Margo A. Halm

Effects of music therapy on physiological and psychological outcomes for patients undergoing cardiac surgery.

Background: Cardiac surgery is a common interventional procedure for ischemic and valvular heart disease. Cardiac surgery is accompanied by postoperative pain and anxiety. The use of music therapy has been shown to reduce pain, anxiety, and physiological parameters in patients having surgical procedures. Objectives: To compare the effects of music therapy versus a quiet, uninterrupted rest period on pain intensity, anxiety, physiological parameters, and opioid consumption after cardiac surgery. Subjects and methods: An experimental design was used. A total sample of 86 patients (69.8% males) were randomized to 1 of 2 groups; 50 patients received 20 minutes of music (intervention), whereas 36 patients had 20 minutes of rest in bed (control). Anxiety, pain, physiologic parameters, and opioid consumption were measured before and after the 20-minute period. Results: A significant reduction in anxiety (P ≤ .001) and pain (P = .009) was demonstrated in the group that received music compared with the control group, but no difference was observed in systolic blood pressure (P = .17), diastolic blood pressure (P = .11), or heart rate (P = .76). There was no reduction in opioid usage in the 2 groups. Conclusions: Patients recovering from cardiac surgery may benefit from music therapy.

Women and cardiac rehabilitation: referral and compliance patterns.

Heart disease is the primary killer among American women. Differences in referral for cardiac rehabilitation, as well as compliance rates, have been reported between male and female cardiac patients. This study explored the use of Phase I and Phase II cardiac rehabilitation programs by male and female patients. In particular, the study aimed to investigate the relationship between eligibility and subsequent referral to Phase II cardiac rehabilitation in both men and women, as well as their compliance rates in completing Phase II. In addition, for those patients who never started a Phase II program, their reasons for nonparticipation were explored. Structured patient interviews and chart audits were used to explore cardiac rehabilitation eligibility criteria, referral and completion rates. The sample consisted of 87 patients (46 women and 41 men) who were admitted with a medical diagnosis of angina, myocardial infarction, coronary artery bypass grafting, or valve replacement surgery. Men had higher eligibility rates for Phase I, whereas women had higher eligibility rates for Phase II; more men received a referral for Phase II from their physician than women did. Men had a higher completion rate with Phase II compared with women. For those patients who chose not to start a Phase II program, the most common reasons cited included transportation problems, insurance issues, and having exercise equipment at home. Although women are being referred for cardiac rehabilitation, fewer complete the programs. Continued education is essential to teach women the importance of cardiac rehabilitation to overall recovery and adaptation to an acute cardiac event. In addition, cardiac rehabilitation programs must be structured to meet the unique needs of women and thereby remove obstacles that have prevented higher participation rates by women in the past.

AACN Levels of Evidence: What’s New?

tice related to disease management or skills. As a leader in this area, the American Association of CriticalCare Nurses (AACN) has published numerous resources to help practitioners appraise evidence for integration into clinical practice. Publications such as Practice Alerts, Protocols for Practice, and Procedure Manual contain recommendations for clinical practice based on a comprehensive and scientific review of the evidence. To support these recommendations, AACN developed a hierarchy system to grade the level of evidence. AACN’s grading system was originally referred to as a rating scale and was used to rank individual recommendations according to the level of supporting evidence available (Table 1).

Effect of Oral Care on Bacterial Colonization and Ventilator-Associated Pneumonia

