AACN Clinical Issues Advanced Practice in Acute and Critical Care

Publications in this journal

• Article: Family partnership intervention: a guide for a family approach to care of patients with heart failure.

  Patricia C Clark, Sandra B Dunbar
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  ABSTRACT: While family focused care is recommended in standards of care for heart failure (HF), little data exist to guide the structure, content, and delivery of family care. The purpose of this article is to describe what is known about the impact of HF, and to examine a family based approach to improve self-management and adherence in HF. A scientific and theoretical background was used to formulate a family based approach to HF care, the Family Partnership Intervention (FPI), and to determine the feasibility and acceptability of the intervention to family members and HF patients. The components of the intervention are described as well as examples of how it was used. Lessons learned in implementing the intervention during a pilot study are addressed.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 12/2003; 14(4):467-76.
• Article: Assessment and initial treatment of lacerations, mammalian bites, and insect stings.

  Deborah Brinker, Jerelen DeChatelet Hancox, Stephen O Bernardon
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  ABSTRACT: Millions of wounds are seen in emergency rooms across the United States each year. The goals of wound care for all ages are to avoid infection and achieve an esthetically pleasing and functional scar. This article reviews the care needs associated with acute traumatic wounds. Information presented includes anatomy and physiology of skin and wound healing, and assessment and care of lacerations, bites, and sting wounds.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 12/2003; 14(4):401-10.
• Article: Management of decompensated heart failure.

  Kay Branum
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  ABSTRACT: Much has been written about the management of chronic heart failure (HF) and there is strong evidence from many controlled, multicenter trials to support a specific strategy for management of compensated HF. There is little evidence and limited guidance for the management of patients during a period of decompensation. The use of diuretics, inodilators, and vasodilators is based primarily on anecdotal observation. This article reviews selected current literature in three areas (diuretics, vasodilators, and inotropes) to examine objective evidence and expert opinion that are available to guide the advanced practitioner who manages the care of patients with decompensated HF.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 12/2003; 14(4):498-511; quiz 551-3.
• Article: Brain (B-type) natriuretic peptide: implications for heart failure management.

  Conrad Gordon, Kenneth J Rempher
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  ABSTRACT: Heart failure is the leading cause for hospitalization in the United States, resulting in over $8 billion in costs annually. Over 4.8 million Americans are afflicted with the disease and the number is increasing as the baby boomer generation continues to age. It is imperative that new and innovative modalities of therapy and diagnosis evolve as we continue to redefine the nature of heart failure and discover more about this debilitating disease. This article addresses the implications for endogenous brain (B-type) natriuretic peptide (BNP) testing in patients diagnosed with heart failure as well as the implications for the first available form of exogenous BNP, nesiritide. In addition, the pathophysiology of heart failure and traditional treatment modalities are discussed.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 12/2003; 14(4):532-42.
• Article: Sleep disturbance symptoms in patients with heart failure.

  Virginia S Erickson, Cheryl A Westlake, Kathleen A Dracup, Mary A Woo, Antoine Hage
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  ABSTRACT: Sleep disturbances have a major impact on physical functioning, emotional well-being, and quality of life, but are not well described in patients with heart failure (HF). Eighty-four HF patients completed a sleep survey and provided demographic and clinical data. Seventy percent of the patients were male with a mean age of 54 years and a mean left ventricular ejection fraction of 22%. Forty-seven patients (56%) reported trouble sleeping and one-third used sleeping medication. The most frequently reported problems were inability to sleep flat (51%), restless sleep (44%), trouble falling asleep (40%), and awakening early (39%). Using logistic regression, physiological variables were tested as predictors of sleep disturbance. Severity of HF, age, gender, etiology, obesity, smoking, and use of beta-blockers were not predictors of sleep disturbance. HF patients experience significant sleep disturbances, which are not predicted by severity of symptoms or clinical status. Problems with sleep are an important component of a clinical assessment in this vulnerable population.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 12/2003; 14(4):477-87.
• Article: Continuous renal replacement therapy for management of overhydration in heart failure.

