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Ma S, Zheng X, Gu J, Yang Y, Li C, Li Y, Fan X. Experience of rehabilitation specialist nurses in providing bowel care for stroke patients: A qualitative study. J Adv Nurs 2024; 80:1523-1530. [PMID: 37855380 DOI: 10.1111/jan.15907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 10/03/2023] [Accepted: 10/10/2023] [Indexed: 10/20/2023]
Abstract
AIMS This study aims to explore the experiences of rehabilitation specialist nurses in providing bowel care to stroke patients and to identify the factors that either facilitate or hinder their practice. DESIGN This was a descriptive qualitative design study. METHODS Between May 2022 and October 2022, we conducted in-depth and semi-structured interviews with 12 rehabilitation specialist nurses from two tertiary hospitals in Changsha, China. Thematic analysis was employed to analyse the interview transcripts. FINDINGS Three key themes were revealed from our analysis: (1) acceptance of bowel care as a process, (2) high level of recognition improves the experience and (3) challenges stemming from limited knowledge and rights. Acceptance of bowel care as a dynamic process, coupled with a high level of recognition, enabled nurses to prioritize the health and safety of patients over personal feelings and achieve professional accomplishments. However, they encountered challenges in terms of professional development and restricted prescribing rights for bowel care. CONCLUSION The experiences of rehabilitation specialist nurses in providing bowel care are dynamic. These findings have important implications for healthcare improvement, including the need for collaboration with healthcare professionals and nurturing nurses' self-identity, comprehensive training plans, innovative programs and expanding the scope of rehabilitation specialist nurses' rights. IMPACT This study enhances our understanding of the challenges faced by rehabilitation specialist nurses caring for stroke patients with neurogenic bowel dysfunction. The findings provide insights into how to enhance bowel care experience and develop further in this field. REPORTING METHOD This study adhered to the EQUATOR guideline and utilized the COREQ checklist. PATIENT OR PUBLIC CONTRIBUTIONS This study involved participants who were registered nurses, and there were no contributions from patients or public.
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Affiliation(s)
- Sumin Ma
- School of Nursing, University of South China, Hengyang, China
| | - Xutong Zheng
- School of Nursing, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Jiayi Gu
- Department of Rehabilitation, Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, China
| | - Yongkang Yang
- Department of Intensive Care Medicine, Brain Hospital of Hunan, Changsha, China
| | - Chengjuan Li
- School of Nursing, University of South China, Hengyang, China
| | - Yuan Li
- Department of Neurology, Huai'an First People's Hospital, Huaian, China
| | - Xiaoyan Fan
- Nursing Department, First Hospital of Changsha, Changsha, China
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McConnochie R, O'Brien A, Parke R. A single-centre observational study of delayed defaecation in brain-injured patients in an adult intensive care unit. Aust Crit Care 2024; 37:244-250. [PMID: 37574388 DOI: 10.1016/j.aucc.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 07/07/2023] [Accepted: 07/08/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND The incidence of delayed defaecation is high in enterally fed ventilated patients in intensive care units (ICUs). Those with brain injury may be harmed by increased intracranial pressure if delayed defaecation leads to abdominal distension. There are no studies evaluating a bowel guideline in the treatment of delayed defaecation in ventilated brain-injured ICU patients. OBJECTIVE The objective of this study was to assess the incidence and clinical associations of delayed defaecation and level of compliance to an ICU bowel guideline. METHODS Data were collected on ventilated adult patients with brain injury admitted for more than 3 days to one New Zealand ICU over a 2-year period. RESULTS Data were analysed for 117 patients; 56 (48%) who defaecated within 3 days of ICU admission (Group one) and 61 (52%) with delayed defaecation after 3 days (Group two). Compliance with the bowel guideline was low. Only 1 of 61 patients who should have had a rectal examination did so, and only 7 of 61 patients who should have had an aperient on day 3 did so. All seven received Movicol®, which was not part of the guideline. Use of aperients and enemas was found to be associated with stool passage (odds ratio: 93; 95% confidence interval: 5.2-1668; p = 0.002). Patients with delayed defaecation had longer ICU stays (mean 7.1 ± 4 SD vs 5.9 ± 3 days, p = 0.07) and more often had high gastric residual volumes after day 4 (27/61 vs 14/56; p = 0.003). No differences were seen between the groups in the incidence of ventilator-associated pneumonia, bacterial infections, diarrhoea, vomiting, duration of mechanical ventilation, or mortality. CONCLUSION Delayed defaecation was common, and compliance with the guideline was low. Movicol® and phosphate enemas were effective in stool production.
