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Evidence-Based Practice Habits: Putting More Sacred Cows Out to
Pasture
Mary Beth Flynn Makic, Kathryn T. VonRueden, Carol A. Rauen and Jessica Chadwick
Crit Care Nurse 2011;31:38-62 doi: 10.4037/ccn2011908
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Feature
Evidence-Based Practice
Habits: Putting More
Sacred Cows Out to Pasture
Mary Beth Flynn Makic, RN, PhD, CNS, CCNS
Kathryn T. VonRueden, RN, MS, ACNS-BC
Carol A. Rauen, RN, MS, CCNS, CCRN, PCCN
Jessica Chadwick, RN, MSN, CCNS
For excellence in practice to be the standard for care, critical care nurses must
embrace evidence-based practice as the norm. Nurses cannot knowingly continue a
clinical practice despite research showing that the practice is not helpful and may even
be harmful to patients. This article is based on 2 presentations on evidence-based
practice from the American Association for Critical-Care Nurses’ 2009 and 2010
National Teaching Institute and addresses 7 practice issues that were selected for 2
reasons. First, they are within the realm of nursing, and a change in practice could
improve patient care immediately. Second, these are areas in which the tradition and
the evidence do not agree and practice continues to follow tradition. The topics to
be addressed are (1) Trendelenburg positioning for hypotension, (2) use of rectal
tubes to manage fecal incontinence, (3) gastric residual volume and aspiration risk,
(4) restricted visiting policies, (5) nursing interventions to reduce urinary
catheter–associated infections, (6) use of cell phones in critical care areas, and (7)
accuracy of assessment of body temperature. The related beliefs, current evidence,
and recommendations for practice related to each topic are outlined. (Critical Care
Nurse. 2011;31:38-62)
I
f we want excellence in practice to be the standard for care,
critical care nurses must
embrace evidence-based
practice as the norm. We
CEContinuing Education
1. Understand how embracing evidencebased practice can immediately improve
patient care
2. Recognize 7 areas of clinical practice in
which tradition and the evidence do not
agree
3. Identify recommendations for practice
related to 7 older practice issues or “sacred
cows”
©2011 American Association of CriticalCare Nurses doi: 10.4037/ccn2011908
cannot knowingly continue a clinical practice despite research that
shows that the practice is not helpful and may even be harmful to
the patients we serve. This article
is devoted to putting some clinical
sacred cows out to pasture. It is
based on 2 presentations on
evidence-based practice from the
American Association of CriticalCare Nurses (AACN) National
Teaching Institute in 2009 and 2010.
The Institute of Medicine
defines evidence-based practice as
“The integration of best research,
clinical expertise, and patient values
in making decisions about the care
of individualized patients.”1 One
would hope that clinicians would
strive for this goal in all practice
decisions. Unfortunately, philosophical goals and clinical realities are
not always congruent. Many practice
decisions that were originally based
on intuition and tradition have not
changed despite compelling evidence
that change is warranted. The classic
example (addressed in the first article in this series, “Seven EvidenceBased Practice Habits: Putting Some
Sacred Cows Out to Pasture”2) is the
use of instillation of normal saline
into an endotracheal tube before
suctioning to “loosen secretions.”
Not only does this practice not loosen
secretions, it harms patients and
may be a major contributing factor
to ventilator-associated pneumonia.2
Cutting-edge practice decisions are
commonly based on research or the
best available evidence.3 It is the
older practice habits or “sacred cows”
that are more challenging to change
because the practices are considered
routine and beyond dispute.
The implementation of evidencebased practice at the bedside takes
commitment and an effective process.
Excellent process models to assist in
38 CriticalCareNurse Vol 31, No. 2, APRIL 2011
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Table 1
Evidence-based practice
Table 2
Systems for evaluating levels of evidence
models
Iowa model4
American Association for Critical-Care
Nurses (AACN)13
AACN levels of evidence: 6-level tool for
grading; level A is the strongest evidence
and M is manufacturer’s recommendation
only
Centers for Disease Control and
Prevention14
Modified HICPAC Categorization Scheme for
Recommendations: 5-scale system
Society of Critical Care Medicine15
Grades of Recommendation, Assessment,
Development and Evaluation (GRADE System)
was used to evaluate evidence for Surviving
Sepsis Guidelines
American Heart Association16
Used an 8-level scale with 4 classifications
to support recommendations for Basic Life
Support and Advanced Cardiac Life Support
Stetler’s model5
Rosswurm and Larrabee’s model6
Johns Hopkins Nursing model7
ACE Star Model of Knowledge
Transformation8
ARCC (Advancing Research and
Clinical Practice Through Close
Collaboration) model9
AHRQ (Agency for Healthcare
Research and Quality) model10
PARIHS (Promoting Action on
Research Implementation in Health
Services) framework11
Colorado model12
this goal have been published.
Table 14-12 lists 9 evidence-based
practice models that offer step by
step approaches and frameworks
to use. The typical process prescribed by the models is to ask a
clinical question, determine whether
solid evidence exists to support a
particular practice, compare current
practice with the research recommendations, and make appropriate
clinical changes based on the evidence. Although the process is
seemingly simple, articulating the
implementation is more challenging, although not impossible. Once
the research or evidence is collected,
it must be evaluated for strength
and quality by using levels of evidence. AACN recently published an
updated guide for level of evidence
in Critical Care Nurse.13 Table 2 provides examples of other evaluation
tools that may be used to assist clinicians in the evaluation of research
and evidence in deciding if the evidence is compelling enough to recommend a change in practice.
This article addresses 7 practice
issues that were selected for 2 reasons. First, they are within the realm
of nursing, and a change in practice
Authors
Mary Beth Flynn Makic is a research nurse scientist in critical care at the University of
Colorado Hospital and an adjoint assistant professor at the University of Colorado,
Denver, in Aurora, Colorado.
Kathryn T. VonRueden is a clinical nurse specialist at the R. Adams Cowley Shock
Trauma Center at the University of Maryland Medical Center and an assistant professor
at the University of Maryland School of Nursing in Baltimore.
Carol A. Rauen is an independent clinical nurse specialist and education consultant and
a staff nurse in the emergency department at Outer Banks Hospital in The Outer Banks
of North Carolina.
Jessica Chadwick is a clinical nurse specialist in the emergency department at Inova
Fairfax Hospital in Fairfax, Virginia.
Corresponding author: Mary Beth Flynn Makic, RN, PhD, CNS, CCNS, 7830 W. 72nd Place, Arvada, CO 80005
(e-mail: [email protected]).
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].
www.ccnonline.org
could improve patient care immediately. Second, these are areas in which
the tradition and the evidence do
not agree and practice continues to
follow tradition or “sacred cows.”
The topics to be addressed are as
follows:
1. Trendelenburg positioning for
hypotension
2. Use of rectal tubes to manage
fecal incontinence
3. Gastric residual volume
(GRV) and aspiration risk
4. Restricted visiting policies
5. Nursing interventions to
reduce urinary catheter–associated
infections
6. Use of cell phones in critical
care areas
7. Accuracy of assessment of
body temperature
The related beliefs, current evidence,
and recommendations for practice
related to each topic are described.
Trendelenburg Positioning
for Hypotension
Use of the Trendelenburg position
was originally intended to improve
surgical exposure for abdominal
procedures. In the late 1800s,
Friedrich Adolf Trendelenburg and
one of his students, W. Meyer, first
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described the position as a supine
head-down tilt of at least 45º.17 Use
of this position became common
practice in the operating room but
was associated with complications
such as increased central venous
pressure, engorgement of head and
neck veins, increased cerebral spinal
fluid pressure, hypertension, retinal
detachment, impaired oxygenation
and ventilation, gastric secretions
and mucus in the oropharynx causing aspiration.17 From a practical
aspect, patients placed in the Trendelenburg position had to be prevented from sliding head-down off
the table.17 Despite these adverse
outcomes for patients, the practice
of placing patients in the Trendelenburg position persists.
Related Beliefs and
Current Evidence
The use of the Trendelenburg
position for hypotension and shock
has been studied for more than 50
years. The proposed physiological
benefit is the shift of intravascular
volume from the lower extremities
and abdomen to the upper part of
the thorax, the heart, and the brain,
thus improving perfusion to heart
and brain. It is estimated that a headdown position results in a 1.8% displacement of blood volume.18 In the
1960s, however, Weil and Whigham19
reported deleterious effects of using
the Trendelenburg position in animals
and humans. In a hemorrhagic shock
model with rats, mortality and hemodynamic responsiveness were least
favorable in the head-down position;
in humans with hypotensive shock,
blood pressure decreased, lung volumes were compromised, and the
risk of retinal detachment and cerebral edema increased.19,20
Cardiovascular response to the
Trendelenburg position appears to
be influenced by the presence of
hypotension and the patient’s ability
to maintain homeostasis. For example, in normotensive patients placed
in the Trendelenburg position, little
deleterious hemodynamic effect is
observed.21-23 Even in elderly normotensive patients, who may have
some degree of impairment of vasomotor control owing to their age,
no deterioration was noted in cardiac hemodynamic parameters with
use of the Trendelenburg position.24
Hypotensive patients appear to
have different and more varied cardiovascular responses to the headdown position,21,25 and they show no
improvement in blood pressure or
cardiac index.18-21,24-26 As well, key
components of tissue oxygenation
are not improved with the Trendelenburg position.27 Most investigators have concluded that use of the
Trendelenburg position in hypotensive patients has no cardiovascular
benefit.18-21,24-26
Hewer,17 in his 1956 review of
complications of the Trendelenburg
position, discussed the untoward
effects on lung ventilatory mechanics and pulmonary gas exchange.