  Kenneth J Rempher
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  ABSTRACT: An estimated 4.8 million Americans are diagnosed with heart failure. Of those, 5% to 10% meet criteria for the refractory state of the disease. While therapeutic interventions continue to evolve with the changing conceptualization of heart failure pathophysiology, overhydration and its deleterious sequelae remain a problem for those in the refractory state. The incidence of heart failure continues to rise in older individuals. As baby-boomers age across America, greater focus on new, more effective therapies must be considered for treatment of this disease. Continuous renal replacement therapy (CRRT) is one such treatment. The gentle removal of fluid and metabolites while maintaining electrolyte balance helps reduce the effects of overhydration in patients with heart failure. Increasing use of the therapy in the refractory state of heart failure is generating support for early initiation as it continues to demonstrate positive effects. Reduction in edema, attenuation of the sympathoadrenal cascade, and improved respiratory status have all been documented using the therapy. The intent of this article is to provide information for advanced practice nurses and direct care providers regarding CRRT for the treatment of heart failure refractory to typical therapy.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 12/2003; 14(4):512-9.
• Article: Pressure ulcer prevention and management: the current evidence for care.

  Mary C Arnold
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  ABSTRACT: Pressure ulcers, a common occurrence across healthcare settings, are a costly phenomenon. Since the publication of the AHCPR Guidelines on Pressure Ulcer Prevention and Treatment in the 1990s, additional attention has been focused on pressure ulcer prevention and management. This article discusses current evidence regarding known causes of pressure ulcers, pressure ucler prevention, pressure ulcer classification and assessment, and interventions to effectively manage pressure ulcers.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 12/2003; 14(4):411-28.
• Article: Role of Vernix caseosa in the neonate: potential application in the adult population.

  Kathleen A Haubrich
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  ABSTRACT: Vernix caseosa is a naturally occurring fetal barrier film produced in late pregnancy as a result of sebaceous and epidermal lipids combined with desquamation of maturing fetal corneocytes. Vernix lacks desmosomal interconnections between corneocytes as demonstrated in adult stratum corneum and is, therefore, referred to as a "mobile phase" stratum corneum. Vernix is proposed to have multiple fetal/newborn overlapping biological functions: moisturization, anti-infective, antioxidant, wound healing, and waterproofing. Patients with altered skin integrity due to burn injuries lack the protective qualities necessary for wound healing. Emerging research suggests that Vernix applied to skin cultures may enhance wound healing. Application of the fetal/neonatal skin science findings to the adult burn population offers the potential for a clinically relevant homologous substitute for impaired tissue integrity.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 12/2003; 14(4):457-64.
• Article: Left ventricular assist devices as destination therapy.

  Virginia Fidrocki Mason, Annette Jakubisin Konicki
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  ABSTRACT: Although an estimated 16,500 Americans annually could benefit from a heart transplant, in 1999 only 2184 heart transplants were performed in the United States. These statistics emphasize the severity of the shortage of available hearts for transplantation. Circulatory support provided by an implantable Left Ventricular Assist Device (LVAD) that meets Food and Drug Administration approval as destination therapy is a promising alternative that impacts patient survival. As medical technology creates smaller implantable battery-powered circulatory assist devices that allow patients to safely live independently in the community, nursing's role must change in response. Long-term LVAD patients require strategic, anticipatory planning for extended care and emergency preparedness for mechanical support. Therefore, practitioners must familiarize themselves with these devices as they care for larger numbers of patients with implanted LVADs who require assessment and treatment of noncardiac problems during their lengthened lifespan.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 12/2003; 14(4):488-97.
• Article: The measurement of brain natriuretic peptide in heart failure: precision, accuracy, and implications for practice.

