Mary Lou Sole

The Effect of Music on Postoperative Pain and Anxiety

The purpose of this study was to determine if listening to music or having a quiet rest period just before and just after the first ambulation on postoperative day 1 can reduce pain and/or anxiety or affect mean arterial pressure, heart rate, respiratory rate, and/or oxygen saturation in patients who underwent a total knee arthroplasty. Fifty-six patients having a total knee arthroplasty were randomly assigned to either a music intervention group or a quiet rest group. A visual analog scale was used to measure pain and anxiety. Physiologic measures, including blood pressure, heart rate, oxygen saturation, and respiratory rate, were also obtained. Statistical findings between groups indicated that the music groups decrease in pain and anxiety was not significantly different from the comparison rest groups decrease in pain (F = 1.120; p = .337) or anxiety (F = 1.566; p = .206) at any measurement point. However, statistical findings within groups indicated that the sample had a statistically significant decrease in pain (F = 6.699; p = .001) and anxiety (F = 4.08; p = .013) over time. Results of this research provide evidence to support the use of music and/or a quiet rest period to decrease pain and anxiety. The interventions pose no risks and have the benefits of improved pain reports and decreased anxiety. It potentially could be opioid sparing in some individuals, limiting the negative effects from opioids. Nurses can offer music as an intervention to decrease pain and anxiety in this patient population with confidence, knowing there is evidence to support its efficacy.

Nursing Strategies to Prevent Ventilator-Associated Pneumonia

Critically ill patients who require mechanical ventilation are at high risk for development of pneumonia during the course of treatment. Ventilator-associated pneumonia leads to higher rates of mortality and morbidity, increased length of hospital stay, and higher hospital costs. The intubation that is necessary for mechanical ventilation impairs the patients normal defense mechanisms for fighting infection. Impaired defenses, along with such risk factors as age of the patient, equipment used, and failure of the staff to wash hands increase the likelihood of colonization of the lower airways. Colonization and subsequent pneumonia commonly occurs from microaspiration of secretions from the oropharynx and gastrointestinal tract. In this article, the mechanism of microaspiration, diagnosis of ventilator-associated pneumonia, and nursing strategies to reduce the incidence of pneumonia are described.

Evaluation of an Intervention to Maintain Endotracheal Tube Cuff Pressure Within Therapeutic Range

BACKGROUND Endotracheal tube cuff pressure must be kept within an optimal range that ensures ventilation and prevents aspiration while maintaining tracheal perfusion. OBJECTIVES To test the effect of an intervention (adding or removing air) on the proportion of time that cuff pressure was between 20 and 30 cm H(2)O and to evaluate changes in cuff pressure over time. METHODS A repeated-measure crossover design was used to study 32 orally intubated patients receiving mechanical ventilation for two 12-hour shifts (randomized control and intervention conditions). Continuous cuff pressure monitoring was initiated, and the pressure was adjusted to a minimum of 22 cm H(2)O. Caregivers were blinded to cuff pressure data, and usual care was provided during the control condition. During the intervention condition, cuff pressure alarm or clinical triggers guided the intervention. RESULTS Most patients were men (mean age, 61.6 years). During the control condition, 51.7% of cuff pressure values were out of range compared with 11.1% during the intervention condition (P < .001). During the intervention, a mean of 8 adjustments were required, mostly to add air to the endotracheal tube cuff (mean 0.28 [SD, 0.13] mL). During the control condition, cuff pressure decreased over time (P < .001). CONCLUSIONS The intervention was effective in maintaining cuff pressure within an optimal range, and cuff pressure decreased over time without intervention. The effect of the intervention on outcomes such as ventilator-associated pneumonia and tracheal damage requires further study.

Outcomes of an Infection Prevention Project Focusing on Hand Hygiene and Isolation Practices

Nosocomial infections are a major health problem for hospitalized patients and their families. Since the 1800s, hand hygiene has been recognized as the single best method to prevent the spread of pathogens and nosocomial infections. Despite this fact, many healthcare workers do not adhere to hand hygiene policies. The Centers for Disease Control and Prevention issued a guideline for hand hygiene practices in 2002. Multifaceted approaches to improve hand hygiene have been shown to increase compliance among healthcare workers and subsequently reduce infections. A performance improvement project was initiated to implement this guideline and other strategies to prevent nosocomial infection. This article summarizes the performance improvement processes and the preliminary outcomes on adherence to infection prevention policies related to hand hygiene and isolation practices. Clinically and statistically significant increases were noted for hand hygiene prior to patient care and in wearing masks when indicated. Nurses and patient care technicians had the greatest increases in compliance. Increases in hand hygiene after patient contact and wearing of gown and gloves were also noted, but results were not statistically significant. Nosocomial infection rates from antibiotic-resistant organisms decreased in the first surveillance, but rates increased during the 1-year surveillance. Consumption of alcohol-based foam disinfectant doubled from baseline. Findings are consistent with other published studies. The project will continue with further reinforcement and education over the second year.