These effects included reduced vital
capacity even at 20º head-down tilt,
increased work of breathing, and
impaired respiration causing
hypercarbia and hypoxemia. In the
head-down tilt position, the cephalad shift of abdominal contents
increases abdominal pressure,
impairs diaphragmatic function,
and impedes lung expansion. In the
Trendelenburg position, mechanical
impedance of the lung and chest wall
increases and is associated with
increased resistance and decreased
tidal volume.28,29 Lung compliance
can decrease by 20%, PaCO2 increases,
and a mild metabolic acidosis may
develop.26 Ventilation and perfusion
abnormalities, evidenced by an
increase in intrapulmonary shunting, are also reported in the Trendelenburg position.21 Not surprisingly,
as body weight increases, lung
resistance and gas exchange abnormalities also increase significantly,28,29 which has important
clinical implications for obese critically ill patients; thus the Trendelenburg position should be avoided
in such patients.
Little research is available on
the effect of Trendelenburg position
on intracranial pressure; however,
some agree that it is likely to increase
intracranial pressure because of
the increased central venous pressure,17,24,30-32 but the effects on cerebral blood flow are uncertain.
Distension of the internal jugular
vein has been measured and is
increased in head-down tilt, but
internal jugular blood flow is
unchanged. Researchers disagree
on the effect of the Trendelenburg
position on intracranial pressure
and cerebral blood flow, with some
concluding that those factors do
increase,32 while others conclude
that cerebral hemodynamics are
not affected.22 One clinical protocol
that uses Trendelenburg positioning for postural drainage of the
lungs in patients with brain injury
originally incorporated criteria
based on changes in intracranial
pressure and cerebral perfusion
pressure33 and now also includes
reduced brain tissue oxygenation
for more precision, as the basis for
returning the patient to supine or
head-up position.
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In reviewing the literature related
to the physiological effects of the
Trendelenburg position and its use
to treat hypotension and shock, we
encountered a number of limitations
that made it difficult to draw definitive conclusions. Studies were conducted with a variety of populations
(eg, animals, healthy volunteers, or
normotensive patients), sample sizes
were relatively small, the methods
used various degrees of head-down
positioning that ranged from 10º to
30º and the length of time in this
position also varied, and various
end points were measured. Despite
these study limitations, most of the
findings are consistent in that they
show no demonstrated benefit of
the Trendelenburg position for
hypotension or shock. Thus the evidence does not support the use of
head-down tilt for hypotension.
Recommendations for Practice
Trendelenburg position increases
venous return but has little or no
beneficial effect on cardiac output
or blood pressure; the improvement,
if any, is temporary. Pulmonary gas
exchange is impaired in the headdown tilt position, thus overall oxygen delivery may not improve at all.
As well, the deleterious effects on
lung mechanics and oxygenation are
more exaggerated in obese patients.
Cerebral blood flow and intracranial pressure most likely increase in
the Trendelenburg position, and
the effect may be deleterious in
some patients with brain injuries.
The gravitational movement of
mucus and gastric secretions to the
oropharynx may increase the potential for aspiration. Table 3 provides
a summary of the evidence and
physiological response to the Tren-
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delenburg posiTable 3 Physiological effects of Trendelenburg positioning
tion.17,21,24,25,27-32
in hypotensive patients
Alternatives
Cardiovascular
to TrendelenSlight increase in mean arterial pressure
burg positionNo increased preload
Dilated right ventricle
ing, such as
Decreased right ventricular ejection fraction
passive leg lift,
Decreased cardiac output
may provide
Increase in systemic vascular resistance
greater benefit
Pulmonary
Reduced vital capacity
for initial manIncreased work of breathing
agement of
Decreases in PaO2
hypotension or
Increases in mechanical impedance of lung and chest wall
Decreased tidal volume
prediction of
Decreased lung compliance
fluid responIncreases in PacO2
siveness with
Tissue perfusion
No change in oxygen delivery
minimal or no
No change in oxygen extraction
untoward
No change in oxygen consumption
effect.34,35 RaisGastrointestinal
ing the patient’s
Cephalad shift of abdominal contents
Increased abdominal pressure
legs while keepImpaired diaphragmatic function
ing the head of
Impeded lung expansion
the bed horiNeurological
zontal relative
Possible increase in intracranial pressure associated with increase
in central venous pressure
to the patient’s
Distention of internal jugular vein
trunk produces
an approximate
Trendelenburg position for patients
volume shift of 150 to 300 mL to
34,35
with hypotension and/or hypothe upper part of the thorax.
volemic shock, and such positioning
This shift increases aortic volume,
is associated with impaired ventilamay not activate baroreceptors, and
tion and oxygenation and may have
avoids risk of gastric aspiration. In
25
other deleterious effects as just menone study, researchers reported
tioned. Despite these findings, a
the same adverse cardiovascular
survey of critical care nurses about
and pulmonary effects for passive
practices related to use of Trendelenleg raising as for Trendelenburg
burg position conducted in the late
positioning in 18 cardiac surgery
1990s showed that 80% of the
patients. Others have shown that
respondents would consider using
this maneuver correlates with the
Trendelenburg positioning to improve
response to fluid loading and is
hypotension.36 Although little new
predictive of the need for fluid
research has been done since that
when a patient’s cardiac output,
time, dissemination of information
stroke volume variation, or blood
related to the deleterious effects and
pressure respond positively to the
34,35
lack of benefit of this position has
leg lift maneuver.
continued.37 A repeat survey would
The evidence, despite the aforebe useful to determine if this traditionmentioned limitations, does not
based practice persists.
show a demonstrated benefit of the
21-27
21,26,28,29
27
26,28,29
17,24,30-32
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Use of Rectal Tubes to
Manage Fecal Incontinence
Critically ill patients with incontinence are at high risk for perineal
skin damage, which may also increase
the patient’s risk for pressure ulceration, secondary dermal injury, and
infection.38-40 Urinary and fecal
incontinence harm the protective
skin barrier through excessive moisture that macerates the skin, compromising its defensive functions
for the body. Digestive enzymes and
bacteria inherently found in feces
alter the pH and irritate the skin,
increasing the risk of incontinenceassociated dermatitis and infection.38,40,41 Nursing management of
critically ill patients with acute diarrhea is focused on protecting the
skin as well as containing the diarrhea. Research to effectively manage
acute fecal incontinence is limited;
however, evidence is evolving and
best practice guidelines are available
to guide practice.40,42
Related Beliefs and
Current Evidence
Use of rectal tubes to divert fecal
material away from the skin and
into a collection bag, a traditional
approach, is the least safe intervention and the procedure is poorly
defined.40,42,43 Little research exists to
support the use of traditional rectal
tubes (eg, mushroom catheter with
a soft flared tip, urinary catheter
with a balloon); however, these
devices have been used in practice
without clear evidence of the efficacy
and safety of the devices for management of fecal incontinence.44
Best practice for the management
of fecal incontinence, to minimize
skin breakdown (ie, incontinenceassociated dermatitis and pressure
Table 4 Possible risk factors to consider in evaluating the cause of acute
fecal incontinence
Type
Risk factor
Disease processes45,47
Gastrointestinal and hepatic diseases
Sepsis
Spinal cord injury
Enterotoxins
Medications48
Nonsteroidal anti-inflammatory drugs, antimicrobial agents,
angiotensin-converting enzyme inhibitors, β-blocking
agents, digoxin, lactulose, diuretics
Nutrition49
Enteral tube feeding (consult nutritionist to determine optimal
tube feeding formula and rate to minimize diarrhea)
ulcers), starts with an evaluation of
the cause of the diarrhea.41,45,46 Begin
by reviewing the patient’s medical
history, current medications, and
treatments that may increase gastric
motility or diarrhea. Table 445,47-49
provides a list of factors to consider
in evaluating the etiology of the
patient’s diarrhea.
Fecal incontinence may be a secondary consequence of the patient’s
disease or treatment (eg, antibiotics),
so several interventions can be
implemented to protect the skin
before placement of a device in the
rectum to divert stool. Nursing
interventions to minimize skin
breakdown from fecal incontinence
should be implemented early by
anticipating excessive moisture or
diarrhea on the basis of the patient’s
current plan of care (Table 5).
When fecal incontinence is
excessive or incontinence-associated
dermatitis is progressing, the use of
fecal containment devices may be
indicated. These devices can be
divided into 2 categories: fecal
pouches or indwelling retention
devices (tubes). When choosing a
fecal containment device to move
effluent away from the perigenital
skin, critical care nurses should
assess the patient’s perineal skin
and factors believed to be associated with the diarrhea.
Fecal collectors, also called anal
bags/pouches, when applied correctly are an effective option to
control and contain liquid feces.38,40,57
Fecal collectors are external devices
that consist of a self-adhering skin
barrier and attached pouch that
connects to a drainage bag, providing a closed system to move liquid
stool away from the skin. This system is external, providing less risk
to the patient’s rectal sphincter and
internal mucosa.40,57 When applied
correctly, fecal collectors can prevent skin breakdown, minimize
odor, track output accurately,
decrease exposure to fecal material,
minimize caregiver time, enhance
patients’ comfort, and save money.40
In a study57 conducted in Europe,
the fecal collector was evaluated in
120 hospitalized patients. The vast
majority (96%) of nurses reported
that the device preserved perineal
skin integrity, and none of the
patients had adverse skin breakdown while the device was in place.
