Tag Archives: Nursing Assessment

Is capnography or end tidal CO2 assessment effective for monitoring adult patients in emergency departments or intensive care units who are undergoing moderate sedation or mechanical ventilation?

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Bottom line:  There is evidence that associates capnography with improved detection of respiratory depression during procedural sedation and in management of mechanical ventilation.

Monitoring during moderate sedation:

PubMed search: (capnography OR end tidal carbon dioxide) AND sedation AND (emergency department OR intensive care OR critical care) AND humans[mesh]
Includes prospective studies, a systematic review and some lower quality comparative studies.

Higher quality study (Randomized controlled trial and prospective studies)
Proehl J, et al. J Emerg Nurs. 2011 Nov;37(6):533-6. Emergency Nursing Resource: the use of capnography during procedural sedation/analgesia in the emergency department.
Systematic review describes evidence from research studies, meta-analyses, systematic
reviews, and existing guidelines. Rates evidence using Appraisal of Guidelines Research & Evaluation methodology.

Deitch K, et al. Ann Emerg Med. 2010 Mar;55(3):258-64. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial.
Patients (n=132) in the ED who received propofol sedation received standard monitoring plus capnography and were randomized so that physicians administering care either had access to capnography readings or were blinded to capnography readings.  RESULTS:  Hypoxia was observed in 17 of 68 (25%) subjects with capnography and 27 of 64 (42%) with blinded capnography (P=.035; difference 17%; 95% confidence interval 1.3% to 33%).  Capnography identified all cases of hypoxia before onset (sensitivity 100%; specificity 64%), with the median time from capnographic evidence of respiratory depression to hypoxia 60 seconds (range 5 to 240 seconds)

Burton JH, et al. Acad Emerg Med. 2006 May;13(5):500-4. Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices?
60 patients (enrollment stopped after review of 20 acute respiratory events) underwent capnographic monitoring while under procedural sedation. Abnormal end tidal CO2 findings were documented in 36 patients (60%). Abnormal ETCO2 findings were documented before changes in SpO2 or clinically observed hypoventilation in 14 patients (70%) with acute respiratory events.

Monitoring during mechanical ventilation

PubMed:  (capnography OR end tidal carbon dioxide) AND mechanical ventilation AND (emergency department OR intensive care OR critical care) AND humans[mesh]
Filters:  Systematic reviews

Walsh BK, Crotwell DN, Restrepo RD. Capnography/Capnometry during mechanical ventilation: 2011.  Respir Care. 2011 Apr;56(4):503-9.
Applied GRADE criteria to 200+ identified studies and guidelines. Includes several recommendations for use of capnography in monitoring patients on mechanical ventilation.

What are the barriers to implementing family presence during resuscitation?

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Paplanus L. Salmond S. Jadotte Y. Viera D. A Systematic Review of Family Witnessed Resuscitation and Family Witnessed Invasive Procedures in Adults in Hospital Settings Internationally. [Systematic Review]
Part I: Perspectives of Patients and Families
Part II: Perspectives of Healthcare Providers

Madden E ; Condon C Emergency nurses’ current practices and understanding of family presence during CPR. Journal of Emergency Nursing , 2007 Oct; 33(5): 433-40

Briguglio A. RN. Should the family stay? TN. 2007 May;705):42-8; quiz 49.

Nykiel L, Denicke R, Schneider R, Jett K, Denicke S, Kunish K, Sampson A, Williams JA. Evidence-based practice and family presence: paving the path for bedside nurse scientists. J Emerg Nurs. 2011 Jan;37(1):9-16. Epub 2010 Mar 20.

Basol R, Ohman K, Simones J, Skillings K. Using research to determine support for a policy on family presence during resuscitation.Dimens Crit Care Nurs. 2009 Sep-Oct;28(5):237-47; quiz 248-9.

Clark AP, Aldridge MD, Guzzetta CE, Nyquist-Heise P, Reverend Mike Norris, Loper P, Meyers TA, Voelmeck W. Family presence during cardiopulmonary resuscitation. Crit Care Nurs Clin North Am. 2005 Mar;17(1):23-32, x.

Critchell CD, Marik PE. Should family members be present during cardiopulmonary resuscitation? A review of the literature.Am J Hosp Palliat Care. 2007 Aug-Sep;24(4):311-7.

Reviewed JKN 4/14

Is hemoglogin A1c associated with wound healing in the orthopedic population?

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Bottom line:  For patients undergoing orthopedic procedures, there is some evidence suggesting an association between perioperative HbA1c levels and complications involvoing the surgical site.

PubMed search:  (orthopedic procedures OR orthopedic surgery) AND (hemoglobin A1c OR hba1c)
The following references from the search results provided data on HbA1c in patients undergoing orthopedic procedures.

Jamsen (2010):  prospective cohort study of 1565 elective knee surgeries for which preoperative plasma glucose was recorded. Patients followed 20 months.  Mean HbA1c

Younger (2009):  Case-control study matching 21 patients with failed transmetatarsal amputation (TMA) with 21 successful TMAs.  HbA1c was the factor most closely associated with success of the TMA.

