Level of dyspnoea experienced in mechanically ventilated adults with and without saline instillation prior to endotracheal suctioning

The purpose of this study was to compare the level of dyspnoea with and without the use of 5-cc saline instillation prior to endotracheal suctioning of mechanically ventilated adults. A crossover, quasi-experimental design was used. Seventeen alert, mechanically ventilated adults were asked to rank their level of dyspnoea using the vertical visual analogue scale at specific time intervals surrounding two suctioning events. Saline was randomly assigned to be instilled prior to one of two suctioning episodes. Dyspnoea was ranked immediately after suctioning, and at 10-, 20-, and 30-minute intervals. Data were analyzed using repeated measures analysis of variance with time of measure (immediately after suctioning, 10-, 20-, and 30-minute intervals) and treatment type (with saline versus without saline instillation). The level of dyspnoea based on treatment type (with or without saline) was non-significant. Treatment type by age group interaction was significant (F(1, 15) = 5.41, P = 0.034). The nature of the interaction revealed that older patients (< or = 60 years of age) experienced less dyspnoea without saline prior to suctioning and greater dyspnoea with saline instillation as compared to the younger subjects (<60 years of age). This study documented no beneficial effects of saline. However, it did demonstrate that saline instillation might precipitate a significantly increased level of dyspnoea for up to 10 minutes after suctioning in patients older than 60 years of age. Recommendations based on the results of this study would be to avoid the use of saline instillation prior to suctioning.

Nurses' knowledge and attitudes about antibiotic therapy in critical care

PURPOSE

To assess critical care nurses' knowledge about antibiotic use in critical care settings, and attitudes concerning the role of the nurse in monitoring response to and appropriate use of antibiotic therapy.

METHOD

90 critical care nurses from 6 adult critical care units at a 780-bed academic, health sciences centre, completed an investigator-developed survey about their knowledge of antibiotic use and their attitudes concerning the role of the nurse.

RESULTS

The majority of respondents worked full time (83%) and were BSN (Bachelor of Science in Nursing) prepared (62%), with an average of 9 years' nursing experience and 7 years' experience in intensive care. Using a 100-mm visual analog scale, mean scores on knowledge and comfort with: (1) interpreting culture and sensitivity; (2) white blood cell (WBC) data; and (3) discussing results and therapy with physicians were all less than 50 mm. However, the mean score for nurses' belief of responsibility related to this collaborative role was 76. A knowledge quiz of lab interpretation and antibiotic therapy revealed a mean score of 53.8%. Beliefs about roles were correlated with comfort in discussing therapies with physicians rather than with knowledge. Although nurses value the collaborative surveillance role, they may lack the knowledge and confidence to enact it.

Multidisciplinary Management of Sedation and Analgesia in Critical Care

Management of sedation and analgesia in critical care medicine is a multidisciplinary process that involves physicians, nurses, pharmacists, and other healthcare providers. Optimal management of these common issues includes recognition of the importance of predisposing and causative conditions that contribute to the sensations of pain and discomfort, anxiety, and delirium. Treatment includes pharmacological intervention, correction of predisposing factors, and use of other preventative and nonpharmacological measures. It is increasingly clear that, although necessary for patient comfort, sedative and analgesic medications can have adverse consequences, including side-effects as well as prolonged mechanical ventilation and ICU length of stay. Optimal use of sedative and analgesic medications involves matching unique properties of specific medications with individual patient characteristics. Guidelines that minimize unnecessary variability in practice, prevent excessive medication, and emphasize management based on individual patient characteristics improve the effective utilization of these medications.

Continuous measurement of backrest elevation in critical care: a research strategy

OBJECTIVE

To develop and test a procedure for continuous measurement of backrest elevation in critical care for enhancing the precision of this measurement for research purposes.

DESIGN

Descriptive, correlational. SETTING AND MEASUREMENTS: Backrest elevation, defined as the height of the head of the bed in degrees of elevation above horizontal, can be continuously monitored by using two transducers, one attached to the bed frame just distal to the head of the bed gatch and another attached to the bed frame at the top of the bed. By monitoring the differential head pressure between the two pressure channels, the height of the head of the bed can be calculated. A total of 30 random measurements of backrest elevation, from 0 degrees to 60 degrees, were taken by using the backrest elevation measurement on the bed frame, a handheld protractor, and the pressure differential between two transducers attached to the bed frame. Data collectors recorded one measurement independent of the other measurements. All measurements were conducted on the same bed.