Additional benefits of a fecal collector include the following: it can be
used indefinitely, as needed, to
manage diarrhea; it will not interfere with gastrointestinal activity as
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Table 5
Evidence-based management of fecal incontinence
Assessment
Evidence-based intervention
Assess patient’s risk for fecal incontinence; anticipate
fecal incontinence associated with disease, medications, interventions40,42,44,48
Protect the skin with moisture barrier products in anticipation of diarrhea
Assess the patient for risk of pressure ulcers and
excessive moisture and prolonged immobility by
using a valid and reliable risk assessment tool39,46
Complete a risk assessment daily and with a change in patient’s condition39;
implement interventions based on specific findings on risk assessment
Assess skin during the cleansing process
Cleanse the skin with no-rinse cleanser, moisturize
and protect the skin with each episode of incontinence38,42,45,50
Using soap and water with a washcloth is not optimal for basic skin care40,42
Soaps are frequently alkaline and further damage the protective acidic mantle
of the skin40,42
Washcloths may increase friction and damage fragile skin40,42
No-rinse bathing/perineal cleansing wipes are pH balanced, gentle on the skin,
and enhance removal of organic debris38,42,45,51
Research shows that no-rinse bathing products are effective in reducing
bacteria on the skin50
Incontinence overhydrates skin but removes essential oils that need to be
replenished by applying moisturizers and moisture barrier products38,40,41,51
Assess the need for moisture absorbing incontinence
pad to wick effluent away from the skin42,44
Assess the need for air flow near the skin and advanced
bed redistribution technology (follow hospital protocol for advanced bed therapy); avoid excessive
linen52,53
Use a single moisture-absorbing or wicking underpad under the patient to pull
effluent/moisture and liquid stool away from skin38,51,54-56
Avoid the use of diapers, especially with immobile patients, as diapers trap
fecal material against the skin and exacerbate skin damage40,51
Limit layers of linens beneath the patient; multiple layers of linen can inhibit
bed redistribution technology and air flow from reaching the skin39,52,53
Excessive linen entraps moisture, creates crinkles and pressure, and may
increase the risk of pressure ulcers52,53
Assess patient’s mobility and encourage toileting
Obtain bedside commodes and implement a toileting schedule to minimize
incontinence epidose47
Assess nutritional needs and evaluate tolerance of
tube feeding
Consider consult a nutritionist for diarrhea believe to be related to tube
feeding49
Evaluate skin for fungal infection associated with
fecal incontinence38,51
Fungal infection may be managed effectively with the application of topical
antifungal barrier creams
Assess skin, development of incontinence-associated
dermatitis, as well as frequency and consistency of
stool to determine need for a fecal containment
device42,44,57-62
Consider fecal collectors or bowel-management system42,44,57-62
Assess resolution of cause of diarrhea, changes in diarrhea flow, consistency, and skin condition to determine need for ongoing fecal containment device57-62
Remove fecal containment devices when liquid stool resolves57-62
diarrhea resolves; and it will not
compromise the rectal sphincter
and mucosa.
The nasopharyngeal airway
(nasal trumpet) has been studied
as a device to contain fecal incontinence in critically ill patients.58
With this method, a soft nasopharyngeal airway is inserted into the
rectum and connected to a drainage
collection system. Research on this
method of fecal containment is
limited; however, initial results
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indicate that the device was well tolerated by patients, was practical for
nurses, and effectively contained
fecal matter without untoward
effects for patients.47
Traditional rectal tubes (eg,
mushroom catheter with a soft flared
tip, urinary catheter with a balloon)
for management of liquid stool are
considered the least safe approach
for management of diarrhea.38,40,44
These devices are inserted into the
rectal vault and held in place by
inflating the balloon or mushroom
tip of the catheter. Table 6 outlines
the advantages and disadvantages
of these traditional devices for fecal
diversion. The use of balloon tubes
or mushroom catheters is an adaptation of the device for fecal containment, and because of the lack
of evidence to support their safe
and effective use and the availability
of other fecal containment systems,
these devices should be avoided in
current practice.38,40,42,44
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Table 6
Advantages and disadvantages of traditional rectal tubes (mushroom
catheter with soft flared tip, urinary catheter with a balloon)a
Advantages
Disadvantages
Diverts liquid stool away from skin
Fecal material must be liquid to pass through tube
Tubes may leak and create perirectal skin damage
As diarrhea resolves, the tube may block stool
Ballooned devices require strict periodic deflation
to prevent rectal mucosal injury
Injury of anal sphincter is not easily assessed
Duration for use of the device has not been
established
a Based on evidence from Gray et al,38,41 Wishin et al,40 Petterson,41 Beitz,42 Beekman et al,44 and Grogan and
Kramer.58
Bowel management systems
(BMSs), also called fecal management systems, are medical device
systems designed to direct, collect,
and contain liquid stool in immobile
patients. Several BMSs are commercially available and approved by the
Food and Drug Administration for
up to 29 days of use for management of liquid stool.42,59 BMSs have
unique characteristics and specific
insertion techniques (readers are
referred to device instructions for
insertion); however, the indications
and contraindications are similar
across device manufacturers. BMSs
are soft flexible catheters with containment drainage systems. The balloon used to inflate and secure the
catheter within the rectum is soft
and conforms to the rectal vault,
reducing the risk of anorectal
trauma.42,44 When used properly,
the BMS contains liquid stool,
allows accurate measurement of output, decreases health care providers’
exposure to body fluids, and may
protect perirectal skin or denuded
perigenital skin or wounds, thus
enhancing healing.38,42,44,59 Several
studies have been conducted to
evaluate the effectiveness and safety
of using BMSs for diarrhea management. Padmanabhan and colleagues60 evaluated the outcomes of
42 patients in whom a BMS was used
to contain diarrhea. The researchers
found that the device did not harm
the rectal mucosa (by performing
endoscopy at baseline and after
removal of the BMS), perigenital
skin condition improved in 92% of
the patients, and the health care
providers reported that the system
was easy to manage. Keshava et al61
conducted a prospective study of
inpatients admitted for burn management or to the geriatric unit.
Twenty-two patients with diarrhea
were managed with a BMS. Mean
duration of therapy was 14 days.
Proctoscopy after tube removal
showed normal rectal tissue, and
the health care providers in that
study also reported ease of use of
the device. In a quality improvement study,62 researchers found that
the combination of interventions to
prevent pressure ulcers along with
the introduction of a BSM in their
critical care unit resulted in a significant decrease in the frequency of
pressure ulcers. Although a direct
correlation cannot be made between
the BMS and the reduction in frequency of pressure ulcers, use of a
BMS to contain diarrhea and manage excessive moisture combined
with strategies for preventing pressure ulcers resulted in good outcomes for patients. Critical care
nurses should assess the need for a
BMS to manage severe diarrhea with
the goal of removing the devices as
soon as possible.
Recommendations for Practice
Management of fecal incontinence to minimize incontinenceassociated dermatitis and pressure
ulcers begins with an accurate nursing assessment of the patient’s risk
for fecal incontinence, early proactive perineal skin hygiene to protect
skin and minimize irritation, and
critical evaluation of when an external fecal containment device or
BMS is needed. Evidence-based
interventions (Table 5) should be
used in the care of patients with
fecal incontinence.
Gastric Residual Volume
and Aspiration Risk
Little evidence supports the use
of measurement of GRV to assess
gastric emptying and tolerance of
tube feeding, yet the practice of
assessing GRV while a patient is
receiving tube feeding persists.63,64
Several assumptions may exist
related to the assessment of GRV.65-67
First, the nurse may assume that
GRV provides information about
normal and abnormal gastric
emptying. Second, the nurse may
think that an elevated GRV indicates delayed gastric emptying
and intolerance of enteral tube
feeding. Third, a high GRV may be
believed to result in a higher risk
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for aspiration that may lead to aspiration pneumonia. In fact, the evidence has demonstrated that
checking a GRV in enterally fed
patients does not improve patients’
outcome or reduce complications.65-71
So why do we continue to check
GRV, and what evidence supports
continuing this practice?
Related Beliefs and
Current Evidence
The lack of definition of how to
measure GRV accurately creates a
challenge in clinical practice.68,69
Most guidelines suggest the use of
a large-volume syringe (60 mL) for
aspiration of fluid because smaller
syringes may collapse the gastric
tube.64,66 However, use of a syringe
may not consistently result in aspiration of the total volume of fluid
present in the stomach.70,73 GRV is
more easily obtained from large-bore
gastric tubes (eg, 14F-16F diameter)
than small-bore gastric tubes (8F-12F
diameter). Metheny and colleagues74
reported that larger GRVs were
detected 2 to 3 times more often
with large-bore gastric tubes than
with gastric tubes with a smaller
bore. Other variables that affect
measurement accuracy include the
position of the tube port in the gastric antrum, the patient’s position,
and the tube’s location near the
gastroesophageal junction.68,72 GRV
with enteral feeding tubes placed
beyond the pylorus is questionable
because of the small size of these
tubes and the physiological properties of the small bowel to continuously propel gastric contents
forward, unlike the gastric antrum.66
Similarly, if a gastric tube migrates
near the gastroesophageal junction,
GRV will be negligible in most
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cases.69 Frequent monitoring (eg,
every 4 hours) of GRV is indicated
as one method to monitor gastric
tube location. After obtaining
radiographic confirmation of accurate placement of a gastric tube,
observing the appearance and
changes in the volume of gastric
aspirate may assist in monitoring
for migration of the gastric tube.75
Another debate about the monitoring and interpretation of GRV
is defining what constitutes a high
gastric residual.64,66-68 Under normal
conditions, saliva and gastric fluids accumulate at approximately
188 mL/h in the stomach; thus any
order to withhold tube feedings for
a GRV less than 188 mL is inappropriate.64 Published reports vary in
providing guidance for what constitutes a high gastric residual, ranging from 150 mL to 500 mL of
aspirate.64,65,66,68,71,72 Best evidence
suggests that a single high GRV
should be monitored for the following hour, but enteral feeding
should not be ceased or withheld
for an isolated GRV greater than
250 mL.65,68 Serial hourly elevated
GRVs greater than 250 mL may
require withholding enteral feeding
for an hour in conjunction with
evaluation for prokinetic agents to
promote gastric motility and assessment of possible causes for decreased
gastric tolerance, including a
change in the patient’s acuity.64,66,68
Elevation of GRV is anticipated to
be greatest in the first few days of
enteral feeding. Questions remain
unanswered on when to stop checking GRV to evaluate tolerance of
enteral feeding.
The greatest concern with withholding enteral feeding because of
GRV or concern for aspiration is
underfeeding critically ill patients.
Elpern et al76 studied enteral feedings in an intensive care unit and
found that tube feedings were frequently withheld or stopped for
procedures, changes in patients’
body positions, high GRV, and diarrhea. Of the patients studied, a mean
of 64% of the patients had their
nutrition goals met, and the mean
length of interruptions for enteral
feeding was 5.23 hours per patient
per day. McClave and colleagues67
reported similar results. In their
study, only 14% of the patients
received 90% goal feeding within 72
hours of starting enteral feeding.