Critical care nurses are mindful of the need for oral care in patients receiving mechanical ventilation. The Centers for Disease Control and Prevention (CDC) recommend comprehensive oral hygiene programs (potentially including antiseptic agents) for patients at risk for nosocomial pneumonia. The Centers for Medicare and Medicaid Services (CMS) have recently identified 10 “neverevent” diagnoses with hospital reimbursement implications. CMS has indicated that it will create a code to identify ventilator-associated pneumonia (VAP) as a future preventable hospital-acquired condition. Nosocomial pneumonia has been correlated with dental plaque and oropharynx colonization in patients receiving mechanical ventilation. Oropharyngeal flora and microbes undergo changes within 48 hours of admission to the intensive care unit (ICU). Endotracheal tubes most likely serve as conduits for colonization because these same microorganisms can be traced to respiratory infections. Subglottal suctioning of secretions lying above the endotracheal cuff has proven effective in reducing rates of VAP. Although many believe that oral care regimens reduce oropharyngeal colonization, insufficient research exists on the impact of such regimens on VAP. In this review, we summarize the current evidence on the effect that oral care has on dental plaque, oropharyngeal colonization, and nosocomial pneumonia in patients receiving mechanical ventilation.

Feeding Tube Placement in Adults: Safe Verification Method For Blindly Inserted Tubes

E nteral feeding is a common and necessary practice in critical care. Clinical practice for verification of smalland large-bore feeding tubes is variable. Although radiographic confirmation is the reference standard for blindly inserted small-bore tubes, it is not consistently performed to verify large-bore tubes before administration of formula or medication. These practices raise concerns; both smalland large-bore tube placement in the tracheobronchial tree have been reported. Malpositioning has also involved the intracranial cavity. In a review of more than 2000 insertions of small-bore tubes, 50 pulmonary placements (3%) were detected. In another study, the incidence of inadvertent pulmonary placement did not differ between smalland large-bore tubes. Of note, endotracheal or tracheostomy tube cuffs do not prevent pulmonary malposition. Unfortunately, pulmonary malplacement may occur silently, without coughing, dyspnea, or oxygen desaturation. Adding confusion, aspirated fluids that resemble gastric fluids have been obtained from tubes placed in the lungs. Malpositioned tubes may cause pneumonia, pneumothorax, perforations, empyema, and bronchopleural fistula—events that can lead to death in rare cases. The Joint Commission identified pulmonary malposition of nasogastric tubes as one of the most frequent procedural complications that result in postoperative sentinel events. Expert recommendation included checking tube placement with an abdominal radiograph. Also, failure to report malpositioned tubes and complications due to insertion continues to be a problem. In addition to pulmonary malposition, aspiration risk is high when tubes are placed in the esophagus A regular feature of the American Journal of Critical Care, Clinical Evidence Review unveils available scientific evidence to answer questions faced in contemporary clinical practice. It is intended to support, refute, or shed light on health care practices where little evidence exists. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click “Respond to This Article” on either the full-text or PDF view of the article. We welcome letters regarding this feature and encourage the submission of questions for future review.

Correlates of Caregiver Burden After Coronary Artery Bypass Surgery

Background: Coronary artery bypass (CAB) patients often rely on spouses for care and assistance during recovery after surgery. Caregiving can be stressful and meaningful depending upon the interplay of many factors not completely understood. These factors may affect the spouse caregivers health-related quality of life (HRQL), which may impact ability to care for the CAB patient. Objective: To investigate patient-spouse caregiver relationship and role variables associated with caregiver burden during the first year after CAB surgery. Methods: Using a cross-sectional design, a convenience sample of CAB spouses was recruited at 3, 6, or 12 months. Spouses (n = 166) completed a survey that included perceptions of patient health status, caregiver burden and other caregiving variables, and caregiver HRQL. Results: Higher burden scores were associated with patients gender (female), poorer patient health status, lower caregiver mental HRQL, increased personal gain, and increased caregiver competence. These correlates explained 38% of the variance in caregiver burden. Discussion: Only poorer patient health status and lower caregiver mental HRQL were supported by previous research in this population. Positive relationships between burden and caregiver competence and personal gain may be a reflection that spouse caregivers were invested and working hard. They felt satisfied from enhancement of self but were burdened from their caregiving role, providing support for a previously described two-domain caregiving model. Caregiver screening is essential to identify spouses at high risk for negative outcomes. Longitudinal research is needed to identify the correlates and predictors most likely to influence burden and caregiver gain over time, and to more fully understand caregiving in the CAB population.