RESULTS

When the transduced method was compared with measurements by using a protractor, the Bland-Altman analysis technique yielded upper and lower limits of agreement of 8.93 degrees and -5.91 degrees, respectively. The bias was 1.51 degrees, and the precision was 3.71 degreees.

CONCLUSIONS

The measurement technique described here was developed for research purposes to add precision to research studies examining the appropriate height of the backrest. However, the procedure could be used in a continuous quality improvement process to enhance compliance with patient care procedures involving backrest elevation or to confirm actual nursing practice and its correlation with patient outcome. In light of the risks associated with the use of supine positioning in critically ill and mechanically ventilated patients, the information gained from continuous measurement of backrest position could be an extremely valuable research tool.

Telephone monitoring after early discharge for cardiac surgery patients

BACKGROUND

Monitoring the postoperative course of cardiac surgery patients remains essential but requires creative strategies now that length of hospitalization has been shortened to 5 days or less.

OBJECTIVES

To determine patients' concerns in the early recovery period after open-heart surgery and to describe the impact of advanced practice nurses on this phase of recovery.

METHOD

A cardiovascular clinical nurse specialist conducted follow-up by telephone for 342 cardiac surgery patients 7 to 14 days after discharge. Patients were asked both open-ended and direct questions.

RESULTS

The major problems were leg edema (48%), appetite disturbance (35%), dyspnea (29%), sleep disturbance (12%), and wound drainage (9%). The nurse's interventions over the telephone included reassuring the patient about postoperative progress (86% of sample), giving diet information (31%), instructing about activity (29%), providing emotional support (25%), referring for medical treatment (16%), and explaining medications (13%). In response to these findings, the nursing practice council revised postoperative teaching to emphasize wound healing, sleep, and appetite issues.

CONCLUSIONS

Telephone monitoring of cardiac surgery patients after early discharge can alleviate the often stressful transition to postoperative recovery at home. A cardiovascular clinical nurse specialist can provide patients and patients' family members with reassurance and ongoing reinforcement of the discharge information.

Telephone monitoring after early discharge for cardiac surgery patients

BACKGROUND: Monitoring the postoperative course of cardiac surgery patients remains essential but requires creative strategies now that length of hospitalization has been shortened to 5 days or less. OBJECTIVES: To determine patients' concerns in the early recovery period after open-heart surgery and to describe the impact of advanced practice nurses on this phase of recovery. METHOD: A cardiovascular clinical nurse specialist conducted follow-up by telephone for 342 cardiac surgery patients 7 to 14 days after discharge. Patients were asked both open-ended and direct questions. RESULTS: The major problems were leg edema (48%), appetite disturbance (35%), dyspnea (29%), sleep disturbance (12%), and wound drainage (9%). The nurse's interventions over the telephone included reassuring the patient about postoperative progress (86% of sample), giving diet information (31%), instructing about activity (29%), providing emotional support (25%), referring for medical treatment (16%), and explaining medications (13%). In response to these findings, the nursing practice council revised postoperative teaching to emphasize wound healing, sleep, and appetite issues. CONCLUSIONS: Telephone monitoring of cardiac surgery patients after early discharge can alleviate the often stressful transition to postoperative recovery at home. A cardiovascular clinical nurse specialist can provide patients and patients' family members with reassurance and ongoing reinforcement of the discharge information.

Preparing the patient and family for home mechanical ventilation

In the search for patients' improved quality of life and lower health care costs, home mechanical ventilation (HMV) has emerged as a method for treating stable chronic respiratory failure, particularly restrictive neuromuscular diseases. Data suggest that the use of home mechanical ventilation will rise because of the documented benefits to patients and the economic pressure to shorten hospital stays. The goal of HMV is to help impaired individuals function at their optimal levels. The criteria for HMV, the process of preparation for HMV, and the activities at discharge are described.