Reasons reported in this study for
stopping enteral feeding included the
following: placement of the patient
supine for procedures or nursing
care, high GRV, and preprocedure
protocols. Little evidence supports
the practice of stopping or withholding tube feeding to reposition patients
or when placing patients supine
briefly for routine care.67 Current
evidence suggests reducing the time
that enteral feedings are withheld
before procedures to minimize
underfeeding critically ill patients.66,67
The primary belief associated
with high GRV is risk for aspiration
by the patient. Aspiration has been
demonstrated with GRVs from 5 mL
to 500 mL.67 Aspiration is often clinically silent. No reliable clinical
marker has been found for risk of
aspiration, including GRV assessment.65,68,72,76 Risk for aspiration is
increased with hemodynamic instability, increased acuity or critical
illness (eg, sepsis), altered level of
consciousness, neurological compromise, sedation, and mechanical
ventilation. Interventions to minimize aspiration include elevating
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the head of bed more than 30º, initiating continuous enteral feedings,
using medications to promote gastric motility, and consideration of
postpyloric feeding.64-66,68,69 Ongoing
evaluation of patients’ tolerance of
enteral feeding is also necessary to
interpret GRV. Signs of intolerance
may include bloating, abdominal
pain, nausea, vomiting, and emesis.
Implementing and adhering to
enteral feeding protocols (Figure 1)
to minimize unnecessary cessation
of enteral feeding is needed to optimize nutrition in critically ill patients.
Isolated high GRVs should be
reassessed in subsequent hours and
accepting higher GRVs in the absence
of signs of intolerance is necessary
in clinical practice.65 Increasing GRV
may be a symptom of another underlying problem manifesting itself as
delayed gastric emptying.68 If serial
measurements of GRV remain elevated, the cause should be explored
rather than simply withholding
enteral feeding, which is likely to
result in underfeeding of critically
ill patients.67,68,76
Recommendations for Practice
Critically ill patients are at risk
of aspiration because of severity of
illness and interventions that compromise the gag reflex. Variables that
increase a patient’s risk for aspiration
include sedation, mechanical ventilation, neurological compromise/
altered level of consciousness, hemodynamic instability, and sepsis. Preventing aspiration begins with
accurate and ongoing assessment of
feeding tube placement (see AACN
Practice Alert: Verification of Feeding Tube Placement75), maintaining
the elevation of the head of the
patient’s bed at greater than 30º, and
evaluating the patient’s tolerance of
tube feeding.65,66,71 Assessment of
GRV is not an effective method of
determining aspiration risk.64-68,70,74
Table 7 outlines the evidence for
GRV monitoring and interventions
to prevent aspiration. Implementing an evidence-based enteral feeding protocol inclusive of increased
acceptance of higher GRV along
with physical assessment of the
patient’s tolerance and intolerance
of tube feeding will maximize the
delivery of adequate nutrition to
critically ill patients.
Restricted Visiting Policies:
A Thing of the Past?
Restriction of visitors for hospitalized patients has been practiced
for many decades. For example, in
the late 1800s, restricted visiting
hours were implemented in some
hospitals and applied to nonpaying
patients to establish order in general wards. In the early 1900s, paying patients were permitted to have
visitors anytime, anywhere. The
advent of intensive care units during the 1960s saw restricted visiting
implemented to protect patients
and family from exhaustion caused
by too many visitors.77 The spectrum of “visiting” can be thought of
as a continuum (Figure 2). Current
attitudes and practices in critical
care units span this continuum.78,79
Related Beliefs and
Current Evidence
Evaluation of the evidence
related to friends and family visiting
patients reflects both practitioner
preferences and a focus on patientand family-centered care.80 A landmark study by Molter81 in 1979
began to change the attitudes and
practices of nurses with regards to
visitation. Using the Critical Care
Family Needs Inventory, the primary needs of families of critically
ill patients were identified to be
related to the need for information,
support, comfort, assurance, and
proximity to the patient. A subsequent study reported that in addition to these needs, families also
have a need to be present in order
to provide reassurance and support
to the patient and to protect the
patient.82
The needs, preferences, and
stressors of critically ill patients also
have been examined.83 In a survey
of critical care patients, 40 stressors
were identified; number 4 was
“missing your spouse,” and number
8 was “only seeing family and
friends for a few minutes each
day.”83(p100) These investigators concluded that although some visiting
restrictions were appropriate, the
policies should be modified and
flexibility should be exercised.
Perceived barriers to liberalized
visiting and the rationales for restricting visiting in critical care units are
multifactorial (Table 8).80,84-86 These
concerns were distilled into 3 major
groups in a recent study87 of 171
hospitals, of which 32% had unrestricted, open visiting. The categories are (1) Space: interference
with patients right to privacy and
confidentiality in instance of shared
rooms; (2) Conflict: crowding and
traffic, hindering the ability to care
for patients and loss of structure
and authority for nurses; and (3)
Burden: to provide care for both
patients and their visitors.
In the past several decades,
many studies have been conducted
related to the psychological and
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ENTERAL NUTRITION (EN) FEEDING GUIDELINE
UNIVERSITY OF COLORADO
H OSPITAL
EN may be contraindicated with: Mesenteric ischemia, SBO, paralytic ileus, or GI fistula
Goals: 1) Initiate EN within 24-48 hours of admission*♦ 2) Deliver >90% of required calories on a daily basis.
Elevate HOB to 30-45°.♦ Initiate Osmolite 1.2 (unless formula otherwise specified) at 25 mL/hour.
1st residual > Maximum GRV?
1) Refeed residual to maximum 400 mL;
discard excess
2) Go to PROKINETIC GUIDE (Box A).
3) Continue feeds at same rate.
2nd consecutive residual > Maximum GRV?
1) Continue below
YES
Q4H residual > Maximum
GRV (350 mL♦)?
NO
1) Refeed gastric residual.
2) Continue feeds at same rate if at goal
rate; ↑feeds by 25 mL every 4 hours
if not at goal rate.
MAXIMUM GASTRIC RESIDUAL VOLUME (GRV): 350 mL
(unless otherwise specified by physician)
1) Refeed gastric residual to maximum
400 mL; discard excess
2) Hold feeds; recheck residual in 1 hour.
NO
Rechecked residual > Maximum GRV?
BOX A: PROKINETIC GUIDE
1) Initiate metoclopramide*#♦ 10 mg IV Q6H (5 mg Q6H if↓ renal function)
2) Continue metoclopramide if already receiving.
3) Do not stop feeds; continue ‘Enteral Nutrition Feeding Guideline’.
4) If residuals > Maximum GRV after 4 doses of metoclopramide, consider
combination prokinetic therapy and/or small-bowel feeding tube. Refer to
SMALL-BOWEL FEEDING GUIDE (BOX B).
YES
1) Discard gastric residual.
2)↓feed rate by 50% (ie, 100→50 mL) to a
minimum of 25 mL / hour.
3) Do not stop feeds.
4) If residuals > Maximum GRV
after 4 doses of IV metoclopramide consider
combination prokinetic therapy and/or smallbowel feeding tube. Refer to SMALLBOWEL FEEDING GUIDE (Box B)
Refer to “Enteral Nutrition
Problem Solving Guide” on UCH
Critical Care QI Committee
Web site for further EN practice
guidelines and recommendations.
BOX B: SMALL-BOWEL FEEDING GUIDE
1) Placement: Insert postpyloric feeding tube*#♦
2) Feed resumption: Following confirmation of postpyloric tip position,
resume feeds at previous rate,↑feeds by 25 mL Q4H if not at goal rate.
3) Aspiration prevention (In sedated/intubated patients only):
Insert a large-bore nasogastric tube (NG) for gastric decompression.*#
Clamp NG and discard gastric residuals Q4H (or place on straight drainage).
4) Tube maintenance: Flush postpyloric tube with 10-30 mL water
every 4 hours
If tube clogs,*# instill pancreatic enzyme mixture (8000 units crushed
pancrelipase; 650 mg crushed sodium bicarbonate; 5-15 mL water) into
postpyloric tube per policy. Resume feeds at previous rate,
↑feeds by 25 mL Q4H if not at goal rate. Notify physician after 3
unsuccessful attempts.
5) If EN contraindications (above) or significant N/V or abdominal
distention develop, notify physician and consider stopping smallbowel tube feeds.
# Requires MD order
* Unless contraindicated
♦ Evidence-based recommendation; all other information opinion-based.
Developed by: J Greenwood (Vancouver General Hospital) in collaboration with the CCCCPGC 7/2003.
Revised by: B Fulmer, L Kassel, R Saucier, G Vigue. P Wischmeyer (University of Colorado Hospital) 7/2009.
Figure 1 University of Colorado Hospital’s protocol for enteral nutrition.
Abbreviations: CCCCPGC, Critical Care Clinical Practice Guidelines Committee; EN, enteral nutrition; GI, gastrointestinal; GRV, gastric residual volume; HOB, head of
bed; IV, intravenous; MD, physician; N/V, nausea/vomiting; Q4H, every 4 hours; Q5H, every 5 hours; QI, quality improvement; SBO, small-bowel obstruction; UCH,
University of Colorado Hospital.
Reprinted with permission of the University of Colorado Hospital, Aurora, Colorado.