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Affiliation(s)
- Rachael McConnochie
- Department of Critical Care Medicine, Auckland City Hospital, 2 Park Road, Grafton, Auckland, New Zealand.
| | - Anthony O'Brien
- Te Huataki Waiora - School of Health, University of Waikato, Private Bag 3105, Hamilton 3240, New Zealand
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand; School of Nursing, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
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López J, Sánchez C, Fernández SN, González R, Solana MJ, Urbano J, López-Herce J. Development and validation of a clinical score for early diagnosis of constipation in critically ill children. Sci Rep 2023; 13:14822. [PMID: 37684310 PMCID: PMC10491593 DOI: 10.1038/s41598-023-41674-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
Constipation affects almost 50% of critically ill pediatric patients and is related to their morbidity and mortality. However, little attention is paid to it and it is diagnosed late and when there are already complications. The objective of this study is to develop and validate a score to identify critically ill children with high risk of constipation 48 h after admission. A single center two phase-study was carried out; the first one (retrospective observational study) to develop the score and the second one to validate it in another prospective observational study. Children between 15 days of life and 18 years old admitted to the PICU for more than 3 days were included. Demographic and clinical data during the first 48 h after PICU admission were collected. Univariate and multivariate analysis and ROC curves were used to develop and validate the score. Data from 145 patients (62.8% boys) with a mean age of 34.9 ± 7.3 months were used to develop the score. Independent factors identified to develop the score were: weight > 7 kg, admission to PICU after surgery, need of vasoconstrictors, doses of fentanyl ≥ 2 mcg/kg/h, and initiation of enteral nutrition later than 48 h after admission. Two cut-off values were identified to set low constipation risk (< 5.7 points) and high constipation risk (> 6.2 points). This score was validated in 124 patients showing a sensibility of 63.2%, specificity of 95.5% and a positive/negative predictive values (P/NPV) of 100% and 82.1% respectively to identify constipated patients. This is the first score to identify high constipation risk in critically ill children. This score is easy to apply, and internal validation has shown a PPV of 100%.
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Affiliation(s)
- J López
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011 of Instituto de Salud Carlos III, Complutense University of Madrid, Spain. C/ Dr Castelo 47, 28009, Madrid, Spain.
| | - C Sánchez
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011 of Instituto de Salud Carlos III, Complutense University of Madrid, Spain. C/ Dr Castelo 47, 28009, Madrid, Spain
- Pediatric Gastroenterology Unit, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011 of Instituto de Salud Carlos III, Complutense University of Madrid, Madrid, Spain
| | - S N Fernández
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011 of Instituto de Salud Carlos III, Complutense University of Madrid, Spain. C/ Dr Castelo 47, 28009, Madrid, Spain
| | - R González
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011 of Instituto de Salud Carlos III, Complutense University of Madrid, Spain. C/ Dr Castelo 47, 28009, Madrid, Spain
| | - M J Solana
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011 of Instituto de Salud Carlos III, Complutense University of Madrid, Spain. C/ Dr Castelo 47, 28009, Madrid, Spain
| | - J Urbano
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011 of Instituto de Salud Carlos III, Complutense University of Madrid, Spain. C/ Dr Castelo 47, 28009, Madrid, Spain
| | - J López-Herce
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011 of Instituto de Salud Carlos III, Complutense University of Madrid, Spain. C/ Dr Castelo 47, 28009, Madrid, Spain.
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López J, Barba MG, Fernández SN, Solana MJ, Urbano J, Sánchez C, López-Herce J. Protocol for treatment of constipation with polyethylene glycol 3350 plus electrolytes in critically ill children. An Pediatr (Barc) 2023; 99:176-184. [PMID: 37640660 DOI: 10.1016/j.anpede.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/02/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES No studies have analysed the effectiveness of treatment for constipation in critically ill children. The aim of this study was to assess the implementation, efficacy and safety of a treatment protocol using polyethylene glycol 3350 with electrolytes (PEG 3350 + E) for constipation in critically ill children. METHODS We conducted a single-centre prospective study in children admitted to the paediatric intensive care unit for a minimum of 72 h and who developed constipation. Children with previous gastrointestinal disorders or diseases were excluded. The patients were treated with rectal enemas or with the oral PEG 3350 + E protocol at the discretion of the treating physician. We compared clinical and demographic variables as well as adverse events (diarrhoea, abdominal distension and electrolyte imbalances). RESULTS The sample included 56 patients with a mean age of 48.2 ± 11.9 months, of who 55.4% were male. Forty-four patients (78.6%) were treated with PEG 3350 + E and 12 (21.4%) with rectal enemas. The proportion of patients that responded well to treatment was greater in the PEG 3350 + E group (79.5%) compared to the enema group (58.3%), but the difference was not statistically significant (P = .151). There were no significant differences between the groups in any of the adverse effects. Treatment with PEG 3350 + E was more effective in children aged less than 2 years (100%) compared to older children (100% vs 65.4%; P < .01), with no significant differences in the development of adverse events. CONCLUSIONS The PEG 3350 + E treatment protocol for constipation in critically ill children was effective and associated with few adverse events, even in children aged less than 2 years.