Endotracheal tube narrowing after closed-system suctioning: prevalence and risk factors

BACKGROUND: Few data exist about buildup of secretions within endotracheal tubes of patients treated with closed-system suctioning in the intensive care unit. OBJECTIVES: To describe the extent, prevalence, and distribution of narrowing of endotracheal tubes related to buildup of secretions and to determine contributing factors. METHODS: Forty endotracheal tubes were examined within 4 hours of extubation, after at least 72 hours of use. Data on patients' daily weight and fluid balance, ventilator humidification temperatures, and nurses' descriptions of secretions during the 3 days preceding extubation were recorded. Any secretion debris in the endotracheal tubes was weighed. At 1-cm intervals along the tube, the debris was described and the depth of the debris was measured to the nearest 0.5 mm. RESULTS: Mean duration of intubation was 6.6 days. Two tubes had no debris. Mean overall depth of debris was 0.64 mm, mean greatest depth was 2.0 mm (range, 0-5 mm), and mean weight was 1.16 g. The entire tube was affected, with the greatest depth of debris at the 6- to 9-cm and 13- to 14-cm markings. Duration of intubation correlated with mean greatest depth of debris (r = 0.37, P = .02), mean overall depth of debris (r = 0.48, P = .002), and mean weight of debris (r = 0.38, P = .02). CONCLUSIONS: Endotracheal tubes are markedly narrowed by the buildup of secretions after closed-system suctioning. Duration of intubation, but not endotracheal tube size or amount of secretions, was associated with the degree of narrowing.

Endotracheal tube narrowing after closed-system suctioning: prevalence and risk factors

BACKGROUND

Few data exist about buildup of secretions within endotracheal tubes of patients treated with closed-system suctioning in the intensive care unit.

OBJECTIVES

To describe the extent, prevalence, and distribution of narrowing of endotracheal tubes related to buildup of secretions and to determine contributing factors.

METHODS

Forty endotracheal tubes were examined within 4 hours of extubation, after at least 72 hours of use. Data on patients' daily weight and fluid balance, ventilator humidification temperatures, and nurses' descriptions of secretions during the 3 days preceding extubation were recorded. Any secretion debris in the endotracheal tubes was weighed. At 1-cm intervals along the tube, the debris was described and the depth of the debris was measured to the nearest 0.5 mm.

RESULTS

Mean duration of intubation was 6.6 days. Two tubes had no debris. Mean overall depth of debris was 0.64 mm, mean greatest depth was 2.0 mm (range, 0-5 mm), and mean weight was 1.16 g. The entire tube was affected, with the greatest depth of debris at the 6- to 9-cm and 13- to 14-cm markings. Duration of intubation correlated with mean greatest depth of debris (r = 0.37, P = .02), mean overall depth of debris (r = 0.48, P = .002), and mean weight of debris (r = 0.38, P = .02).

CONCLUSIONS

Endotracheal tubes are markedly narrowed by the buildup of secretions after closed-system suctioning. Duration of intubation, but not endotracheal tube size or amount of secretions, was associated with the degree of narrowing.

Use of backrest elevation in critical care: a pilot study

BACKGROUND: Use of lower backrest positions occurs frequently and is a factor in the development of ventilator-associated pneumonia. OBJECTIVES: To determine the usual bed elevation and backrest position in a medical intensive care unit and their relationship to hemodynamic status and enteral feeding. METHODS: Data were collected in a 12-bed medical respiratory intensive care unit for 2 months. A protractor was used to measure the elevation of the head of the bed. Hemodynamic status was defined by systolic, diastolic, and mean arterial blood pressure measurements retrieved from each patient's flow sheet. RESULTS: The sample included 347 measurements of 52 patients. Mean backrest elevation was 22.9 degrees, and 86% of patients were supine. Backrest position differed significantly (P = .005) among nursing shifts (days, evenings, nights) but not for systolic (r = -0.04, P = .49), diastolic (r = 0.01, P = .83), or mean arterial blood pressure (r = -0.01, P = .84). Backrest elevation did not differ significantly between patients who were receiving enteral feedings and patients who were not (P = .23) or between patients receiving intermittent versus continuous nutrition (P = .22). CONCLUSIONS: Use of higher levels of backrest elevation (&gt; or = 30 degrees) is minimal and is not related to use of enteral feeding or to hemodynamic status. The rationale for using lower backrest positions for critically ill patients may be based on convenience, the patient's comfort, or usual patterns in the unit. However, the dangers of supine positioning and its relationship to aspiration and ventilator-associated pneumonia should not be minimized.

Use of backrest elevation in critical care: a pilot study

BACKGROUND

Use of lower backrest positions occurs frequently and is a factor in the development of ventilator-associated pneumonia.

OBJECTIVES

To determine the usual bed elevation and backrest position in a medical intensive care unit and their relationship to hemodynamic status and enteral feeding.