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Table 7
Best evidence for monitoring enteral feeding
Follow an evidence-based enteral feeding protocol65,68
Verify correct placement of enteral feeding tubes on a radiograph, with ongoing monitoring every 4 hours and as needed75
When possible, use a large-bore gastric tube for enteral feeding and evaluate gastric residual volume (GRV) the first few days after
initiating enteral feeding with a 60-mL syringe68
Maintain head of bed at 30° elevation or higher
Monitor trends in GRV; repeatedly high GRV (ie, >1 high GRV; high GRV is defined as a range between 250 and 500 mL) may require
additional interventions65-68; consider use of promotility/prokinetic agents64-66,71
Follow institutional protocol for reinstilling gastric aspirate; to reduce tube occlusions if GRV is reinstilled, increase routine water
flushes of the feeding tube64; if aspirate is discarded, record volume in output measurements
Evaluate patient for signs of intolerance to tube feeding (eg, bloating, abdominal pain, nausea, vomiting, and emesis)
Consider postpyloric feeding in patients with consistently high GRV65,68
en
Op
led
rol
t
n
ed
co
act
nt
tie
ntr
a
o
P
C
le
xib
Fle
ive
lus
c
n
I
d
ure
uct
r
t
S
d
icte
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e
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Figure 2 Spectrum of visiting policies.
Table 8
Perceived barriers to liberalized visitinga
Barriers related to patients
Adverse physiological effects
Hinder patients from getting
sufficient sleep or rest
Interrupt and interfere with
the provision of care
Barriers related to clinicians
Uncomfortable providing care or conducting procedures in front of family members
Create a sense of loss of control or structure during
emergency situations
Feel intimidated
Concerns regarding litigation
Uncomfortable interacting with family members
Tax limited health care provider resources
Worries that family members might ask multiple
questions
Increased stress, physical and mental exhaustion of
family and friends thus becoming more of a
burden and requiring more time of the staff
Concerns for maintaining the privacy of other patients
Concerns for safety of self and other patients because
of a fear of increased gang violence
a Based
on evidence from Sims and Miracle,80 Fernandez et al,84 Petterson,85 and Roll.86
physiological effects of visitors on
patients and staff. If patients’ wishes
regarding visiting are to be considered, nonstressful and flexible visiting
is of primary importance. In one
study,88 researchers reported that
patients preferred usually no more
than 3 visitors, for about 35 to 55
minutes, on average 3 or 4 times
per day and that visitors offered
reassurance, comfort, and calming.
Regarding the physiological
effects of visitors on patients,
research results indicate that visitors have no effect on patients’
blood pressure or heart rate.89-92 In
a randomized study91 of a coronary
care population, patients having a
visitor at a frequency and length of
time of the patient’s choosing had
fewer cardiovascular complications
than did patients whose visitors
were permitted to visit only twice a
day. The lower complication rate
may be due to reduced anxiety and
lower cortisol levels associated with
time spent with their families and
visitors.91
Similarly, no physiological
rationale exists for restricting
visitors of patients with brain
injuries. No deleterious effects on
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neurological status related to visiting have been reported, and some
patients experience a reduced
intracranial pressure associated
with visits by loved ones.93,94 Patients
with traumatic brain injury were
monitored during family conversations at the bedside. These patients
experienced no change in intracranial pressure; systolic, diastolic, and
mean blood pressure; heart rate; respiratory rate; arterial saturation; or
restlessness when listening to family
voices.95
The beneficial effects of liberal
visiting policies on patients’ families
are well supported. These effects
include reduced family stress and
burden; lower anxiety96; family’s
ability to serve as a historian, protector, coach, facilitator, and voluntary caregiver97; providing basic care
such as baths, mouth care, or massage improves respect, collaboration, perceived support of health
care providers, and scores on a
family-centered care survey.98
Another mechanism that supports flexible visiting and increases
families’ participation in care of
loved ones is including patients’
families in daily rounds with the
health care team.99,100 Benefits of
daily family rounds include the following: decrease in unexpected calls
or disruptions of physician team
rounds; structured time for clinicians
to focus on one patient with that
patient’s family; increased participation and active, constructive engagement with the staff; identification of
families who may benefit from more
formal care conferences; and greater
satisfaction of patients and their
families with the critical care experience.99 The total time commitment
for nurses and physicians on a
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Table 9 Recommendations for family visiting from the American College of
Critical Care Medicinea
Open visitation to provide flexibility for patients and their families is permitted and
established on a case-by-case basis
A visitation schedule that is determined collaboratively between patient, patient’s family,
and nurse, taking into account the best interest of the patient
Whenever possible, family presence and participation is encouraged at rounds, and
family presence is permitted during resuscitation
Family participation in patients’ care is encouraged as much as the patient’s condition
and the family’s comfort level will allow
Clean and immunized pets are allowed to visit in the intensive care unit
a Based
on evidence from Davidson et al.103
Table 10
Practice implications for family visiting
Assess and consider the needs of the patient and the patient’s family
Support flexible visiting hours through the development and implementation of less
restrictive and more collaborative visiting protocols
Include patient’s desires and signage regarding accepting visitors in the protocols
Develop family presence on rounds program
Encourage family members to participate in patient care as much as possible when
they are visiting
Address staff security concerns in visiting protocols
Educate patients’ families about the intensive care unit and visiting protocols, and have
the family identify a key spokesperson/contact
Educate health care providers about evidence that supports open, flexible family visiting
12-bed neurotrauma unit was 1
hour or less per day.99 Daily rounds
and early and routine family meetings can provide an opportunity to
assess the family and foster communication, understanding, and collaboration between the family and
health care providers.101,102
The American College of Critical
Care Medicine charged an interdisciplinary group of physicians,
nurses, and a clinical pharmacist to
develop evidence-based guidelines
for support of family-centered care.
The authors reviewed numerous
studies and made 43 recommendations for practice.103 Table 9103 outlines the key recommendations
relating to family visiting.
Recommendations for Practice
Critical care nurses, in their
roles as advocates for patients and
their families, are in a pivotal position to support patient- and familycentered care, which includes open,
flexible visiting. Table 10 lists
evidence-based practice implications.
The Joint Commission recently
acknowledged the importance of
family-centered care and visitation
in providing support to patients. As
of 2011, the Patient Rights Standard
regarding hospitals’ respect, protection, and promotion of patients’
rights (RI.01.01.01) will have a new
element of performance: “The hospital allows a family member, friend
or other individual to be present
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Table a11
Evidence-based guidelines for placement of indwelling urinary
catheters
Clear Indications
Contraindications
Urinary obstruction/retention
Fall prevention
Alteration in blood pressure or volume status
Routine urine specimens
Need accurate measurements of fluid input and output but
the patient cannot use urinal or bedpan
Staff/patient request
Emergency surgery
Excoriated skin
Altered mental status
Major trauma
Urologic procedures
Bladder irrigation
Management of stage III or greater pressure ulcer
Comfort care for terminally ill patients
a Based
on evidence from Hooton et al,106 Greene et al,108 Gould et al,109 and Saint et al.110
with the patient for emotional support during the course of stay.”104
This new element should provide
further impetus to develop and
implement flexible visiting protocols
in the critical care areas. Perhaps the
endorsement of open, flexible visiting is best stated by McAdam and
colleagues: “families need to be recognized for contributions they
make and invited ‘into the world
and work’ of ICUs.”97(p1100)
Nursing Interventions to
Prevent Catheter-Associated
Urinary Tract Infections
Improving patients’ outcomes
often requires rethinking practice,
systems, and the “why” behind common interventions and devices used
in the management of critically ill
patients.105 The insertion of a urinary
catheter device is one example in
which reexamining the evidence and
nursing care associated provides an
opportunity to improved patients’
outcomes. Catheter-associated urinary tract infections (CaUTIs) are
the most common hospital-acquired
infection, accounting for almost 40%
of all nosocomial infections. An estimated 80% of CaUTIs are associated
with indwelling urinary catheters.106-109
Related Beliefs and
Current Evidence
Obviously the easiest way to prevent a CaUTI is to avoid insertion of
the device. When an indwelling urinary catheter is needed to monitor
a patient, however, prevention of
CaUTIs begins by understanding
the clinical indication for the device
and removing the catheter when the
clinical condition has resolved. The
primary use of a urinary catheter is
for close monitoring of a patient’s
hemodynamics and fluid balance,
surgical procedures, and urologic
diseases.106,108,109 The literature suggests that urinary catheters are not
indicated to prevent falls, for management of patients with altered
mental status, to avoid skin excoriation, or to obtain urine specimens.106,108,110 Table 11 provides a list
of clear indications for insertion of
urinary catheters as well as a list of
conditions in which a catheter is
not indicated.
Delirium in critically ill patients,
especially older hospitalized
patients, is an increasing concern
that is associated with poor outcomes for patients.111 Multiple factors contribute to delirium, and
indwelling urinary catheters have
been identified as a specific risk
variable.112 Bladder catheters can
act as an informal restraint, limiting patients’ movement, especially
when the clinical indication for the
device is no longer evident.113 The
presence of an indwelling urinary
catheter in a delirious patient
increases the risk of falls and the
risk for traumatic dislodgment of
the catheter and subsequent urethral
trauma. Early removal of urinary
catheter devices and implementation of normal toileting practices
(eg, bedside commode, offering
urinal), frequent rounds, use of
moisture wicking underpads, reorientation with specific questions
concerning elimination needs, and
review of medications that may
increase urgency/need to void are
important nursing interventions in
the management of patients with
acute delirium.114,115 Similarly,
indwelling urinary catheters are not
indicated as a primary intervention
to manage moisture-related skin
breakdown.106,108,109 Skin care interventions to manage incontinence,
such as moisture barrier creams
and moisture wicking products,
should be explored before insertion
of a urinary catheter. In the presence of stage III or IV pressure
ulcers in the perineal region, an
indwelling catheter may be necessary to assist with wound healing.106
The need for a bladder catheter
with concomitant thoracic patientcontrolled epidural analgesia is
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another area for opportunity to
reexamine practice and reduce
CaUTIs. Research results indicate
that an indwelling urinary catheter
can be safely removed in conjunction with thoracic patient-controlled
analgesia therapy.116,117 Early removal
of the catheter in these studies was
associated with earlier ambulation,
shorter length of hospitalization,
lower CaUTI rate, and lower incidence of postoperative urinary
retention.117,118 Once a patient with a
thoracic patient-controlled epidural
for analgesia is hemodynamically
stable, the evidence suggests that
removal of the bladder catheter
should be considered.116-118
Knowing the clear indication for
the bladder catheter and minimizing catheter duration are important
first steps in preventing CaUTIs.