  Jill N Howie, Mary A Caldwell, Kathleen Dracup
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  ABSTRACT: Although advances have been made in the management of heart failure (HF), hospital readmission rates remain high. Finding a simple blood test to identify HF would dramatically impact the diagnosis and treatment of this syndrome. A better understanding of the pathophysiology of HF may result in improved treatment measures. Current guidelines do not target any clinical or hemodynamic criteria to achieve before discharge. Most efforts to reduce readmissions have been focused on drugs, technology, and the use of specialty HF clinics. Brain natriuretic peptide (BNP) levels have the potential of providing diagnostic, prognostic, and therapeutic information. In addition, BNP levels appear to be associated with future cardiac events such as hospital readmission. The purpose of this article is to review the precision and accuracy of BNP measurement in those with HF, and to describe how measurement of BNP can be used in clinical practice. Ultimately, BNP testing may improve the accuracy of the diagnosis of HF and guide best treatment practices.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 12/2003; 14(4):520-31.
• Article: Wound care of the pediatric burn patient.

  Jean Merz, Christina Schrand, Donna Mertens, Cynthia Foote, Kelly Porter, Lisa Regnold
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  ABSTRACT: Pediatric burn care requires an extensive knowledge of the pathophysiology of burns. Critical to a positive patient outcome is the correlation of burn size and depth with appropriate fluid administration, respiratory management, nutritional support, and wound care. Due to the nature of the injury where patients' recovery times are lengthy, consideration of the child's psychosocial needs must also be part of the total plan of care.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 12/2003; 14(4):429-41.
• Article: Assessment and management of patients with venous, arterial, and diabetic/neuropathic lower extremity wounds.

  Phyllis A Bonham
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  ABSTRACT: Most healthcare providers recognize that management of lower extremity wounds presents a difficult challenge. These chronic wounds significantly impact the quality of life for individuals and have implications for costs and utilization of healthcare resources. Lower extremity wounds can be due to a myriad of different diseases, but the primary causes are chronic venous insufficiency, lower extremity arterial disease, and diabetes/neuropathy. Differential assessment is necessary prior to implementation of management strategies in order to address the etiology and pathogenesis factors that are related to each type of leg wound. This article presents an overview of the risk and predisposing factors for venous, arterial, and diabetic/neuropathic wounds. Additionally, it addresses issues of differential assessment including typical locations, common clinical characteristics, typical wound appearance, key management issues, considerations for alternative treatments, collaborative care, and patient/family education.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 12/2003; 14(4):442-56; quiz 548-50.
• Article: Nursing informatics, outcomes, and quality improvement.

  Kathleen G Charters
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  ABSTRACT: Nursing informatics actively supports nursing by providing standard language systems, databases, decision support, readily accessible research results, and technology assessments. Through normalized datasets spanning an entire enterprise or other large demographic, nursing informatics tools support improvement of healthcare by answering questions about patient outcomes and quality improvement on an enterprise scale, and by providing documentation for business process definition, business process engineering, and strategic planning. Nursing informatics tools provide a way for advanced practice nurses to examine their practice and the effect of their actions on patient outcomes. Analysis of patient outcomes may lead to initiatives for quality improvement. Supported by nursing informatics tools, successful advance practice nurses leverage their quality improvement initiatives against the enterprise strategic plan to gain leadership support and resources.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 09/2003; 14(3):282-94.
• Article: Use of personal digital assistants with acute care nurse practitioner students.

  Kristine A Scordo, Susan Yeager, Linda Young
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  ABSTRACT: Personal digital assistants (PDAs) are attaining increased functionality by acute care nurse practitioners (ACNPs). Supplemented by recently developed medical software, these devices assist nurse practitioners in having information available at the point of care. This article reviews the introductory use of PDAs throughout ACNP graduate training with an emphasis on clinical and classroom application.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 09/2003; 14(3):350-62.
• Article: Privacy and confidentiality: the Health Insurance Portability and Accountability Act in critical care nursing.

  Darryl W Roberts
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  ABSTRACT: Nurses are responsible to protect the confidentiality and security of patients' health information. In the critical care setting, these privacy and confidentiality issues may be even more poignant. If able to carry on with their normal lives after discharge, many of the patients that nurses treat will have some sequelae from their illnesses that could affect their careers, finances, and personal lives. This article reviews the current literature, presents a discussion of confidentiality and security as it applies to uniquely identifiable health information, and offers some "best practices" that can be used in daily practice. Furthermore, the author discusses the Health Insurance Portability and Accountability Act of 1996 and details some reasons why the act is not fully implemented a full 6 years after it was signed into law.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 09/2003; 14(3):302-9.
• Article: Nursing informatics: the key to unlocking contemporary nursing practice.