METHODS

Data were collected in a 12-bed medical respiratory intensive care unit for 2 months. A protractor was used to measure the elevation of the head of the bed. Hemodynamic status was defined by systolic, diastolic, and mean arterial blood pressure measurements retrieved from each patient's flow sheet.

RESULTS

The sample included 347 measurements of 52 patients. Mean backrest elevation was 22.9 degrees, and 86% of patients were supine. Backrest position differed significantly (P = .005) among nursing shifts (days, evenings, nights) but not for systolic (r = -0.04, P = .49), diastolic (r = 0.01, P = .83), or mean arterial blood pressure (r = -0.01, P = .84). Backrest elevation did not differ significantly between patients who were receiving enteral feedings and patients who were not (P = .23) or between patients receiving intermittent versus continuous nutrition (P = .22).

CONCLUSIONS

Use of higher levels of backrest elevation (> or = 30 degrees) is minimal and is not related to use of enteral feeding or to hemodynamic status. The rationale for using lower backrest positions for critically ill patients may be based on convenience, the patient's comfort, or usual patterns in the unit. However, the dangers of supine positioning and its relationship to aspiration and ventilator-associated pneumonia should not be minimized.

Ventilator-associated pneumonia: clinical significance and implications for nursing

Pneumonia is the second most common nosocomial infection in the United States and the leading cause of death from nosocomial infections. Intubation and mechanical ventilation greatly increase the risk of bacterial pneumonia. Ventilator-associated pneumonia (VAP) occurs in a patient treated with mechanical ventilation, and it is neither present nor developing at the time of intubation; it is a serious problem--with significant morbidity and mortality rates. Aspiration of bacteria from the oropharynx, leakage of contaminated secretions around the endotracheal tube, patient position, and cross-contamination from respiratory equipment and health care providers are important factors in the development of VAP. Nurses caring for patients treated with mechanical ventilation must recognize risk factors and include strategies for reducing these factors as part of their nursing care. This article summarizes the literature related to VAP: its incidence, associated factors, diagnosis, and current therapies, with an emphasis on nursing implications in the care of these patients.

Hemodynamic monitoring: a comparison of research and practice

BACKGROUND: Measurement of hemodynamic parameters is a common practice and is well researched, but little information is available on the translation of the research into actual practice. OBJECTIVES: To determine (1) the current practice of hemodynamic measurement in relation to positioning of patients and (2) the barriers to use of research related to hemodynamic monitoring. METHODS: A stratified, random, national sample of 1000 members of the American Association of Critical-Care Nurses was surveyed by mail about hemodynamic monitoring procedures related to the positioning of patients and beds, technique used to determine the position of the bed, number of measurements of cardiac output, use of iced versus room-temperature injectate, use of printed or digital information, nurses' input into written procedures, and barriers to research utilization. RESULTS: In actual practice, 24.1% of the respondents always keep the bed flat when measuring pulmonary artery pressures, 55.0% elevate the head of the bed 30 degrees or less, 80.7% always have patients supine for measurements, and 13.3% place patients in lateral or other positions. Unit policy dictated the flat position in 25.8% of the sample; nurse managers (41.4%), staff nurses (27.5%), and staff committees (31.2%) were involved in writing the procedure. Respondents viewed research related to hemodynamic monitoring procedures as relevant and valuable. The greatest barriers to utilization were lack of staff support for implementation, insufficient time to implement research findings, and feelings among nurses that they lacked authority to implement change. CONCLUSIONS: Research findings are generally being implemented at the bedside, although not completely or consistently. Minimizing the barriers to use of research is within the scope of nurses' practice.

Hemodynamic monitoring: a comparison of research and practice

BACKGROUND

Measurement of hemodynamic parameters is a common practice and is well researched, but little information is available on the translation of the research into actual practice.

OBJECTIVES

To determine (1) the current practice of hemodynamic measurement in relation to positioning of patients and (2) the barriers to use of research related to hemodynamic monitoring.

METHODS

A stratified, random, national sample of 1000 members of the American Association of Critical-Care Nurses was surveyed by mail about hemodynamic monitoring procedures related to the positioning of patients and beds, technique used to determine the position of the bed, number of measurements of cardiac output, use of iced versus room-temperature injectate, use of printed or digital information, nurses' input into written procedures, and barriers to research utilization.