Assessment of Endotracheal Cuff Pressure by Continuous Monitoring: A Pilot Study

BACKGROUND Endotracheal tube cuff pressure must be maintained within a narrow therapeutic range to prevent complications. Cuff pressure is measured and adjusted intermittently. OBJECTIVES To assess the accuracy and feasibility of continuous monitoring of cuff pressure, describe changes in cuff pressure over time, and identify clinical factors that influence cuff pressure. METHODS In a pilot study, data were collected for a mean of 9.3 hours on 10 patients who were orally intubated and receiving mechanical ventilation. Sixty percent of the patients were white, mean age was 55 years, and mean intubation time was 2.8 days. The initial cuff pressure was adjusted to a minimum of 20 cm H2O. The pilot balloon of the endotracheal tube was connected to a transducer and a pressure monitor. Cuff pressure was recorded every 0.008 seconds during a typical 12-hour shift and was reduced to 1-minute means. Patient care activities and interventions were recorded on a personal digital assistant. RESULTS Values obtained with the cufflator-manometer and the transducer were congruent. Only 54% of cuff pressure measurements were within the recommended range of 20 to 30 cm H2O. The cuff pressure was high in 16% of measurements and low in 30%. No statistically significant changes over time were noted. Endotracheal suctioning, coughing, and positioning affected cuff pressure. CONCLUSIONS Continuous monitoring of cuff pressure is feasible, accurate, and safe. Cuff pressures vary widely among patients.

Getting Ready for Simulation-Based Training: A Checklist for Nurse Educators

&NA; Nurse educators are incorporating computerized patient simulators into curricula with increasing frequency. Although several studies have focused on implementation and a framework for designing simulation using patient simulation, discussion of pre‐training planning for simulation is limited. This article highlights some of the seminal literature from the science of training and discusses principles most applicable to nursing education. A key principle that is critical to successful training is the pre‐training analysis. A framework and checklist were derived from the training literature review and are proposed to assist nurse educators in performing a pre‐training analysis when planning simulation activities. This analysis will help educators define the knowledge, skills, and attitudes appropriate for the simulation experience. The tools are intended to complement existing strategies for planning simulations to provide a more comprehensive approach to simulation, resulting in a targeted and effective use of the teaching strategy.

Oropharyngeal Secretion Volume in Intubated Patients: The Importance of Oral Suctioning

BACKGROUND Aspiration of secretions that accumulate above the cuff of the endotracheal tube is a risk factor for ventilator-associated pneumonia. Routine suctioning of oropharyngeal secretions may reduce this risk; the recommended frequency for suctioning is unknown. OBJECTIVES To quantify the volume of secretions suctioned from the oropharynx of critically ill patients at 2 different intervals to assist in identifying a recommended frequency for oropharyngeal suctioning. METHODS A prospective, repeated measure, single-group design was used. Twenty-eight patients who were orally intubated and treated with mechanical ventilation were enrolled; 2 were extubated during data collection, yielding a sample of 26 patients. The patients were suctioned at baseline with a deep suction catheter, and the volume and weight of secretions were recorded. The procedure was repeated at 2-hour and 4-hour intervals. RESULTS Most of the patients were male (mean age, 49 years). Three suctioning passes were needed to clear secretions, with a mean time of 48.1 seconds. The mean volume of secretions at the 2-hour interval was 7.5 mL. Five patients required suctioning before the 4-hour interval. For the remaining 21 patients, the volume retrieved was 6.5 mL at the 2-hour interval and 7.5 mL at the 4-hour interval (P = .27). The 5 patients who required extra suctioning had significantly more secretions at the 2-hour interval (11.6 mL vs 6.5 mL; P = .05). CONCLUSIONS A minimum frequency of oropharyngeal suctioning every 4 hours is recommended. However, more frequent suctioning may be needed in a subset of patients.