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Affiliation(s)
- Jorge López
- Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network, Redes de Investigación Cooperativa Orientadas a Resultados en Salud [RICORS]) (RD21/0012/0011), Instituto de Salud Carlos III, Universidad Complutense de Madrid, Madrid, Spain.
| | - María G Barba
- Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Montepríncipe, Madrid, Spain
| | - Sarah N Fernández
- Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network, Redes de Investigación Cooperativa Orientadas a Resultados en Salud [RICORS]) (RD21/0012/0011), Instituto de Salud Carlos III, Universidad Complutense de Madrid, Madrid, Spain
| | - María J Solana
- Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network, Redes de Investigación Cooperativa Orientadas a Resultados en Salud [RICORS]) (RD21/0012/0011), Instituto de Salud Carlos III, Universidad Complutense de Madrid, Madrid, Spain
| | - Javier Urbano
- Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network, Redes de Investigación Cooperativa Orientadas a Resultados en Salud [RICORS]) (RD21/0012/0011), Instituto de Salud Carlos III, Universidad Complutense de Madrid, Madrid, Spain
| | - César Sánchez
- Unidad de Gastroenterología Infantil, Hospital Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, RICORS (RD21/0012/0011), Instituto de Salud Carlos III, Universidad Complutense de Madrid, Madrid, Spain
| | - Jesús López-Herce
- Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network, Redes de Investigación Cooperativa Orientadas a Resultados en Salud [RICORS]) (RD21/0012/0011), Instituto de Salud Carlos III, Universidad Complutense de Madrid, Madrid, Spain
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Park YG, Kim BS, Kang KT, Ha YC. Effects of Abdominal Massage for Preventing Acute Postoperative Constipation in Hip Fractures: A Prospective Interventional Study. Clin Orthop Surg 2023; 15:546-551. [PMID: 37529190 PMCID: PMC10375809 DOI: 10.4055/cios22091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 10/03/2022] [Accepted: 10/10/2022] [Indexed: 08/03/2023] Open
Abstract
Background This prospective randomized controlled study aimed to determine the effects of abdominal massage on constipation management in elderly patients with hip fractures. Methods From August 2017 to December 2018, patients aged above 65 years with hip fractures (n = 88) were randomly assigned to a massage group that received a bowel massage (n = 48) or a control group that did not receive a bowel massage (n = 40). Patients in the bowel massage group received a bowel massage from a trained caregiver after breakfast at approximately 9:00 AM for an hour. On admission, 5 days after surgery, and on the day of discharge, the patient's normal and actual defecation pattern, stool consistency, and any problems with defecation were assessed through a structured interview. The questionnaire comprising the Bristol Stool Scale, patient assessment of constipation, time to defecation, medication for defecations, failure to defecate, cause of admission, admission period, and date of surgery were recorded. Statistical analyses were performed 5 days after surgery and on the day of discharge. Results The mean age of the study cohort was 81.4 years (range, 65-99 years). The number of constipation remedies was significantly lower in the massage group than in the control group on postoperative day (POD) 5 and at discharge (9 vs. 15, p = 0.049 and 6 vs. 11, p = 0.039, respectively). The number of defecation failures was significantly lower in the massage group than in the control group (10 vs. 17, p = 0.028) on POD 5. However, the number of defecation failures at discharge was not significantly different between the two groups (p = 0.131). The development of postoperative ileus (p = 0.271) and length of hospital stay (p = 0.576) were not different between the groups. Conclusions The number of constipation remedies was significantly lower in the massage group than in the control group on POD 5 and discharge, and the number of defecation failures was significantly lower in the massage group than in the control group on POD 5. Therefore, abdominal massage may be considered as an independent nursing initiative for constipation management.
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Affiliation(s)
- Yong-Gum Park
- Department of Surgery, Chung-Ang University Hospital, Chung-Ang University School of Medicine, Seoul, Korea
| | - Boo Seop Kim
- Department of Orthopedic Surgery, Chung-Ang University H.C.S. Hyundae General Hospital, Namyangju, Korea
| | - Kyu-Tae Kang
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University School of Medicine, Seoul, Korea
| | - Yong-Chan Ha
- Department of Orthopedic Surgery, Seoul Bumin Hospital, Seoul, Korea
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Wanik J, Teevan C, Pepin L, Andrews L, Dalessio L, Feda J, Kevorkian NM, Weintraub S. Implementation of a Bowel Protocol to Improve Enteral Nutrition and Reduce Clostridium difficile Testing. Crit Care Nurse 2020; 39:e10-e18. [PMID: 31961942 DOI: 10.4037/ccn2019304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Underfeeding is common among adult patients receiving enteral nutrition. Constipation and diarrhea have been associated with low enteral nutrition volume in critically ill patients. In patients with diarrhea, Clostridium difficile is often suspected and tested for, although medications, illness, or enteral formulas are usually the cause. The use of bowel protocols to proactively address constipation, diarrhea, and inappropriate testing for hospital-onset C difficile infection, thereby improving enteral nutrition, remains unclear. OBJECTIVE To evaluate the efficacy of implementing protocols to decrease constipation, diarrhea, and inappropriate testing for hospital-onset C difficile infection, and to deliver larger enteral nutrition volumes in a critical care unit. METHODS A prospective convenience sample was used. The primary outcome was the proportion of patients receiving greater than or equal to 80% of their prescribed caloric volume 1 week (minimum 4 days) after initiating enteral nutrition. Rates of testing for hospital-onset C difficile infection were analyzed before and after the protocol was implemented. RESULTS After the protocol was implemented, patients experienced significant increases in delivery of enteral nutrition volume-up to 78% of the goal volume (P = .048). The standardized infection ratio of hospital-onset C difficile infection decreased 43% (P = .04). CONCLUSIONS The implementation of bowel protocols improved delivery of total enteral volumes and reduced inappropriate testing for hospital-onset infections with C difficile, and they may improve patient safety and facilitate positive patient outcomes.