RESULTS

In actual practice, 24.1% of the respondents always keep the bed flat when measuring pulmonary artery pressures, 55.0% elevate the head of the bed 30 degrees or less, 80.7% always have patients supine for measurements, and 13.3% place patients in lateral or other positions. Unit policy dictated the flat position in 25.8% of the sample; nurse managers (41.4%), staff nurses (27.5%), and staff committees (31.2%) were involved in writing the procedure. Respondents viewed research related to hemodynamic monitoring procedures as relevant and valuable. The greatest barriers to utilization were lack of staff support for implementation, insufficient time to implement research findings, and feelings among nurses that they lacked authority to implement change.

CONCLUSIONS

Research findings are generally being implemented at the bedside, although not completely or consistently. Minimizing the barriers to use of research is within the scope of nurses' practice.

Care of the patient requiring mechanical ventilation

Today patients that are otherwise stable may require mechanical ventilation for prolonged periods of time. The medical-surgical nurse may be expected to care for these patients in a setting outside the intensive care unit. Basic knowledge of the modes of ventilation, assessment, and troubleshooting of ventilators and assessment and care of the patient requiring mechanical ventilation are reviewed in this article.

The incidence of gastrointestinal symptoms in cardiac surgery patients through six weeks after discharge

OBJECTIVE

To determine the incidence and the effect of intraoperative and discharge variables on gastrointestinal (GI) symptoms after cardiac surgery during hospitalization and 2 and 6 weeks after discharge.

DESIGN

Prospective and descriptive.

SETTING

Two university-affiliated medical centers.

PATIENTS

One hundred twenty-two adult patients undergoing cardiac surgery.

OUTCOME MEASURES

Frequency of GI symptoms and level of distress caused by GI symptoms during hospitalization and 2 and 6 weeks after hospital discharge.

INSTRUMENTS

GI symptoms were measured by The Gastrointestinal Symptom Frequency and Symptom Distress Scale. Depression was measured by The Center for Epidemiologic Studies Depression Scale.

INTERVENTION

Demographic and physiologic variables were collected by chart review. Patients completed the Gastrointestinal Symptom Frequency and Symptom Distress Scale and The Center for Epidemiologic Studies Depression Scale in the hospital. Telephone interviews were used to collect 2- and 6-week data.

RESULTS

Fifty-seven percent of patients after surgery reported poor appetite, 37% lack of taste, and 34% nausea during hospitalization. The frequency of all GI symptoms decreased with time; 19% of subjects reported poor appetite, 19% lack of taste, and 10% nausea at 6 weeks after discharge. Although poor appetite occurred with the greatest frequency, patients reported the greatest distress with lack of taste. When analyzed with a logistic regression model, use of antihypertensive agents was associated with lack of taste; use of diuretic and antiarrhythmic agents was associated with nausea; and level of depression was associated with all three GI symptoms. Length of cardiopulmonary bypass time mean arterial blood pressure during surgery, mixed venous oxygen saturation during surgery, and subject age did not significantly affect the frequency of GI symptoms at any data collection point.

CONCLUSIONS

The incidence of GI symptoms after cardiac surgery is significant, but their etiology has yet to be determined.

Endotracheal suctioning: ventilator vs manual delivery of hyperoxygenation breaths

BACKGROUND: Despite a large number of studies on endotracheal suctioning, there is little data on the impact of clinically practical hyperoxygenation techniques on physiologic parameters in critically ill patients. OBJECTIVE: To compare the manual and mechanical delivery of hyperoxygenation before and after endotracheal suctioning using methods commonly employed in clinical practice. METHODS: A quasi-experimental design was used, with twenty-nine ventilated patients with a lung injury index of 1.54 (mild-moderate lung injury). Three breaths were given before and after each of two suction catheter passes using both the manual resuscitation bag and the ventilator. Arterial pressure, capillary oxygen saturation, heart rate, and cardiac rhythm were monitored for 1 minute prior to the intervention to obtain a baseline, continuously throughout the procedure, and for 3 minutes afterward. Arterial blood gases were collected immediately prior to the suctioning intervention, immediately after, and at 30, 60, 120, and 180 seconds after the intervention. Data were analyzed with repeated measures analysis of variance. RESULTS: Arterial oxygen partial pressures were significantly higher using the ventilator method. Peak inspiratory pressures during hyperoxygenation were significantly higher with the manual resuscitation bag method. Significant increases were observed in mean arterial pressure during and after suctioning, with both delivery methods, with no difference between methods. Maximal increases in arterial oxygen partial pressure and arterial oxygen saturation occurred 30 seconds after hyperoxygenation, falling to baseline values at 3 minutes for both methods. CONCLUSION: Using techniques currently employed in clinical practice, these findings support the use of the patient's ventilator for hyperoxygenation during suctioning.

