Reducing complications of thoracic gunshot wounds

With the persistent presence of violence in our urban areas and the availability of guns, penetrating injuries as a result of firearm use continue to be a challenge for the emergency, surgery, and operating room nurse. Because gunshot wounds may be rapidly fatal, an understanding of firearms and the injuries they produce, as well as their possible complications, can assist the critical care nurse in caring for patients with gunshot wounds to the chest. Thoracic trauma is present in 50% of all trauma patients and is the cause of death in 25% of these victims. Penetrating trauma from violent episodes accounts for approximately 50% of cases of chest trauma in the urban setting.

Multimethod teaching modules

The information in this article is for a wide variety of nurses who find themselves in a teaching role: the critical care nurse orienting another nurse (experienced or new graduate); the critical care manager who needs to present an inservice program; and the educator or clinical specialist looking for a new way to present the same information. The author describes how self-paced modules for inservice education offer variety to learners since learners choose the teaching strategy that best suits their learning styles.

Thermal gradients and shivering following open heart surgery

Critical care nurses caring for postoperative cardiac surgery patients are confronted, on a regular basis, with care issues related to thermal gradients and shivering. Thermal gradients are defined as temperature differences between two body parts. Monitoring the central and peripheral temperatures, evaluating the thermal gradients, and measuring shivering with reliable means are the prerequisites for the prediction of shivering. The detrimental physiologic effect of shivering necessitates additional clinical research to further define causative factors of shivering.

Ethical considerations in conducting clinical research

Each step of the research process has specific ethical considerations. This article presents the ethical aspects that the nurse researcher needs to incorporate into a clinical research project and that the critical care staff nurse can use to identify potential unethical research practices involving critical care patients.

Nursing diagnosis. Powerlessness in critical care patients

The critical care environment, with its fast-paced tempo, its vast technology, and its many invasive procedures, carries the potential for creating feelings of powerlessness within patients, their families, and even in the nurses who work there. This article examines the nursing diagnosis of powerlessness and its etiologic factors. The authors present a challenging case in which creative nursing techniques decrease powerlessness for a partially paralyzed and intubated patient.

Re-evaluating the role of the charge nurse

Charge nurses are used in most critical care units to facilitate quality patient care by serving as resources to the nursing staff. These authors suggest strategies for initiating or evaluating the charge nurse role in critical care. Interviews with critical care charge nurses show how different viewpoints remain regarding this key role of the charge nurse.

Supervising unlicensed technicians in critical care

As the nursing shortage continues and there is an increased demand for technicians and other nurse extenders, critical care nurses may be asked to supervise numerous types of other health care workers. This nurse-attorney author describes the legal aspects of the situation for the licensed nurse who supervises registered or unregistered, unlicensed technicians.

Aortic valvuloplasty: medical and critical care nursing perspectives

Aortic valvuloplasty, an investigational alternative to valve replacement, is explained from the perspectives of a nurse in a cardiac catheterization laboratory, a nurse in a coronary care unit, and a cardiologist. A case study is presented along with a plan of care developed around three nursing diagnoses. A prevalvuloplasty nursing diagnosis includes a teaching plan to assist nurses in preparing patients for aortic valvuloplasty.

Tissue-plasminogen activator: nursing implications

Coronary thrombolysis has been proved to be beneficial in the treatment of myocardial infarction. Much attention has been focused on tissue-type plasminogen activator (t-PA) as a fibrinolytic agent. This article will discuss the unique properties of t-PA and the role of the critical care nurse in providing the safe delivery of t-PA.

Ration or rescue: the elderly patient in critical care

1. Persons who require the intensive interventions of critical care units enter with a contract of trust. They place their well-being, and often their lives in the hand of caregivers. To respect that trust by the most vigorous effort is a moral responsibility. 2. It is not the task of the practitioner in critical care to evaluate the social worth of the patient. Judgments as to the quality of life of individual patients are inappropriate and unsupportable and should never be used as a rationale for withholding or withdrawing essential care. 3. The decisions for introducing treatments should be based (as they have been historically) on the physician's evaluation of the patient's condition and the consequent appropriate interventions. The interference of third party payers in this clinical relation in which therapeutic decisions are dictated by cost or any other extraneous factors is morally repugnant. 4. Life or death decisions are not properly those of caregivers and should never be left to those whose mission is to protect life and relieve suffering. Decisions to use extraordinary means of sustaining life processes should be made in advance of the actual events by the informed wisdom of the physician whenever possible. The caregivers--physicians and nurses-should bring all their skills to bear to alleviate suffering, but that does not include hastening the death of another human being.