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Affiliation(s)
- Jillian Wanik
- Jillian Wanik is an assistant professor, University of Connecticut, and a dietician, Hospital of Central Connecticut, New Britain, Connecticut
| | - Colleen Teevan
- Colleen Teevan is a critical care pharmacist, Hospital of Central Connecticut
| | - Lynn Pepin
- Lynn Pepin is an infection control nurse, Hospital of Central Connecticut
| | - Laura Andrews
- Laura Andrews is an associate professor, Yale School of Nursing, and senior acute care nurse practitioner, Hospital of Central Connecticut
| | - Linda Dalessio
- Linda Dalessio is an assistant professor, Nursing Western Connecticut State University, Danbury, Connecticut
| | - Jennifer Feda
- Jennifer Feda is a nutrition support dietitian, Hospital of Central Connecticut
| | - Noubar M Kevorkian
- Noubar Kevorkian is a surgical intensivist, Hospital of Central Connecticut
| | - Sharon Weintraub
- Sharon Weintraub is a surgical intensivist, Hospital of Central Connecticut
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Danielis M, Palese A, Terzoni S, Destrebecq ALL. What nursing sensitive outcomes have been studied to-date among patients cared for in intensive care units? Findings from a scoping review. Int J Nurs Stud 2019; 102:103491. [PMID: 31862529 DOI: 10.1016/j.ijnurstu.2019.103491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/18/2019] [Accepted: 11/22/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Although many studies have considered mortality and adverse effects as outcomes sensitive to nursing practice, it seems that other outcomes of nursing care in intensive care units have been explored less commonly. OBJECTIVES To describe the state-of-science in research in the field of nursing sensitive outcomes in intensive care units and to synthesize outcomes that have been documented to date as being influenced by nursing care. DESIGN A scoping review study based on the framework proposed by Arksey and O'Malley, further refined by the Levac and Joanna Briggs Institute was performed in 2019. DATA SOURCES The Medline, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Scopus, and Google Scholar electronic databases were searched. In addition, the reference list of included articles was screened. REVIEW METHODS Two researchers independently identified publications on the basis of the following criteria: (a) articles that reported nursing sensitive outcomes on critically-ill adult patients admitted to the intensive care unit, (b) as primary and secondary studies, (c) written in English, and (d) without any time frame limitation. RESULTS Of the 4,231 records, 112 fully met the inclusion criteria and were included. Publications were mainly authored in the US and Canada (n = 44, 39.2%), and the majority (n = 62, 55.3%) had an observational design. A total of 233 nursing sensitive outcomes emerged, categorized in 35 outcomes, with, on average, two per study included. The most often measured outcomes were pressure ulcers (20 studies) and ventilator-associated pneumonias (19 studies); the less studied outcomes were quality of life, secretion clearance, patient-ventilator dysynchrony, and post-extubation dysphagia. When categorizing outcomes, the ones concerning safety (n = 77, 33.1%) were represented the most, followed by those concerning the clinical (n = 72, 30.9%), functional (n = 70, 30.0%), and perceptual (n = 14, 6.0%) domains. The interdependent outcomes linked to multi-professional interventions (e.g., ventilator-associated pneumonias) were the most frequently studied nursing sensitive outcomes (n = 20, 57.1%), while independent outcomes resulting from autonomous interventions performed by nurses were less often studied (n = 8, 22.9%). CONCLUSIONS From a clinical point of view, a large heterogeneity of outcomes influenced by nursing care emerged. However, identified outcomes have been studied with different approaches and metrics, so that future efforts will need to establish homogeneous conceptual and operative definitions. Moreover, increasing efforts in establishing perceptual outcomes, or those close to the fundamentals of nursing care, are suggested in order to better depict the contribution of critical care nurses in the field.