Endotracheal suctioning: ventilator vs manual delivery of hyperoxygenation breaths

BACKGROUND

Despite a large number of studies on endotracheal suctioning, there is little data on the impact of clinically practical hyperoxygenation techniques on physiologic parameters in critically ill patients.

OBJECTIVE

To compare the manual and mechanical delivery of hyperoxygenation before and after endotracheal suctioning using methods commonly employed in clinical practice.

METHODS

A quasi-experimental design was used, with twenty-nine ventilated patients with a lung injury index of 1.54 (mild-moderate lung injury). Three breaths were given before and after each of two suction catheter passes using both the manual resuscitation bag and the ventilator. Arterial pressure, capillary oxygen saturation, heart rate, and cardiac rhythm were monitored for 1 minute prior to the intervention to obtain a baseline, continuously throughout the procedure, and for 3 minutes afterward. Arterial blood gases were collected immediately prior to the suctioning intervention, immediately after, and at 30, 60, 120, and 180 seconds after the intervention. Data were analyzed with repeated measures analysis of variance.

RESULTS

Arterial oxygen partial pressures were significantly higher using the ventilator method. Peak inspiratory pressures during hyperoxygenation were significantly higher with the manual resuscitation bag method. Significant increases were observed in mean arterial pressure during and after suctioning, with both delivery methods, with no difference between methods. Maximal increases in arterial oxygen partial pressure and arterial oxygen saturation occurred 30 seconds after hyperoxygenation, falling to baseline values at 3 minutes for both methods.

CONCLUSION

Using techniques currently employed in clinical practice, these findings support the use of the patient's ventilator for hyperoxygenation during suctioning.

Effects of auditory stimuli on intracranial pressure and cerebral perfusion pressure in traumatic brain injury

The primary goal of medical and nursing management in the traumatic brain-injured patient is to decrease intracranial pressure (ICP) and maintain adequate cerebral perfusion pressure (CPP). Little is known about what effect, if any, auditory stimulation has on these parameters. Therefore, an experimental study was conducted to examine the effects of various auditory stimuli on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in traumatic brain-injured patients. A convenience sample of fifteen participants with admitting Glasgow Coma Scale scores between 3 and 8 was studied. Three types of auditory stimuli: earplugs, a music tape and a tape of ICU environmental noise were applied to patients in a computer-generated random order. The tapes delivered sound at 70 decibels. Each intervention lasted 15 minutes. ICP and CPP were recorded at a 30 second resolution time through a bedside computer. Data were analyzed using analysis of variance for a cross over design. Results showed no statistically significant change in ICP or CPP during the study period. Further studies are needed to examine the effects of auditory stimuli on ICP and CPP in traumatic brain-injured patients.

After the party's over: evaluation of a drinking and driving prevention program

This study evaluated a neuroscience nursing community outreach program titled, "After the Party's Over," focused on teenage drinking and driving prevention. The program consisted of a 20-minute slide presentation with contemporary music and narration that depicted graphic pictures of actual patients who sustained severe head and spinal cord injuries (SCIs) as a result of motor vehicle accidents (MVAs). A convenience sample of 274 high school drivers' education students was obtained. A Likert-type scale that measured reported behaviors was administered immediately before and after the program and one month after program completion. Results indicated a significant change in reported driving behavior of teenagers who participated in this program.

The relationship of health locus of control and cardiac rehabilitation to mastery of illness-related stress

The study examined the relationships among participation in outpatient rehabilitation, health locus of control, and mastery of stress with coronary artery disease completed the Master of Stress Instrument (MSI) and the Multidimensional Health Locus of Control Scale. One fourth of the sample had participated in the hospital's cardiac rehabilitation programme. Results showed no difference between cardiac-rehabilitation participants and nonparticipants on mastery, internal locus of control or stress. Demographic characteristics of age, education, race and gender revealed no significant correlation with either the total MSI score or its component measures. However, internal locus of control was significantly and positively correlated to both growth and total mastery. A stronger relationship was found between internal locus of control and change. This finding supports the hypothesis that health-internals achieve higher levels of mastery.

Accurate assessment of ventilation and oxygenation

Monitoring pulmonary function with an effective nursing assessment can identify patient problems early. An understanding of ventilation, alveolar perfusion, oxygenation, and patient signs and symptoms, guides medical-surgical nurses in assessment and in intervention choices.

