and homeostatic processes in thermoregulation. Examples are drawn from human and animal research. Physiological responses and mechanisms are explained in relation to their relevance to clinical treatment or health care. Gaps in existing research and application are discussed.

Shivering in Acutely Ill Vulnerable Populations

The hazards of thermoregulatory shivering in the critically ill are often overlooked by caregivers. Shivering may accompany heat loss from bathing, dressing, transport, and many therapeutic activities. Febrile shivering is common during chills of fever, blood product transfusions, administration of antigenic drugs, and chemotherapy. Many patients are at risk for shivering and its negative consequences that increase oxygen expenditure and cardiorespiratory effort. Learning how underlying thermoregulatory mechanisms are involved in shivering clarifies how temperature gradients and environmental stimuli induce the shivering response. Knowledge of the anatomical progression of shivering equips the nurse to recognize or prevent this energy-consuming response. This article discusses measures to prevent shivering as well as evidence-based interventions to manage shivering during fever, aggressive cooling, and postoperative recovery. Detailed information is presented on assessment and documentation of the extent and severity of shivering.

Aging in Place: Merging Desire with Reality

Barriers to aging in place include physical mobility and transportation limitations, isolation related loneliness and depression, diminishing health status, housing quality, finances, and caregiving resources. The scope of the aging demographic shift, economic consequences and loss of quality of life urge adoption of such successful approaches as the life course model. Desirable aging in place provides person-centered quality of living that is independence-effective and affordable. Systematic community-centered and person-centered approaches are crucial to accomplishing the central actions of the life course model. Not only are the actions necessary, they are interactive, interdependent, and strategic in supporting one another.

Physical Activity Among Adolescents with Cerebral Palsy: An Integrative Review

PROBLEM Physical activity is necessary for optimum physical and psychosocial health in the general population. It is even more important for adolescents who struggle with impairments that limit motor function. Recommendations for best practice are needed as adolescents transition into adulthood. PURPOSE An integrative review was performed to determine the state of the science regarding 1) what factors impact physical activity in adolescents with cerebral palsy, and 2) how the needs of this population have been addressed regarding physical activity. SEARCH STRATEGY A literature search of MEDLINE, CINAHL, and PubMed was conducted using the terms cerebral palsy, mobility or activity, and adolescents. Exclusion criteria were surgical or pharmacological interventions. RESULTS OF THE LITERATURE SEARCH Descriptive and intervention studies were included and evaluated for purpose, design, and key findings. SYNTHESIS OF EVIDENCE Correcting the decline of physical activity in adolescents with CP may carry benefits over into adulthood. There are few studies that adapt physical activity to age and level of impairment. Several studies support approaching physical activity from a social model, focusing on participation of the person in the context of environment. There is a lack of research incorporating family-centered care. Many study designs are shallow and lack the proper instruments for assessing outcomes. IMPLICATIONS FOR PRACTICE Home and community based interventions need to be developed that are individualized. More studies are needed with stronger research designs and better instruments in order to generalize results for practice.

Managing Fever and Febrile Symptoms in HIV: Evidence-Based Approaches

&NA; Fever remains a common symptom for persons living with HIV (PLWH) despite improving overall health and survival rates. Elevated body temperatures are among the classic symptoms of primary HIV infection and are later harbingers of opportunistic infections. Therapeutic agents, including antiretrovirals, antifungals, interleukins, interferon, and blood products, can produce fever. While research shows that fever holds immunological benefits, and outdated practices to cool febrile patients create distress and energy expenditure from shivering, “fever phobia” persists. This article discusses the evolution of understanding about fever and HIV infection, its influence on caregivers and PLWH, and the existing evidence surrounding (a) physiological threats and benefits of the febrile response for PLWH, (b) goals underpinning assessment and management of fever and related febrile symptoms, and (c) development and testing of fever‐management interventions. This evidence is summarized with rationale for the need to educate both public and professionals about the complexities of fever.

Use of non-human biobehavioral models in critical care nursing research.

The complexity of critical care settings and diversity among vulnerable patient populations often make clinical research study outcomes difficult to evaluate. When interventions are tested, outcomes or improvements in condition often can be questioned on the basis of variations in the patients constitutional, genetic, or disease state. Study of mechanisms underlying physiologic problems in the seriously ill also are complicated by effects of drugs, preexisting cellular damage, and behavioral influences. Animal models are used increasingly in nursing science to study clinical problems and care approaches when there is need to ensure experimental control and provide consistency across subjects. The competent clinical investigator who decides to choose this option is advised to seek training in animal care, work with skilled colleagues in the basic sciences, and use excellent consultants. Several considerations arise when choosing a non-human alternative for biobehavioral research. First, there must be a compelling reason to choose this model, not simply for convenience or novelty. Second, the investigation should be humane, well planned, and well supported. Animal studies are not necessarily more economical than those involving humans, and they require serious ethical and scientific consideration to justify their use. When these conditions are met, the use of non-human models often can clarify a biobehavioral mechanism or biophysical response that will contribute significantly to nursing science.

Aging in place: a life course perspective.

Aging in place, whereby older adults remain at home or a similar preferred setting for as long as possible with asmuch ability and dignity as possible, involves addressing healthand age-related changes within a coordinated plan of health care, social, financial, housing, technology, and resource use. The need to consider issues surrounding health care in an aging population is painfully urgent. Challenges to older adults for dealing with longer life, declining health, and fewer resources are highly complex. Seeking approaches that facilitate aging in place poses challenges beyond health care and no generic plan can adequately meet every older adult’s needs. An integrative approach, viewing problems and solutions from a life course perspective makes sense on several levels. Derived from life course theory, the approach has been used by social scientists for decades to analyze people’s lives within structural, social, and cultural contexts. The need for solutions to promote and maintain health, offer social support, and assure safe environments calls for interprofessional and cross-disciplinary collaboration. The idyllic dreams of restful recreation, vacation travel, or visits to relatives are often economically or physically impossible. Planning for the future for many adults has been inadequate, based on unrealistic expectations of what advanced age would actually be like. Many older persons reside in residences not fully supportive of their life stage needs. Most homes fall into the category of “Peter Pan housing,” quips Dr Jon Pynoos, professor at USC Davis School of Gerontology. The term refers to houses designed for persons who are never going to age and consequently are plagued with obstacles in three major areas: getting in and out of the house, up and down stairs, and using the bathroom. Home infrastructure deteriorates over time and is compounded by physical demands associated with home maintenance and increases in property taxes and utility costs. Limited or no access to transportation due to the built