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Affiliation(s)
- Matteo Danielis
- Department of Clinical Sciences and Community Health, University of Milan, Via Vanzetti 5, 20133 Milan, Italy; School of Nursing, Department of Medical Sciences, University of Udine, Udine, Italy.
| | - Alvisa Palese
- School of Nursing, Department of Medical Sciences, University of Udine, Udine, Italy
| | - Stefano Terzoni
- School of Nursing, San Paolo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
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Sonneborn O, Bui T. Opioid induced constipation management in orthopaedic and trauma patients: treatment and the potential of nurse-initiated management. Int J Orthop Trauma Nurs 2019; 34:16-20. [DOI: 10.1016/j.ijotn.2019.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 03/01/2019] [Accepted: 03/07/2019] [Indexed: 01/12/2023]
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Kourouche S, Buckley T, Van C, Munroe B, Curtis K. Designing strategies to implement a blunt chest injury care bundle using the behaviour change wheel: a multi-site mixed methods study. BMC Health Serv Res 2019; 19:461. [PMID: 31286954 PMCID: PMC6615309 DOI: 10.1186/s12913-019-4177-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 05/20/2019] [Indexed: 12/16/2022] Open
Abstract
Background Blunt chest injury can lead to significant morbidity and mortality if not treated appropriately. A blunt chest injury care bundle was to be implemented at two sites to guide care. Aim To identify facilitators and barriers to the implementation of a blunt chest injury care bundle and design strategies tailored to promote future implementation. Methods 1) A mixed-method survey based on the theoretical domains framework (TDF) was used to identify barriers and facilitators to the implementation of a blunt chest injury care bundle. This survey was distributed to 441 staff from 12 departments across two hospitals. Quantitative data were analysed using SPSS and qualitative using inductive content analysis. 2) The quantitative and qualitative results from the survey were integrated and mapped to each of the TDF domains. 3) The facilitators and barriers were evaluated using the Behaviour Change Wheel to extract specific intervention functions, policies, behaviour change techniques and implementation strategies. Each phase was assessed against the Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side-effects or safety and Equity (APEASE) criteria. Results One hundred ninety eight staff completed the survey. All departments surveyed were represented. Nine facilitators and six barriers were identified from eight domains of the TDF. Facilitators (TDF domains) were: understanding evidence-informed patient care and understanding risk factors (Knowledge); patient assessment skills and blunt chest injury management skills (Physical skills); identification with professional role (Professional role and identity); belief of consequences of care bundle (Belief about consequences); provision of training and protocol design (Environmental context and resources); and social supports (Social influences). Barriers were: not understanding the term ‘care bundle’ (Knowledge); lacking regional analgesia skills (Physical skills); not remembering to follow protocol (Memory, attention, and decision processes); negative emotions relating to new protocols (Emotions); equipment and protocol access (Environmental context and resources). Implementation strategies were videos, education sessions, visual prompt for electronic medical records and change champions. Conclusions Multiple facilitators and barriers were identified that may affect the implementation of a blunt chest injury care bundle. Implementation strategies developed through this process have been included in a plan for implementation in the emergency departments of two hospitals. Evaluation of the implementation is underway. Electronic supplementary material The online version of this article (10.1186/s12913-019-4177-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah Kourouche
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia.
| | - Tom Buckley
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia
| | - Connie Van
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia
| | - Belinda Munroe
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia.,Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong, NSW, Australia
| | - Kate Curtis
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia.,Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong, NSW, Australia
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Warren D, Kent B. Determining the impact of a bowel management protocol on patients and clinicians' compliance in cardiac intensive care: A mixed-methods approach. J Clin Nurs 2018; 28:89-103. [PMID: 30184274 DOI: 10.1111/jocn.14669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 07/14/2018] [Accepted: 08/29/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Bowel management protocols standardise care and, potentially, improve the incidence of diarrhoea and constipation in intensive care. However, little research exists reporting compliance with such protocols in intensive care throughout patients' stay. Furthermore, there is a limited exploration of the barriers and enablers to bowel management protocols following their implementation, an important aspect of improving compliance. AIM AND OBJECTIVE To investigate the impact of a bowel management protocol on the incidence of constipation and diarrhoea, levels of compliance, and to explore the enablers and barriers associated with its use in intensive care. METHODS A mixed-methods study was conducted in cardiac intensive care using two phases: (a) a retrospective case review of patients' hospital notes, before and after the protocol implementation, establishing the levels of diarrhoea and constipation and levels of compliance; (b) focus groups involving users of the protocol, 6 months following its implementation, exploring the barriers and enablers in practice. RESULTS AND FINDINGS Fifty-one patients' notes were reviewed during phase one: 30 pre-implementation and 21 post-implementation. Following the protocol implementation, there was a tendency for a higher incidence of constipation and less severe cases of diarrhoea. Overall compliance with the protocol was low (2.3%). However, there was evidence of behavioural change following protocol implementation, including less variation in aperients given and a shorter, less varied time period between starting enteral feed and administering aperients. Several themes emerged from the focus groups: barriers and enablers to the protocol characteristics and dissemination; barriers to bowel assessment; nurse as a barrier; medical involvement and protocol outcomes. CONCLUSIONS The bowel management protocol implementation generated some positive outcomes to bowel care practices. However, compliance was low and until there is improvement, through overcoming the barriers identified, the impact of such protocols in practice will remain largely unknown.