Effect of level of lung injury on HR, MAP and SaO2 changes during suctioning

25 patients with documented lung injury were suctioned using a manual resuscitation bag (MRB) and a standardised procedure. Level of lung injury was not significantly correlated with changes from baseline in heart rate (HR) oxygen saturation (SaO2) or mean arterial pressure (MAP). However, HR and MAP increased significantly returning to baseline at 5 min. Patients' SaO2 did not change significantly during the procedure or up to 15 min afterwards. No changes in cardiac rhythm were found during the event or for 15 min afterwards. Standards for hyperoxygenation and hyperinflation could not be achieved using the MRB even with a standardised procedure.

Nurses' ability to achieve hyperinflation and hyperoxygenation with a manual resuscitation bag during endotracheal suctioning

OBJECTIVE

To examine nurses' ability to deliver 1.5 times the ventilated tidal volume at 100% FIO2 with a manual resuscitation bag during endotracheal suctioning.

DESIGN

Prospective, descriptive.

SETTING

Six adult critical care units in a large university-affiliated medical center.

SUBJECTS

One hundred nurses randomly selected from the six adult intensive care units.

OUTCOME MEASURES

Nurses' manual resuscitation bag delivery of tidal volume and oxygen, as well as bagging rate, number of breaths delivered, and number of suction catheter passes performed. Patients' heart rate, mean arterial pressure, and arterial oxygen saturation.

RESULTS

The mean FIO2 delivered was 0.71 (range 0.24 to 0.97). Oxygen liter flow and nurses' delivered minute ventilation predicted 24% of the variance in FIO2 delivered. Mean bagging rate was 31 compressions per minute. The mean volume per breath delivered was 626 cc, which resulted in achievement of 57% of the standard (1128 cc). Volume achieved was related to patient lung compliance, but not related to nurses' experience, unit of employment, hand strength, or size.

CONCLUSIONS

Nurses observed were unable to meet the standard for volume or oxygen delivery. However this did not affect the patient's heart rate, mean arterial pressure, or SaO2.

The myth of 100% oxygen delivery through manual resuscitation bags

OBJECTIVE

To determine the actual oxygen delivery of the manual resuscitation bags (MRBs) hanging at the bedsides of patients receiving mechanical ventilation.

DESIGN

Descriptive study of 24 MRBs in use at the patient's bedside from six adult ICUs at a 1100-bed Mid-Atlantic medical center.

METHODS

MRBs were Puritan Manual Resuscitators with reservoir. Oxygen concentration delivered was measured with a Ventronic Oxygen Analyzer Model 5575. Oxygen flow to the MRB was recorded before collecting data and then set at 15 L/min. The MRBs were compressed three times, with a 5-second interval between compressions.

RESULTS

Oxygen flow before data collection varied from 6 L/min to 15 L/min. Measurements taken at the exit port before MRB compression ranged from 23% to 97%. Oxygen concentration ranged from 26% to 95%, with a mean of 59%. The oxygen values for each compression time were significantly lower than 100% (p < 0.001). The first compression values differed significantly from the second compression (p < 0.001) and the second differed from the third compression (p < 0.01).

CONCLUSION

MRBs are not delivering the level of oxygen nurses have assumed. In addition, variation in oxygen delivery occurs from compression to compression.

An epidemiologic study of NCLEX

This study of NCLEX performance was designed to identify the best risk indices for students who do not pass the test, to pinpoint the earliest time in their academic careers that their risk can substantially be known, and to estimate the effectiveness of a formal review course. Results show that 62% of the variance in NCLEX scores can be predicted with a combination of variables that includes four nursing school course grades, the test scores of the Scholastic Aptitude Test, and National League for Nursing test scores. Whether a student took an NCLEX review course was not a significant predictor of performance. A method of deriving risk estimate from these values is also shown.

Personality hardiness, ways of coping, social support and burnout in critical care nurses

Hardiness, ways of coping, social support and burnout in 103 critical care nurses were addressed in this study. Work-related and nonwork-related social support and hardiness were negatively related to burnout. Use of emotion-focused coping was positively correlated with burnout while hardiness was negatively related to the use of emotion-focused coping and positively related to both types of social support. After controlling for working nights, social support, hardiness, emotion-focused coping and problem-focused coping accounted for 44% of the variance in burnout scores.