Clinical nurse specialist assessment of nurses' knowledge of heart failure.

Purpose/Objective: Patients’ self-management of heart failure (HF) is associated with improved adherence and reduced readmissions. Nurses’ knowledge about self-management of HF may influence their ability to adequately perform discharge education. Inadequate nurse knowledge may lead to insufficient patient education, and insufficient education may decrease patients’ ability to perform self-management. Prior to developing interventions to improve patient education, clinical nurse specialists should assess nurses’ knowledge of HF. The purpose of this study was to determine nurses’ knowledge of HF self-management principles. Design: This was a prospective, exploratory, and descriptive online test. Settings: There were 3 patient care settings: tertiary care teaching hospital, community hospital, and home healthcare division. Sample: The sample was composed of 90 registered nurses who worked directly with patients with HF. Methods: Nurses completed an online test of knowledge using the Nurses’ Knowledge of Heart Failure Education Principles instrument. Findings: Registered nurses (n = 90) completed the knowledge test instrument; their average score was 71% (SD, 10.8%) (range, 20%–90%). The percentage of correct items on each subscale ranged from 63.9% (SD, 30.0) for medications to 83.3% (SD, 25.0) for exercise. Only 8.9% of respondents achieved a passing score of greater than 85%, and a passing score was not associated with any demographic characteristics. Conclusions: Overall, nursing knowledge of HF self-management principles was low. Scores from our nurses were similar to those found in other studies. Implications: There is a need to develop interventions to improve nursing knowledge of HF self-management principles. Clinical nurse specialists can be instrumental in developing knowledge interventions for nurses.

Clinical Indicators for Endotracheal Suctioning in Adult Patients Receiving Mechanical Ventilation

BACKGROUND Critically ill patients who need mechanical ventilation require endotracheal suctioning. Guidelines recommend coarse crackles over the trachea and/or the presence of a sawtooth pattern on the flow-volume loop of the ventilator waveform as the best indicators. OBJECTIVE To determine clinical cues for endotracheal suctioning in patients who require mechanical ventilation. METHODS A descriptive study of 42 adult patients receiving mechanical ventilation. After baseline endotracheal suctioning with a closed-system device, patients were assessed hourly up to 4 hours for guideline-based cues for endotracheal suctioning and lung sounds were auscultated. Endotracheal suctioning was done when cues were detected or 4 hours after baseline suctioning. Secretions were collected, measured, and weighed. RESULTS Most patients were male (62%) and white (93%). Mean age was 51 years, and mean duration of mechanical ventilation was 7.5 days. The median time to endotracheal suctioning was 2 hours, and a mean of 4.4 mL of secretions was removed. Three patients had no cues identified but had 1.0 mL or more of secretions. The most frequent cues were crackles over the trachea (88%), sawtooth waveform (33%), coughing (29%), and visible secretions (5%). Cues resolved and physiological parameters improved after suctioning. Coarse lung sounds did not improve. CONCLUSIONS Patients receiving mechanical ventilation should be routinely assessed for coarse crackles over the trachea, the most common indicator for endotracheal suctioning. Despite common practice, assessment of lung sounds to identify the need for suctioning is not supported.

Too much information: research issues associated with large databases.

Purpose: The purpose of this article was to discuss common issues associated with large databases and present possible solutions to improve the quality and usefulness of large database research. Background: The volume of electronic healthcare-related data is growing exponentially. Some of these data are being stored in registries and administrative databases. These data repositories are increasingly common and can serve as sources of nurse-driven research and quality improvement activities. Although these large databases have a wealth of useful information, they have limitations that may bias results. These include missing data and cases, data accuracy and validity, and the statistical effect of large samples. Description: Researchers using large databases to address quality, safety, clinical, or systems issues have a variety of available techniques to deal with data issues. Proper data cleaning activities such as screening, visualization, and outlier/inlier identification are essential for addressing inaccurate values within large data sets. Common methods for addressing missing data include case analyses and various imputation techniques. Statistical approaches such as risk reductions and effect size are also useful when working with large sample sizes. Conclusion/Implications: Registries and administrative databases provide healthcare researchers with increasing opportunities to address a wide variety of important practice and patient care questions. Healthcare researchers are encouraged to explore large data sets as they look for ways to improve patient safety and quality care, develop evidence-based practice guidelines, and fulfill regulatory and accreditation requirements.