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Affiliation(s)
- Dawn Warren
- Faculty of Health and Human Sciences, School of Nursing and Midwifery, University of Plymouth, Plymouth, UK.,Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Bridie Kent
- Faculty of Health and Human Sciences, School of Nursing and Midwifery, University of Plymouth, Plymouth, UK
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Oczkowski SJW, Duan EH, Groen A, Warren D, Cook DJ. The Use of Bowel Protocols in Critically Ill Adult Patients: A Systematic Review and Meta-Analysis. Crit Care Med 2017; 45:e718-e726. [PMID: 28350645 DOI: 10.1097/ccm.0000000000002315] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Constipation is common among critically ill patients and has been associated with adverse patient outcomes. Many ICUs have developed bowel protocols to treat constipation; however, their effect on clinical outcomes remains uncertain. We conducted a systematic review to determine the impact of bowel protocols in critically ill adults. DATA SOURCES We searched MEDLINE, Embase, CINAHL, CENTRAL, ISRCTN, ClinicalTrials.gov, and conference abstracts until January 2016. STUDY SELECTION Two authors independently screened titles and abstracts for randomized controlled trials comparing bowel protocols to control (placebo, no protocol, or usual care) in critically ill adults. DATA EXTRACTION Two authors independently, and in duplicate, extracted study characteristics, outcomes, assessed risk of bias, and appraised the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. DATA SYNTHESIS We retrieved 4,520 individual articles, and excluded 4,332 articles during title and abstract screening and 181 articles during full-text screening. Four trials, including 534 patients, were eligible for analysis. The use of a bowel protocol was associated with a trend toward a reduction in constipation (risk ratio, 0.50 [95% CI, 0.25-1.01]; p = 0.05; low-quality evidence); no reduction in tolerance of enteral feeds (risk ratio, 0.94 [95% CI, 0.62-1.42]; p = 0.77; low-quality evidence), and no change in the duration of mechanical ventilation (mean difference, 0.01 d [95% CI, -2.67 to 2.69 d]; low-quality evidence). CONCLUSIONS Large, rigorous, randomized control trials are needed to determine whether bowel protocols impact patient-important outcomes in critically ill adults.
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Affiliation(s)
- Simon J W Oczkowski
- 1Department of Medicine, McMaster University, Hamilton, ON, Canada.2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.3St Joseph's Healthcare Hamilton, Hamilton, ON, Canada.4Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, Devon, United Kingdom.5Faculty of Health and Human Sciences, University of Plymouth, Devon, United Kingdom
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Prat D, Messika J, Le Meur M, Ricard JD, Sztrymf B. Constipation en réanimation : physiopathologie, définition, valeur pronostique, prise en charge. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1203-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Manning N, Albarran JW. Low-dose intensive insulin therapy in patients with Acute Coronary Syndrome accompanied by Left Ventricular Failure: audit of two UK hospitals. J Clin Nurs 2016; 25:3001-9. [PMID: 27118423 DOI: 10.1111/jocn.13257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2016] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To determine whether a low-dose intravenous insulin regimen reduces blood glucose levels at a timely rate and associated side effects among patients with Acute Coronary Syndrome and Left Ventricular Failure. BACKGROUND Induced hypoglycaemia and the associated risks have questioned the benefits of intensive insulin therapy in patients presenting with raised blood glucose levels and Acute Coronary Syndromes. Local audit data identified that patients with Acute Coronary Syndrome and Left Ventricular Failure experienced more hypoglycaemic episodes than those with Acute Coronary Syndrome alone. Consequently, a new regimen of low-dose insulin for this group was implemented and audited over 12 months. DESIGN Audit. METHODS Thirty-six consecutive patient notes with a diagnosis of Acute Coronary Syndrome and blood glucose of ≥10 mmol/l treated with a new insulin therapy regimen were analysed. Data were extracted using a standardised form and entered into an Excel spreadsheet for analysis. RESULTS The mean age of the sample was 70 years with 66% of subjects being men and 50% presenting with Acute Coronary Syndrome and Left Ventricular Failure. The low-dose regimen was effective in achieving normoglycaemia, (range 4-8 mmol/l) for a consecutive six-hour period. This was achieved in 72% of patients and within a median time of 13 hours. CONCLUSION The audit suggests that a low-dose insulin regimen can effectively stabilise blood glucose in patients presenting with both Acute Coronary Syndrome and Left Ventricular Failure. The importance of regularly monitoring blood sugar levels is vital and highlights the role of nurses in minimising patient risk and promoting safety. RELEVANCE TO PRACTICE Nurses are instrumental in the safe implementation of intensive insulin guidelines. Close monitoring of patients is essential, enabling timely adjustments to treatments and ensuring patient safety. Regular audits allow nurses to evaluate care provision and continue to drive practice forward.