Exploring options for elimination
when an indication for an indwelling
catheter is not clear is essential to
reduce unnecessary insertion of
devices. Daily reevaluation of the
need for the indwelling device, discussing a discontinue order with the
prescribing provider, and prompt
removal are also important steps to
reduce the risk for infection.
Many critically ill patients need
an indwelling urinary catheter to
monitor fluid balance and hemodynamic status. In the event that a
bladder catheter is necessary, nursing interventions in the management
of the bladder catheter may assist in
the reduction of CaUTIs. Table 12
summarizes current evidence to help
prevent CaUTIs.
Placing an indwelling urinary
catheter device is a fundamental
skill taught to all nurses. Opinions
vary on whether to use sterile or
aseptic technique for the placement
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Table 12 Recommendations for practice to reduce occurrence of catheterassociated urinary tract infections
Know the indication for the indwelling urinary catheter. Use automatic stop orders and
reminders to request an order to remove the device when the indication is resolved.119
Use aseptic technique with sterile equipment to insert the device.106,108,109 Aseptic technique is most often defined as the use of sterile gloves, mask, sterile barriers, perineal
washing using an antiseptic cleanser, and no-touch insertion technique.120
Perform routine meatal care with soap and water during daily bathing.106,108,109 Use of
antiseptic cleansers, creams, lotions, or ointments is no better than perineal care
provided with soap and water.106,118,120-122 Antiseptic agents may irritate the urethral
meatus and increase the risk of infection.120
Maintain a closed system106,108,109 with the drainage bag below the level of the bladder.106,108-110,123
Use a catheter securement device.124,125
Explore elimination options to prevent reinsertion (eg, bladder scanner, bedside commode, urinal, moisture wicking underpads, nursing rounds).120-127
of the device to reduce CaUTIs.108,118
Part of the challenge is defining
sterile and aseptic technique within
the clinical context of the skill.121
Willson and colleagues120 conducted
a review of the literature and found
that aseptic technique for urinary
catheter placement was most often
defined as the use of sterile gloves,
mask, sterile barriers, perineal
washing using an antiseptic cleanser,
and no-touch insertion technique.
Current recommendations suggest
that maintaining aseptic technique
and using sterile equipment while
inserting the catheter are both
important elements to minimize
infection.106,108,109
Part of urinary catheter care
includes care of the urethral meatus.
Research on meatal care with antiseptic cleansers, creams, lotions, or
ointments found them to be to be
no better than routine perineal care
provided with soap and water at
reducing CaUTIs.106,118,120-122,124 Some
evidence suggests that antiseptic
agents may actually increase the
risk of infection by irritating the
urethral meatus.120 Current guidelines suggest “routine hygiene”
(eg, cleansing of the meatal surface
during daily bathing) is all that is
needed to maintain an indwelling
urinary catheter.106,108,109
Securing the indwelling urinary
catheter is strongly recommended
in the guidelines of the Centers for
Disease Control and Prevention.109
Research evidence describing the
effectiveness of securing a urinary
catheter and the prevention of
CaUTIs is limited.109,120,122,124,125 The
practice of securing a catheter is
primarily based on clinical experience and expert opinion (ie, Society
of Urologic Nurses and Associates),125
which suggests that securing the
urinary catheter prevents urethral
trauma, erosion, and inadvertent
removal and increases patients’
comfort.124 A number of devices for
securing catheters are available, and
many experts recommend applying
the device to the upper thigh in
women and the abdomen in men.124,125
Maintaining a closed system to
prevent CaUTIs is supported by
current guidelines.106,108-110,120 Catheter
and drainage systems are designed
with prepackaged seals to prevent
inadvertent disconnection and act
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as a physical barrier to the migration
of microbes.120 If drainage system
seals are broken in practice, a systems analysis of the most common
barriers to maintaining the closed
system should be explored. For
example, if the emergency department uses bladder catheter systems
without metered drainage collection
devices, the critical care nurse may
need to break the system to obtain
a metered urometer for hourly
monitoring. System analysis could
suggest a change to all metered
catheter kits, streamlining products
and enhancing compliance with
evidence-based practice guidelines.
Maintaining the collection bag below
the level of the bladder is another
important practice recommendation, as it minimizes reflux into the
catheter itself and prevents retrograde flow of urine.106,108,109 Emptying
the drainage bag frequently and
before all patient transports is a
simple and effective strategy to
reduce CaUTIs. Resist the habit of
placing the drainage bag between
the patient’s legs during transport.
All health care providers need to
work together to keep the drainage
bag below the bladder.123
The effectiveness of ultrasound
bladder scanners as a strategy to
reduce CaUTIs is not well studied,
and further research is needed to
demonstrate effectiveness of this
monitoring intervention. However,
the clinical benefits of bladder scanners include effective diagnosis of
urinary retention, reduction of
unnecessary intermittent catheterizations, enhanced comfort for
patients, and cost savings associated with inappropriate catheterizations.126,127 Ultrasound bladder
technology provides an assessment
tool to assist with early removal of
indwelling invasive urinary catheters.
The evidence to support the use
of urinary catheters coated with an
antimicrobial agent (silver alloy or
antibiotic) to reduce CaUTIs is
inconclusive.106,128 The clinical evidence defining the safety, efficacy,
and appropriate use of silver-coated
urinary catheters in randomized
controlled trials supports the use of
such devices in reducing CaUTI in
patients with short catheter durations128; however, the magnitude of
reduction in infection did not differ
significantly from uncoated catheters
in all trials.127 Current guidelines do
not recommend routine use of
coated catheters in all hospitalized
patients to reduce CaUTI.106,108,109,128-130
In a recent systematic review
and meta-analysis, Meddings et al119
found that urinary catheter
reminders and stop orders appeared
to reduce CaUTI rates. Implementing systems that provide physicians
and nurses with routine reminders
to evaluate the need for the bladder
catheter reduced the rate of CaUTIs
by 56% (P=.005). Automatic stop
orders in this study reduced the
rate of CaUTIs by 41% (P<.001).
Overall use of urinary catheters was
also found to be decreased in several of the studies analyzed in that
meta-analysis.
Recommendations for Practice
Indwelling urinary catheters are
commonly used devices in the management of critically ill patients, and
evidence-based nursing interventions
are needed to prevent infection.
One intervention, in isolation, is
less effective than a bundle of interventions in preventing CaUTIs.110
Focusing nursing care on the basis
of best-practice interventions is
necessary to minimize critically ill
patients’ risk for developing a
CaUTI. Using a multidisciplinary
approach to prevent CaUTIs is the
most effective method of improving patients’ outcomes. Several programs are available to assist
organizations in developing CaUTI
prevention programs (eg, from the
Association for Professionals in
Infection Control and Epidemiology
Inc108). Using these programs along
with frequent publication of the
teams’ efforts in reducing CaUTIs
will support the momentum of this
change. Ensuring that management
of indwelling urinary catheters is
based on best evidence is essential
to improving patients’ outcomes.
Use of Cell Phones in
Critical Care Areas
Cellular phone technology is
used every day by millions of people
in all walks of life, businesses, and
professions. Cell phones have
become an integral tool of the medical community as a means of fast
and convenient communication,
yet cell phone restrictions remain
in critical care units. What is the
science behind the restrictions?
Related Beliefs and
Current Evidence
In many hospitals, cell phones
are used as a primary means of
communication with medical staff
in case of emergency and have
become an essential clinical resource
for accessing information in the
care of critically ill patients.131 In a
recent survey,132 70% of medical
personnel indicated that they carry
their mobile devices to areas such as
the operating room and critical care
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units despite strict restrictions, and
95% ranked their ability to use
mobile phone technology in the
hospital as very important or important. Despite the vast array of uses
and popularity in the health care
arena, mobile technology remains
banned in many hospitals nationwide. These bans originated in the
era of analog telephone devices and
have remained in place despite
numerous technological advances.
Current policies often state that cellular telephones must be turned
completely off when arriving in the
hospital or in the critical care areas,
a difficult policy to enforce. These
rules are based on the premise that
cellular devices when in the “on”
position transmit detrimental electromagnetic interference. The examination of effects of electromagnetic
interference are outlined in Table 13.
Policies regarding patient safety
concerns related to electromagnetic
interference have been focused primarily on the distance between the
cellular device and medical equipment. This has also been the focal
point of clinical studies related to
electromagnetic interference.133,134
Mechanical ventilators have been
identified as one of the most critical
pieces of medical equipment and
therefore have been the most commonly examined biomedical technology. Most studies define cell
phone interference as anything from
a change in screen appearance, to
false alarms, to complete shutdown
of the ventilator.133,135-138 In several
studies,135,136 researchers reported
that the maximum distance between
the cellular devices and various ventilators that would cause interference with the ventilator function
was 100 cm. In another study,137
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Table 13
Electromagnetic interference: effects on medical technology
Electromagnetic radiation is emitted intentionally or unintentionally by devices that
generate electromagnetic fields, and such radiation may affect the functioning of
medical devices.133
The reception of electromagnetic interference by biomedical technologies used
throughout the hospital is a cause for concerns about patient safety.
The effect of electromagnetic interference on biomedical technology is based on 3 key
variables133,134
• Interference is associated with the distance between the cellular device and the
medical equipment.
• The degree of shielding that the medical device has against electromagnetic
interference.
• Amount of electromagnetic interference is closely linked to the characteristics of
the cellular phone.
Testing of effects of electromagnetic interference on biomedical devices in clinical
studies most commonly involves testing the maximum level of frequency required to
accept or receive a phone call and the radiation emitted toward the biomedical equipment and the corresponding reaction.