Obtaining Blood Samples From Peripheral Intravenous Catheters: Best Practice?

Occasionally, nurses perform phlebotomy via intravenous catheters, especially to improve efficiency in short-stay or procedural units. The intent of this practice is to reduce the number of venipunctures and thus increase patients’ comfort. However, obtaining laboratory specimens from peripheral intravenous catheters may hemolyze the specimens, and can even dislodge catheters and necessitate restarts. Both of these scenarios may lead to multiple needle sticks and delayed treatment, not only reducing patients’ satisfaction but also increasing costs of care. 1

Preceptor-Based Orientation Programs: Effective for Nurses and Organizations?

Nursing orientation for acute or critical care nurses typically occurs in 3 stages: general hospital orientation (1 day), general nursing orientation (3-5 days), and a 6to 12-week (or longer) precepted clinical experience whereby new nurses are paired with experienced nurses to learn directly on the unit of hire. Preceptors assist orientees to acquire basic nursing/unit-specific skills and become familiar with patients, protocols, care providers, and the unit’s culture. By the end of orientation, orientees are expected to demonstrate competence in basic unit-specific skills. Casey et al surveyed a cross-section of new graduate nurses (NGNs) from different hospital areas and found high stress and difficulty transitioning from student to professional roles. Root causes included lack of confidence in skill performance, deficits in critical thinking/clinical knowledge, relationships with peers and preceptors, struggles with dependence on others, frustrations related to the work environment (eg, nurse-to-patient ratios), organization/priority setting, and communication with physicians. As Casey et al acknowledged, preceptors are integral to role modeling of professional behaviors and facilitating nurses’ adjustments to their role. Thus, preceptors have immense responsibilities. This review was conducted to discover what impact preceptored orientation programs have on clinical knowledge and skills of nurse orientees as well as organizational and financial outcomes.

Early discharge with home health care in the coronary artery bypass patient.

Early hospital discharge after coronary artery bypass graft surgery has been the standard of practice throughout the United States. This study compared outcomes, readmissions, and costs for patients discharged early with home health care with those of patients discharged a day or more later without home health care. Discharging open-heart surgery patients on postoperative day 4 with home health care was found to be safe and cost-effective.

Relaxation: A Self-Care Healing Modality Reduces Harmful Effects of Anxiety

Anxiety, a state of uneasiness or apprehension toward a vague or nonspecific threat, is prevalent in cardiac patients. Estimates are as high as 70% to 80% during the acute phase, and it persists long-term in 20% to 25% of patients. Anxiety inflicts its toll through 3 major pathways. In the physiological pathway, anxiety affects the musculoskeletal system by causing muscular tension; the autonomic nervous system by arousing sympathetic responses; and the psychoneuroendocrine system (hypothalamic-pituitary-adrenal axis) by triggering secretion of catecholamines and glucocorticoids (see Figure). The psychological pathway elevates negative mood states, whereas the social-behavioral pathway promotes disconnection from self and others and stress inhibition with resultant unhealthy lifestyle behaviors. The deleterious effects of this psychophysiological stress response are troublesome because anxiety is an independent predictor of arrhythmic/ischemic complications and increased mortality in cardiac patients. As part of autonomous nursing practice, relaxation is an integrative therapy that calms the mind and body by reducing sympathetic nervous system activity. The resultant relaxation response is characterized by lower respiration, heart rate, blood pressure, myocardial oxygen consumption, and muscle tone. The beauty of relaxation is that it can be used in any setting, and only a basic set of instructions and a quiet, comfortable environment are needed. The relaxation response, consisting of a mental device, passive attitude, and decreased muscle tone, may be evoked through many techniques. A regular feature of the American Journal of Critical Care, Clinical Evidence Review unveils available scientific evidence to answer questions faced in contemporary clinical practice. It is intended to support, refute, or shed light on healthcare practices where little evidence exists. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click “Respond to This Article” on either the full-text or PDF view of the article. We welcome letters regarding this feature and encourage the submission of questions for future review.