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Affiliation(s)
- Nicola Manning
- Cardiac Rehabilitation Department, North Bristol NHS Trust, Southmead Hospital, Bristol, UK.
| | - John W Albarran
- Centre for Clinical and Health Science Research, Faculty of Health & Social Care, University of the West of England, Bristol, UK
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de Azevedo RP, Freitas FGR, Ferreira EM, Pontes de Azevedo LC, Machado FR. Daily laxative therapy reduces organ dysfunction in mechanically ventilated patients: a phase II randomized controlled trial. Crit Care 2015; 19:329. [PMID: 26373705 PMCID: PMC4572636 DOI: 10.1186/s13054-015-1047-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 08/22/2015] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Constipation is a common problem in intensive care units. We assessed the efficacy and safety of laxative therapy aiming to promote daily defecation in reducing organ dysfunction in mechanically ventilated patients. METHODS We conducted a prospective, randomized, controlled, nonblinded phase II clinical trial at two general intensive care units. Patients expected to remain ventilated for over 3 days were randomly assigned to daily defecation or control groups. The intervention group received lactulose and enemas to produce 1-2 defecations per day. In the control group, absence of defecation was tolerated up to 5 days. Primary outcome was the change in Sequential Organ Failure Assessment (SOFA) score between the date of enrollment and intensive care unit discharge, death or day 14. RESULTS We included 88 patients. Patients in the treatment group had a higher number of defecations per day (1.3 ± 0.42 versus 0.7 ± 0.56, p < 0.0001) and lower percentage of days without defecation (33.1 ± 15.7% versus 62.3 ± 24.5%, p < 0.0001). Patients in the intervention group had a greater reduction in SOFA score (-4.0 (-6.0 to 0) versus -1.0 (-4.0 to 1.0), p = 0.036) with no difference in mortality rates or in survival time. Adverse events were more frequent in the treatment group (4.5 (3.0-8.0) versus 3.0 (1.0-5.7), p = 0.016), including more days with diarrhea (2.0 (1.0-4.0) versus 1.0 (0-2.0) days, p < 0.0001). Serious adverse events were rare and did not significantly differ between groups. CONCLUSIONS Laxative therapy improved daily defecation in ventilated patients and was associated with a greater reduction in SOFA score. TRIAL REGISTRATION Clinical Trials.gov NCT01607060, registered 24 May 2012.
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Affiliation(s)
- Rodrigo Palacio de Azevedo
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 6° andar - Vila Clementino, CEP: 04024-002, São Paulo, SP, Brazil.
| | - Flávio Geraldo Resende Freitas
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 6° andar - Vila Clementino, CEP: 04024-002, São Paulo, SP, Brazil.
| | - Elaine Maria Ferreira
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 6° andar - Vila Clementino, CEP: 04024-002, São Paulo, SP, Brazil.
| | - Luciano Cesar Pontes de Azevedo
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 6° andar - Vila Clementino, CEP: 04024-002, São Paulo, SP, Brazil.
| | - Flávia Ribeiro Machado
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 6° andar - Vila Clementino, CEP: 04024-002, São Paulo, SP, Brazil.
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Mok K, Smith RJ, Reid DA, Santamaria JD. Changing clinical guidelines from delayed to early aperient administration for enterally fed intensive care patients was associated with increased diarrhoea: a before-and-after, intention-to-treat evaluation. Aust Crit Care 2015; 28:208-13. [PMID: 25773579 DOI: 10.1016/j.aucc.2015.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 02/19/2015] [Accepted: 02/21/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The 14-bed intensive care unit of a tertiary referral hospital adopted a guideline to start docusate sodium with sennosides when enteral nutrition was started. This replaced a guideline to start aperients after 24h of enteral nutrition if no bowel action had occurred. We sought to determine the effect of this change on the incidence of diarrhoea and constipation in intensive care. METHODS Retrospective audit of the medical records of consecutive adult patients admitted to intensive care and given enteral nutrition, excluding those with a primary gastrointestinal system diagnosis, between Jan-Aug 2011 (the delayed group, n=175) and Jan-Aug 2012 (the early group, n=175). The early aperient guideline was implemented during Sep-Dec 2011. RESULTS The early and delayed groups were similar in age (median 62 years vs. 64 years; P=0.17), sex (males 65% vs. 63%; P=0.91), and postoperative cases (31% vs. 33%; P=0.82) and had similar proportions who received mechanical ventilation (95% vs. 95%; P=1.00), an inotrope or vasopressor (63% vs. 70%; P=0.17), renal replacement therapy (8% vs. 10%; P=0.71), opiates (77% vs. 80%; P=0.60), antibiotics (89% vs. 91%; P=0.72) and metoclopramide (46% vs. 55%; P=0.11). A significantly larger proportion of the early group received an aperient (54% vs. 29%, P<0.001) and experienced diarrhoea (38% vs. 27%, P=0.04), but the groups had similar proportions affected by constipation (42% vs. 43%, P=0.91). CONCLUSIONS Changing guidelines from delayed to early aperient administration was associated with an increase in the incidence of diarrhoea but was not associated with the incidence of constipation. These findings do not support changing guidelines from delayed to early aperient administration.