Impaired cognition in the critically ill elderly patient: clinical implications

Cognitive impairment is a significant health problem for the critically ill aged and warrants further investigation. Despite the lack of knowledge of all aspects of cognitive impairment, much can be undertaken to improve the care of impaired patients. Nurses must routinely, systematically, and comprehensively assess the cognitive state of each elderly patient at the time of admission and daily throughout hospitalization. On the basis of these assessments, nurses must accurately differentiate among confusion, depression, and dementia in the cognitively impaired patient. To carry out such assessments, modification of existing tools, such as the MMSE, may be necessary. Only through such assessment, however, is it possible to detect, prevent, or treat changes in cognition, and thereby prevent its sequelae.

Effective management of urinary drainage systems in critical care areas

Many invasive procedures are used in the care of critically ill people. These potentially increase the risks of infection which may be fatal, as such patients usually have reduced efficiency of normal defence mechanisms. Urethral catheterisation and continuous urinary drainage is one such procedure which is commonly necessary and is known to carry a considerable risk of urinary tract infections. Effective management should reduce the incidence of these. In some units no rationally-based protocols are available to guide nursing management of urinary drainage and thus minimise this risk. This paper is based on a time-limited literature search undertaken as a basis for producing the guidelines recommended, which are research-based where possible though there is as yet no experimental evidence on some aspects of care.

Understanding the beliefs of Jehovah's Witnesses

The individual religious belief system of the patient who is one of Jehovah's Witnesses regarding the refusal of blood products may have a direct impact on his or her treatment and its outcome. The critical care nurse is in a unique and powerful position to support this patient through the many potentially stressful clinical and emotional situations that this decision may engender. A thorough understanding of the rationale behind the Jehovah's Witnesses' belief system is necessary to provide intelligent and ethical nursing care.

A review of the literature relating to touch and its use in intensive care

This literature review is an exploration of the available literature on and surrounding the subject of touch in order to help nurses to understand this subject and use touch effectively in nursing care. The study is focused particularly on the use of touch in intensive care as this is the area of interest of the author, and several writers have suggested touch is of great importance in this area. The literature on communication in all its forms and particularly in intensive care is discussed first as this explains the framework in which touch occurs and how it fits into nursing care. Theories about touch and studies of the use of touch are linked to try to show the human need, and taboos about touch. This is related to the use of touch by nurses and other health care workers particularly in intensive care. Recommendations are made, from the information gained from the literature, about how nurses' use of touch as part of nursing care can be improved.

The decision-making process in critical care of the aged

Nurses in a critical care setting are challenged daily to provide safe, effective quality care for elderly patients. The decision process underlying this care is complex because of the amount, diversity, and uncertainty of information that must be processed. Some variables associated with the client, the nurse, and the critical care environment are irrelevant to the decision process, yet continue to influence nurses' decision making. Suboptimal and erroneous diagnoses and interventions may result. Awareness of factors that adversely affect decision making should assist nurses in enhancing their information processing. Use of objective and systematic decision-making techniques also can improve the efficiency and quality of decision making in the critical care of aging people.

The limits of decision analysis for rapid decision making in ICU nursing

In a study examining rapid decisions in ICU nursing in the context of decision analysis, 40 nurses in 2 ICUs were asked to describe their decisions for six pretested vignettes, suggest alternatives and answer questions about case characteristics. Later, ICU charge nurses and educators were asked to rate the nurses' responses using a modified Q-sort. The nurses did not perceive a finite set of alternatives; the 40 nurses gave 36 to 40 unique sequences that did not cluster. The experts could not agree on which alternatives were good (no "gold standard"). The assumptions of decision analysis appear to be violated when (a) there is not a small finite set of mutually exclusive alternatives; (b) the merit of an intervention cannot be agreed on; or (c) the link between intervention and outcome is unclear. Not only nursing but other process-oriented areas of medical care as well may not fit the decision analysis model.