Research is needed to explore
The degree of shielding built into different pieces of medical equipment to protect
against electromagnetic interference, with rigorous evaluation of each brand of
equipment used within the hospital.131
Evaluation of characteristics of cellular devices and range of interference, minimal to
maximal radiation release and proximity to cellular tower,131 and the location of cell
phone use in the hospital.
researchers identified 9 hazardous
incidents involving ventilators that
occurred at a median distance of 3
cm (range, 0.1-300 cm) from cellular
device to ventilator. Only one of
those incidents occurred when the
cell phone was more than 100 cm
away from the ventilator, and that
incident was linked to older generation cellular technology.137
Other biomedical equipment
that has been examined for the effect
of electromagnetic interference
includes devices such as pulse oximeters, cardiac monitors, carbon dioxide detectors, and defibrillators.138,139
For those items, it was determined
that the maximum distance for
interference was only 20 cm away.
The evidence suggests that the range
of electromagnetic interference with
various types of medical equipment
is 0 to 300 cm (9 feet).137-139 However,
clinically significant electromagnetic interference with biomedical
devices can occur when a cellular
phone is less than 100 cm from the
device.137,138,140
Based on analysis of the evidence, new guidelines must be
developed that would change current hospitalwide bans of cell phone
technology. Current evidence support the Medicines and Healthcare
Products Regulatory Agency140 recommendations of 2004, which
state that a total ban is not necessary. To address the concern of distance between the cellular device
and biomedical equipment, the
notion of a “1-meter rule” should
be established. Using that rule,
medical personnel as well as patients
and family members would be able
to use their mobile technology as
long as they were more than 1 m
away from critical care equipment.
This practice provides extra safety,
in that interference is most likely to
occur when the cell phone is within
3 cm to 20 cm (1 to 8 in) of biomedical devices.138,139
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Another recommendation is to
create specific, well-marked “cell
phone areas” in convenient locations
throughout the hospital that afford
use of cell phones without concern
for electromagnetic interference. In
a recent study,141 creation of rooms
where cell phone use was acceptable
on an adolescent inpatient unit
increased satisfaction among patients.
Adolescents rely heavily on their cell
phones to remain connected to family and friends while hospitalized.
Once allowed to go to a cell phone–
friendly room, the patients were able
to remain compliant with hospital
rules while still staying in touch with
their “outside lives.” Revision of current policies related to cell phone
use that are based on research will
be useful in increasing satisfaction
of patients, patients’ families, and
health care professionals.
Recommendations for Practice
Hospital policies that ban use
of cellular phone devices are not
only impractical to enforce, they
also exclude a key tool that is used
as a vital source of information for
health care providers. A review of
current evidence indicates that this
position is outdated and unnecessary. Less restrictive guidelines such
as the 1-meter rule and/or cell
phone–friendly areas should be
applied to new policies. Revising
current policies can increase satisfaction of patients, visitors, and
staff. Hospitals and the biotechnology industry will also benefit from
more extensive testing of their
equipment for sensitivity to electromagnetic interference, as there is
tremendous variability between
hospitals and the biotechnical
equipment used in each.
Accuracy of
Assessment
of Body
Temperature
Table 14
Temperature measurement sites and devices
Sites for measurement of
core temperature143,144,146,148
Distal part of esophagus
Accurate
Nasopharynx
measurement of
Tympanic membrane
body temperature is essential
in the management of critically
ill patients. Unfortunately an accurate, noninvasive method to measure core temperature has yet to be
established.142-144 Understanding the
differences in body temperatures
measured at various body sites,
technology limitations, and “user
error” is important when evaluating
body temperature values in critically ill patients.
Related Beliefs and
Current Evidence
In practice, assumptions may
be made about the accuracy of the
temperature measurement device
and the relationship of the temperature measured to the core temperature. Physiological temperature can
be defined as central (core) and
peripheral temperatures. Central
temperature is a stable temperature
reflective of 60% of the body mass
and is tightly regulated by the
body.144-146 Near core temperatures,
peripheral temperatures, may vary
over time or be influenced by
extreme environmental and physiological variables,143 but under normal
conditions correlate closely with
core temperature.144 The most accurate core temperature is obtained
via a pulmonary artery catheter;
although infrequently used, this
method is considered the “gold
standard.”143,144,146-149 Table 14 provides
the evidence on which sites are used
Sites for measurement of
near core temperature144,149
Mouth
Bladder
Rectum
Temporal artery
Axilla
for core and near-core temperature
measurements.
To interpret and track trends in
body temperature correctly, clinicians should consider site-specific
temperature as well as device limitations and accuracy in obtaining the
temperature. Researchers comparing
body temperature measured with
various devices and methods with
core temperatures considered the
temperature device to be accurate if
the mean difference in temperatures
obtained was ±0.3ºC and to be precise if the standard deviation was
from 0.3ºC to 0.5ºC.144,147,149,150 A mean
difference in temperature greater
than 0.5ºC between devices would
represent a clinically significant difference.147 It is unclear whether critical care nurses in clinical practice
differentiate the accepted difference
in temperature measurements
obtained with different devices and
how the clinical interpretation of
the measurement plays into subsequent clinical decisions.
Errors in accurate temperature
measurement are most often associated with choice of measurement
site, instrument-related errors, and
operator error.143,144,148 Temperature
monitoring devices require accurate
application to provide intended
measurement data; however, user
error causes erroneous temperature
measurements.143,147 Device limitations
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Table 15
Summary of different temperature modes, variation from core temperature, clinical advantages and disadvantagesa
Site of temperature measurement Variation from core temperature
Pulmonary artery
Reference standard
Best practice: advantages (+) and disadvantages (–)
+ True core temperature
– Highly invasive
Oral
<0.4°C
+ Ease of use
+ Oxygen up to 6 L and endotracheal tube do not influence
accuracy146,149,155
+ Research has shown that administration of warmed gases
and oxygen through an endotracheal tube does not cause
significantly different oral temperature compared with core
temperature153,155
– Accurate placement of probe in the mouth (posterior sublingual
pocket) is necessary for correct temperature reading143,146,147,149
– May be influenced by fluids and tachypnea156
Esophagus
<0.1°C
+ Correlates closely with pulmonary artery temperature.144,147,150
Optimal placement requires the esophageal temperature
probe to be positioned at the point of maximal heart tones
(left atrium) in the distal part of the esophagus144,146 and at an
insertion depth between 32 and 38 cm.150
+ Minimal lag time for temperature measurement144,147
– Temperature fluctuates according to depth of probe; accurate placement is key150
Bladder
<0.2°C
+ Easy to perform with urinary catheterization; low risk of
dislocation
+ Temperature is accurate during dates of increased diuresis154
– Accuracy of temperature influenced by low urine flow144,150
– Lag time estimated up to 20 minutes during therapeutic
hypothermia interventions150
Rectum
<0.3°C
+ Easy to perform
– Invasive; placed in rectal vault; may be expelled with intestinal motility
– Lag time estimated up to 15 minutes144,150
– Accuracy of readings influenced by stool in the rectum
Temporal artery
<0.4° C
+ Minimally invasive temperature closely correlated with core
temperature
+ Temporal artery is not significantly affected by thermoregulatory changes; therefore perfusion should be stable in most
conditions and closely reflect core temperature.144,156,157
– Current research has provided mixed results as to accuracy
of this device in different practice settings, patient populations, and physiological conditions.
– Diaphoresis may influence accuracy of temperature readings.
– Accuracy of temperature measurement procedure required
for correct temperature reading from the forehead and
behind the ear.156,158
Not recommended for temperature monitoring143,144,147,149,151,159
– Tested in multiple populations of patients; however, user
error and patient’s anatomy reduce accuracy of temperature
obtained.143,144,147-149
Tympanic membrane
a Based on evidence from Hooper and Andrews,143 Sessler,144 Crawford et al,145 Torossian,146 Forbes et al,147 Bridges and Thomas,148 Hooper et al,149 Polderman and
Herold,150 O’Grady et al,151 Exacon Scientific,152 Konopad et al,153 and Fallis.154
include the range of temperatures in
which the thermometer has been
tested. Few devices have been rigorously tested in all populations of
patients and during extremes in
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temperature (hypothermic and hyperthermic states), yet multiple devices
are used in these extremes of body
temperature to assess patients. When
sensing temperature “lag” in patients
with therapeutic hypothermia, both
the temperature-measuring device
and the physiological temperature
site are variables that should be
considered with clinical trending of
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temperature and subsequent therapeutic interventions.150
In some practice settings, the
measurement of a newly elevated
temperature triggers an automatic
order set that includes many tests
that are costly and disruptive to the
patient.151 Knowing which temperature measurement technique is best
to assess a patient may minimize
the frequency of obtaining inaccurate temperature readings. Also, it is
important to remember that temperatures obtained from 2 different
body sites should not correlate exactly
but should be “close in range” (ie,
<0.5ºC apart). Table 15 provides a
summary of different temperature
measurement modes, their advantages and disadvantages, and the
mean variation in temperature from
the core temperature measured in
the pulmonary artery.143-145,148,150-153
Recommendations for Practice
Despite how commonly body
temperature is assessed in the management of critically ill patients, the
best noninvasive device to measure
core temperature accurately remains
to be developed.142,145 Although no
ideal device has been developed yet,
critical care nurses can make good
clinical decisions based on the type
of device used to measure the temperature, the patient’s characteristics, and the user’s competence.
Understanding device limitations
and knowing that temperatures
obtained from 2 devices should differ by less than 0.5ºC are important
To learn more about evidence-based practice,
read “Evidence-Based Practice, Rule-Following,
and Nursing Expertise” in the American Journal
of Critical Care, 2009;18:479-482. Available
at www.ajcconline.org.
to clinical interpretation of temperature measurement and assessment.
Optimally, the same method of temperature assessment should be used
throughout an episode of care to
enable more accurate tracking of
trends in temperature.148 Noting
trends in temperature data, evaluating other vital signs, and assessing
parameters in a patient with a new
fever should guide clinical decisions,
not a single temperature reading.148,151
Closing: Moving Evidence
Into Practice
As Thomas Paine said in 1776,
“A long habit of not thinking a thing
wrong, gives it a superficial appearance of being right.”160 The practices
reviewed in this article are all within
the domain of nursing, and it is
important as nurses that we challenge tradition and “habits in our
nursing practice.” As we continue
to perfect the art of nursing, we
must also remember the science of
nursing. Science is dynamic and ever
changing. Clinical practices should
be based on evidence whenever
possible. The challenge is in getting
the evidence in the right hands and
encouraging and empowering the
clinicians at the bedside to make
clinical changes, moving nursing
practice away from habits of tradition. Practicing by best evidence
improves patients’ outcomes,1,3 and
critical care nurses are instrumental
to the process of examining and
implementing the evidence in practice, putting sacred cows out to pasture. CCN
Now that you’ve read the article, create or contribute
to an online discussion about this topic using eLetters.