Marchant (2009):  Retrospective study of >1 million patients undergoing joint replacement surgery 1988-2005 as recorded in the Nationwide Inpatient Sample.  Patients with controlled diabetes mellitus (determined by combination of patient-measured blood glucose and HbA1c) had increased risk of  wound infection (adjusted odds ratio = 2.28 compared to patients with controlled diabetes mellitus.

Lamloum (2009):  Retrospective study of 318 consecutive diabetic patients undergoing surgery at an orthopedic hospital.   Table 3 compares rates of surgical site infections (SSI) for patients with HbA1c < 7.0 compared to rate for patients with HbA1c ≥ 7.0.  High HbA1c was associated with higher rate of SSI

Reviewed by John Nemeth 4/14

Does screening inpatients for delirium affect hospital length of stay?

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Bottom line:  There are no published experimental studies evaluating the effect of screening inpatients for delirium on the hospital length of stay.

Summary:
Length of stay:  A search of Joanna Briggs and of PubMed and CINAHL using combinations of these concepts–delirium, inpatients, screening, length of stay, outcomes–did not identify any studies of the impact of screening for delirium on length of stay.  There were observational studies documenting that delirium in the hospital is associated with increased length of stay.  See Han (2011), Saravay (2004) and reviews in the PubMed search.  None of these report on effect of screening on length of stay.
Delirium Screening and Assessment.  In:  Joanna Briggs JBIConnect
PubMed:  delirium[mesh] AND (inpatients OR hospitalized patients) AND screening AND length of stay

Clinical outcomes:  None of the papers identifed in the searches describe studies assessing effect of screening for delirium on other clinical outcomes, such as mortality or readmission.  Again, there are observational studies documenting the effect of delirium on these outcomes, i.e., Uthamalingam (2011), Gonzalez (2009) in the search below.
PubMed:  (“delirium/diagnosis”[mesh] OR “delirium/prevention and control”[mesh]) AND (inpatients OR hospitalized patients) AND screening AND (outcomes OR mortality OR readmission)

Is there evidence for optimal frequency for monitoring sedation level?

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Bottom line:  There is little published evidence evaluating frequency of monitoring level sof sedation.

Joanna Briggs did not have any information.

CINAHL and PubMed had guidelines and validation studies evaluating the various sedation assessment scales, but none of that literature addresses how frequently to perform assessments.

DynaMed references recommendations of American Hospital Formulary Service.

Most relevant results

Brook AD, et al.  Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation.  Crit Care Med. 1999 Dec;27(12):2609-15.
Reassessment every 4 hours is part of the protocol; outcomes were reduced time on mechanical ventilator, length of stay in ICU, and rate of tracheostomy for the protocol group compared to the standard care group

DynaMed

Propofol drug information.
Recommends assessing level of sedation at least daily.  See Warning and Precautions>General Precautions>Critical Care Sedation

Guidelines and additional validation studies:

Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult.  Crit Care Med. 2002 Jan;30(1):119-41
-recommends using a validated scale to monitor level of sedation, but cites a systematic review of scales to state that there was no gold-standard scale for assessing sedation level at time of these guidelines.  Does not recommend specific frequency for monitoring patients.  Objective Assessment of Sedation section reviews evidence of Motor Activity Assessment Scale, Riker Sedation-Agitation Scale, and Ramsay Scale and Vancouver Interaction and Calmness Scale.  Does not include the Richmond Agitation-Sedation Scale.

Ely EW, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS).  JAMA. 2003 Jun 11;289(22):2983-91.
-Confirmed interrater reliability and validity of RASS in medical ICU patients.

Vender JS.  Sedation, analgesia, and neuromuscular blockade in sepsis: an evidence-based review.  Crit Care Med. 2004 Nov;32(11 Suppl):S554-61.
-Includes discussion of scales in context of patients with sepsis

For inpatients, are skin assessments by two staff more accurate than skin assessments by one staff at detecting pressure ulcers and areas at risk for ulcers?

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Bottom line:  Practice guidelines recommend having a standard procedure for assessing and documenting skin and training staff who will be making these assessments, but there is no specific recommendation for the number of staff required for assessing skin.

DynaMed topic on Pressure Ulcers includes a section on prevention screening and section on guidelines.  Prevention/screening section summarizes data on utility of specific structured assessment tools.  There are numerous guidelines, which should document studies on which they base recommendations.  One guideline is Institute for Clinical Systems Improvement (ICSI) guideline on pressure ulcer treatment.

JBI+COnNECT – There are several evidence summaries, but the most relevant ones (ex: Pressure Ulcers: Prevention and Management, seem to  reference the guidelines included in DynaMed, such as that of the Royal College of Nursing.

No identifed recommendations or mention of using more than one person to assess a patient’s skin in the DynaMed or JBI+ information.

PubMed search:  pressure ulcers AND (rater* OR observer*) AND (accura* OR reliabl*)

Yielded studies such as these two that compare use of one nurse to two nurses in documenting skin and found no difference in the number of pressure ulcers documented.  These studies did not address assessment for risk.

Kottner J, Tannen A, Dassen T. Hospital pressure ulcer prevalence rates and number of raters. J Clin Nurs. 2009 Jun;18(11):1550-6.

Kottner J, Tannen A, Halfens R, Dassen T. Does the number of raters influence the pressure ulcer prevalence rate? Appl Nurs Res. 2009 Feb;22(1):68-72.