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Affiliation(s)
- Kammy Mok
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Australia
| | - Roger J Smith
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Australia.
| | - David A Reid
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Australia
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Australia
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Knowles S, Lam LT, McInnes E, Elliott D, Hardy J, Middleton S. Knowledge, attitudes, beliefs and behaviour intentions for three bowel management practices in intensive care: effects of a targeted protocol implementation for nursing and medical staff. BMC Nurs 2015; 14:6. [PMID: 25663819 PMCID: PMC4320841 DOI: 10.1186/s12912-015-0056-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 01/12/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bowel management protocols have the potential to minimize complications for critically ill patients. Targeted implementation can increase the uptake of protocols by clinicians into practice. The theory of planned behaviour offers a framework in which to investigate clinicians' intention to perform the behaviour of interest. This study aimed to evaluate the effect of implementing a bowel management protocol on intensive care nursing and medical staffs' knowledge, attitude, subjective norms, perceived behavioural control, behaviour intentions, role perceptions and past behaviours in relation to three bowel management practices. METHODS A descriptive before and after survey using a self-administered questionnaire sent to nursing and medical staff working within three intensive care units before and after implementation of our bowel management protocol (pre: May - June 2008; post: Feb - May 2009). RESULTS Participants had significantly higher knowledge scores post-implementation of our protocol (pre mean score 17.6; post mean score 19.3; p = 0.004). Post-implementation there was a significant increase in: self-reported past behaviour (pre mean score 5.38; post mean score 7.11; p = 0.002) and subjective norms scores (pre mean score 3.62; post mean score 4.18; p = 0.016) for bowel assessment; and behaviour intention (pre mean score 5.22; post mean score 5.65; p = 0.048) for administration of enema. CONCLUSION This evaluation, informed by the theory of planned behaviour, has provided useful insights into factors that influence clinician intentions to perform evidence-based bowel management practices in intensive care. Addressing factors such as knowledge, attitudes and beliefs can assist in targeting implementation strategies to positively affect clinician behaviour change. Despite an increase in clinicians' knowledge scores, our implementation strategy did not, however, significantly change clinician behaviour intentions for all three bowel management practices. Further research is required to explore the influence of opinion leaders and organizational culture on clinicians' behaviour intentions related to bowel management for intensive care patients.
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Affiliation(s)
- Serena Knowles
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Australia, and Clinical Nurse Specialist, Intensive Care Service, St. Vincent's Hospital, Sydney, Australia
| | - Lawrence T Lam
- Department of Health and Physical Education, The Hong Kong Institute of Education, Hong Kong, Hong Kong
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Australia (Syd) and Australian Catholic University, Sydney, NSW Australia
| | - Doug Elliott
- Faculty of Health, University of Technology, Sydney, Australia
| | - Jennifer Hardy
- Sydney Nursing School, University of Sydney, Sydney, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Australia (Syd) and Australian Catholic University, Executive Suite, Level 5, deLacy Building, St. Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW Australia
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Standardized application of laxatives and physical measures in neurosurgical intensive care patients improves defecation pattern but is not associated with lower intracranial pressure. Crit Care Res Pract 2014; 2014:367251. [PMID: 25628896 PMCID: PMC4297633 DOI: 10.1155/2014/367251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 12/15/2014] [Accepted: 12/15/2014] [Indexed: 02/07/2023] Open
Abstract
Background. Inadequate bowel movements might be associated with an increase in intracranial pressure in neurosurgical patients. In this study we investigated the influence of a structured application of laxatives and physical measures following a strict standard operating procedure (SOP) on bowel movement, intracranial pressure (ICP), and length of hospital stay in patients with a serious acute cerebral disorder. Methods. After the implementation of the SOP patients suffering from a neurosurgical disorder received pharmacological and nonpharmacological measures to improve bowel movements in a standardized manner within the first 5 days after admission to the intensive care unit (ICU) starting on day of admission. We compared mean ICP levels, length of ICU stay, and mechanical ventilation to a historical control group. Results. Patients of the intervention group showed an adequate defecation pattern significantly more often than the patients of the control group. However, this was not associated with lower ICP values, fewer days of mechanical ventilation, or earlier discharge from ICU. Conclusions. The implementation of a SOP for bowel movement increases the frequency of adequate bowel movements in neurosurgical critical care patients. However, this seems not to be associated with reduced ICP values.
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