Just visit www.ccnonline.org and click “Respond to
This Article” in either the full-text or PDF view of
the article.
Financial Disclosures
None reported.
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56. Padula CA, Osborn E, Williams J. Prevention and early detection of pressure ulcers
in hospitalized patients. J Wound Ostomy
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57. Palmieri B, Benuzzi G, Bellini N. The anal
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58. Grogan TA, Kramer DJ. The rectal trumpet: use of a nasopharyngeal airway to contain fecal incontinence in critically ill
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59. Echols J, Friedman BC, Mullins RG, et al.
Clinical utility and economic impact of
introducing a bowel management system.
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60. Padmanabhan A, Stern M, Wishin J, et al.
Cilinical evaluation of a flexible fecal incontinence management system. Am J Crit
Care. 2007;16(4):384-393.
61. Keshava A, Renwick A, Stewart P, et al. A
nonsurgical means of fecal diversion: The
Zassi Bowel Management System. Dis
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62. Benoit RA, Watts C. The effect of a puressure
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64. Bourgault AM, Ipe L, Weaver J, et al. Development of evidence-based guidelines and
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65. Martindale RG, McClave SA, Vanek VW,
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66. Parrish CR, McClave SA. Checking gastric
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of ICU delirium. Intensive Care Med. 2007;
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urinary catheters: a one-point restraint?
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and treatment. Hartford Institute for Geriatric Nursing. Updated January 2008.
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with thoracic patient-controlled epidural
analgesia undergoing thoracotomy. Pain
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duration of urinary catheterization after
thoracotomy in patients under postoperative
patient-controlled epidural analgesia. Acta
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drainage necessary during continuous
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Reg Anesth Pain Med. 2000;25(5):498-501.
Meddings J, Rogers MA, Macy M, Saint S.
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Reminder systems to reduce catheterassociated urinary tract infections and urinary catheter use in hospitalized patients.
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Willson M, Wilde M, Webb ML, et al.
Nursing interventions to reduce the risk of
catheter-associated urinary tract infection:
Part 2. J Wound Ostomy Continence Nurs.
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short term indwelling urethral catheter to
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122. Gray M. What nursing interventions reduce
the risk of symptomatic urinary tract infection in the patient with an indwelling
catheter? J Wound Ostomy Continence Nurs.
2004;31(1):3-13.
123. Siegel T. The ins and outs of urinary catheters.
Adv Nurse Pract. August 2008:57-60. www
.advanceweb.com/np. Accessed January 13,
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124. Gray M. Securing the indwelling catheter.
Am J Nurs. 2008;(12):44-50.
125. Society of Urologic Nurses and Associates:
Clinical Practice Guidelines Task Forces.
Care of the patient with an indwelling
catheter. Urol Nurse. 2006;26(1):80-81.
126. Sparks A, Boyer D, Gambrel A, et al. The
clinical benefits of the bladder scanner: a
research synthesis. J Nurs Care Qual. 2004;
19(3):188-192.
127. Lee YY, Tsay WL, Lou MF, et al. The effectiveness of implementing a bladder ultrasound
programme in neurosurgical units. J Adv Nurs.
2006;57(2):192-200.
128. Cummings J. Silver-coated foley catheters for
the prevention of urinary tract infections.
Techflash: Illuminating Evidence to Aid Decision Making. Oak Brook, IL: University
HealthSystem Consortium; August 2009.
https://www.uhc.edu.
129. Johnson JR, Kuskowski MA, Wilt TJ. Systematic review: antimicrobial urinary catheters
to prevent catheter-associated urinary tract
infection in hospitalized patients. Ann Intern
Med. 2006;44(2):116-126.
130. Lo E, Nicolle L, Classen D, et al. Strategies
to prevent catheter-associated urinary tract
infections in acute care hospitals. Infect
Control Hosp Epidemiol. 2008;29:S41–S50.
http://www.journals.uchicago.edu/doi/pdf
/10.1086/591066. Accessed January 13, 2011.
131. Dang B, Nel P, Gjevre J. Mobile communication devices causing interference. J Crit Care.
2007;22(2):137-141.
132. Ramesh J, Carter AO, Campbell MH, et al.
Use of mobile phones by medical staff at
Queen Elizabeth Hospital, Barbados: evidence
for both benefit and harm. J Hosp Infect. 2008;
70(2):160-165.
133. Lapinsky S, Easty A. Electromagnetic interference in critical care. J Crit Care. 2006;21(3):
267-270.
134. Brodie M, Robertson D, Wyllie J. Interference of electrocardiographic recordings by a
mobile telephone. Cardiol Young. 2007;17(3):
328-329.
135. Shaw CI, Kacmarek RM, Hampton RL, et al.
Cellular phone interference with the operation of mechanical ventilation. Crit Care
Med. 2004;32(4):928-931.
136. Jones RP, Conway DH. The effect of electromagnetic interference from mobile communication on the performance of intensive
care ventilators. Eur J Anaesthesiol. 2005;
22(8):578-583.
137. van Leishout EJ, van der Veer SN, Hensbroek
R, et al. Interference by new-generation
mobile phones on critical care medical
equipment. Crit Care. 2007;11(5):1-6.
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138. Tat FH, Wah KC, Hung YH. A follow-up study
of electromagnetic interference of cellular
phones on electronic medical equipment in
the emergency department. Emerg Med.
2002;14(3):315-319.
139. Tri JL, Severson RP, Hyberger LK, Hayes DL.
Use of Cellular Telephones in the Hospital
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unit. Paediatr Nurs. 2009;21(7):14-18.
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measurement of body temperature. Nurs
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acutely ill adults: the state of the science.
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2009;209(4):492-502.
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guideline for the promotion of perioperative
normothermia. J Perianesth Nurs. 2009;
24(5):217-287.
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hypothermia and controlled normothermia
in the intensive care unit: practical considerations, side effects, and cooling methods.
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critically ill adult patients: 2008 update
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1130-1349.
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Hebbar K, Fortenberry JD, Rogers K, et al.
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CE Test Test ID C1123: Evidence-Based Practice Habits: Putting Sacred Cows Out to Pasture
Learning objectives: 1. Understand how embracing evidence-based practice can immediately improve patient care 2. Recognize 7 areas of clinical practice in
which tradition and the evidence do not agree 3. Identify recommendations for practice related to 7 older practice issues or “sacred cows”
1. What is a physiological effect of Trendelenburg positioning in
hypotensive patients?
a. Increased right ventricular ejection fraction
b. Increased lung compliance
c. Increased abdominal pressure
d. Increased tidal volume
7. What is considered a physiological effect of visitors on hospitalized
patients?
a. Decreased cortisol levels
b. Increased systolic blood pressure
c. Decreased arterial saturation
d. Increased intracranial pressure
2. What is a potential benefit of passive leg lift for initial management of
hypotension?
a. Decreased aortic volume
b. Decreased aspiration risk
c. Baroreceptor activation
d. Upper thorax volume shift of 500 mL
8. What is an appropriate indication for urinary catheter insertion?
a. Fall prevention
b. Routine urine specimen collection
c. Skin excoriation management
d. Comfort care for terminally ill patients
3. What is the least safe intervention to divert fecal material away from skin?
a. Fecal pouches
b. Traditional rectal tubes
c. Bowel management systems
d. Rectally-inserted nasopharyngeal airway
9. What is considered a best practice to prevent catheter-associated
urinary tract infections in hospitalized patients?
a. Minimizing catheter duration
b. Using silver alloy-coated urinary catheters
c. Routinely using ultrasound bladder scanners
d. Performing daily urinary meatal cleansing with antiseptic agents
4. What is an evidence-based intervention to manage fecal incontinence?
a. Cleanse the skin with a no-rinse cleanser
b. Use soap and water with a washcloth for basic skin care
c. Use diapers for immobile patients
d. Use multiple layers of bed linen to pull liquid stool away from skin
10. The “1-meter rule” provides extra safety because electromagnetic
interference is most likely to occur within what distance of biomedical devices?
a. 3 to 20 mm
c. 3 to 20 m
b. 3 to 20 cm
d. 3 to 20 km
5. What has evidence demonstrated about gastric residual volume
(GRV) measurement in enterally fed patients?
a. Elevated GRV indicates enteral tube feeding intolerance.
b. Elevated GRV indicates delayed gastric emptying.
c. A high GRV increases aspiration pneumonia risk.
d. Measuring GRV does not improve patient outcomes.
11. What site of temperature measurement most closely correlates
with pulmonary artery temperature?
a. Bladder
b. Rectum
c. Temporal artery
d. Esophagus
6. What is considered a best practice for enteral tube feedings?
a. Withhold enteral feeding for an isolated GRV greater than 250 mL
b. Use a 30 mL syringe to aspirate GRV
c. Consider postpyloric feeding in patients with consistently high GRV
d. Discontinue tube feedings to reposition patients
12. What is correct about monitoring urinary bladder temperature?
a. It has a high risk of dislocation.
b. Temperature is not accurate during periods of increased diuresis.
c. Estimated lag time is up to 20 minutes during therapeutic hypothermia.
d. Its accuracy is uninfluenced by low urine output.
Test answers: Mark only one box for your answer to each question. You may photocopy this form.
1. K a
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2. K a
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Test ID: C1123 Form expires: April 1, 2013 Contact hours: 1.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%) Synergy CERP: Category A
Test writer: Denise Hayes, RN, MSN, CRNP
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or mail this entire page to:
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The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACN
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