Families in crisis: making the critical difference

As nurses, we are educated to care for the whole patient, to provide care for the body, mind, and spirit, and to improve the quality of life. When a patient has a crisis, his or her family is propelled into the crisis as well. Although critical care nurses have always participated in a caring manner by interacting with families of critically ill patients, nurses must be encouraged to actively seek ways in which to help these families. This article has provided guidelines and strategies for caring for families in crisis. The most effective way to care for family members in crisis is by demonstrating a conscientious concern for their loved one, that is, the patient. The knowledge that our nursing actions make a difference in the lives of family members gives us renewed insight into maintaining the care in critical care nursing.

Clinical management of the organ donor

Critical care nurses play a vital role in the clinical management of potential organ donors. Knowledge of the physiologic traits a donor will exhibit and the clinical interventions necessary to prevent circulatory collapse are essential in providing care to the organ donor. Maintaining hemodynamic stability in the donor optimizes organ function and improves the chances of successful results in transplant recipients.

Substance abuse among nurses: types of drugs

Substance abuse among nurses can have significant ramifications for patient care, productivity, and personal well-being. Existing evidence suggests that critical care nurses are especially vulnerable to pressures that induce substance abuse. Consequently, critical care leaders and nurses need to be prepared to help their impaired colleagues. This paper provides several valuable guidelines for addressing substance abuse based on an exploratory study of the types of drugs or substances most frequently abused among nurses.

Hyperbaric oxygen therapy--nursing opportunity

Hyperbaric nursing is a challenging new role for critical care nurses. The authors discuss this expanding career opportunity along with the science of hyperbaric oxygen (HBO) therapy, clinical uses, types of chambers, and steps toward developing this exciting nursing career.

Increasing reliability and validity of pulmonary artery measurements

Pulmonary artery (PA) catheter pressure measurements are a primary means of assessing the cardiac output status of critically ill patients. Critical care nurses are responsible for obtaining these measurements accurately; yet preliminary studies demonstrate that critical care nurses have difficulty making reliable and valid PA catheter measurements. Nurses in critical care need to insure the accuracy of the PA measurements they obtain through the use of a systematic measurement process.

Neonatal nosocomial infections

Prevention of infection in the high-risk infant presents a challenge for all members of the health care team. The infant's condition must be constantly assessed for risk factors, and a plan of care must be developed to reduce that risk. That plan requires a thorough understanding of the multiple factors (the infant host, potential pathogens, and therapeutic procedures) involved in neonatal infections and strict adherence to infection control procedures.

Dying and bereavement. The role of the critical care nurse

The critical care units of today are environments totally dedicated to implementing life saving and life supporting measures. The development of the critical care unit is such that now many critical care units offer specific specialised disease/surgical management e.g. the cardiothoracic unit, transplant centres. As the ability of the critical care units to offer extensive life supportive measures continually improves, the fact is that there is still an increased potential for death to occur in the critical care unit, more than in other acute areas. While the prime function of the critical care staff will always be to support and sustain the life of their patients for whom they care, they also have a responsibility to offer a caring and compassionate level of care to the dying critically ill patient and to ensure that they support the dying patients' relatives in every way that they can. The prospect of death (for the patient), and the actual loss of the patient (for the relatives/medical and nursing staff) can present a number of difficulties for all those involved. These difficulties, which will be identified in the course of the article, may if unresolved predispose to a poor and traumatic bereavement process for the relatives, while the critical care staff may experience possible feelings of frustration, helplessness and low morale. (Caughill, 1976). It is therefore the aim of this article to examine the role of the critical care nurse in caring for the dying patient in the intensive care areas.(ABSTRACT TRUNCATED AT 250 WORDS)

Employee health for critical care duty

Many patients present for care in critical care settings every day. Some have known or suspected infectious diseases, whereas others may have infections that remain undetected throughout the hospital course. Through careful attention and compliance to the primary, secondary, and tertiary strategies of prevention, practitioners in critical care can remain healthy and uninfected while providing lifesaving care to their patients.

Hope-inspiring strategies of the critically ill

Sixty persons who had been critically ill were studied to determine what mechanisms they used to maintain or increase their hope while confronting a life-threatening event. Patients were interviewed 2 to 4 days after discharge from a critical care unit. Responses to the interviews were categorized into nine hope-inspiring themes. The findings provide direction for developing strategies to inspire hope in the critically ill.