  Marianela E Zytkowski
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  ABSTRACT: Nursing informatics is a relatively new nursing specialty. Recognized by the American Nurses' Association in 1992, this field within nursing has grown exponentially. Once the purview of highly specialized individuals, nursing informatics has now crept into all dimensions of nursing, from domain of advanced nurse practitioners to prominence in critical care nursing. Nowhere is the management and processing of health-related information more important than in the care of the critically ill patient. Fast-paced environments, split-second decision making, wireless communications, monitoring systems run with computerized backbones, and computerized ordering and documentation, all things unimaginable just a decade ago, are now fundamental to nursing practice. Each requires a baseline understanding of informatics for true mastery. The domain of nursing informatics continues to grow as nursing incorporates expanded roles and new technology into practice. Education for nurse informaticians includes preparation from the baccalaureate level through the doctorate level and national board certification. Areas of practice are expansive, including hospitals, industry, education, policy-making, research, administration, and international settings. Although informaticians work with computers, computing technology is not the heart of the domain. Computers are simply tools that are used. Examples of informatics tools include handheld devices, point-of-care documentation, computerized provider order entry, and bar code medication administration. Nursing informatics plays an essential role in the future directions of healthcare by defining the relationship between nurses and information technology as well as the knowledge that can be gained when these domains work together.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 09/2003; 14(3):271-81.
• Article: Clinical decision support in critical care nursing.

  Ann Lyons, Stephanie Richardson
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  ABSTRACT: A clinical decision support system (CDSS) is a computerized application that helps clinicians detect and prevent untoward clinical events such as drug interactions, errors of omission, and trends in symptomatology. A CDSS in healthcare usually is built around an alerting system based on rules of logic. The alerting system of a CDSS can notify clinicians immediately on clinical data entry, or it can generate alerts over time after relating data from multiple sources. A CDSS for nurses and patients offers immediate benefits for nurses and patients by detecting potential drug-laboratory and drug-drug combinations and impending pharmacologic complications, monitoring microbiology results, and helping nurses relate symptoms to pharmacology and medication side effects. Other benefits include savings in time and money and reductions in morbidity and mortality. A CDSS presents an opportunity for nursing informatics and critical care nursing to collaborate for the benefit of the patient and the profession.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 09/2003; 14(3):295-301.
• Article: Handheld technologies in a clinical setting: state of the technology and resources.

  Mary Joan Tooey, Alexa Mayo
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  ABSTRACT: Handheld or palm-based computing technology, commonly known as personal digital assistants (PDAs), are having a tremendous impact in many personal, educational, and business settings. The potential is particularly compelling for healthcare, specifically in the clinical setting. By exploring the development of the technology, applications, and products, as well as issues regarding its use, a better understanding of this technology can be gained. The rapid acceptance and ongoing swift development of handheld computing technology is leading to an evolution in the way clinical data and information move to and from the bedside and into the patient record. This article focuses on three main areas related to PDAs: the development of the palm technology, its potential in clinical settings, and available specific resources.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 09/2003; 14(3):342-9.
• Article: Leveraging palm technology in the advanced practice nursing environment.

  Kenneth J Rempher, Caterina E M Lasome, Terry J Lasome
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  ABSTRACT: The use of personal digital assistants (PDAs) in healthcare has expanded exponentially in the past several years. In addition to common feature functions such as contact lists, calculators, calendars, and expense logs, current PDAs boast a wide variety of practical healthcare-related applications such pharmacologic databases, infectious disease programs, medication calculators, and patient scheduling and billing applications. This article examines PDAs in general and the Palm series of handheld devices in particular for use in the advanced practice setting. These devices have several implications for advanced practice nursing including support of both differential diagnosis and diagnostic reasoning, reduction of medication errors, and development of effective treatment protocols. Personal digital assistant technology will inevitably become part and parcel of advanced practice nursing. The rapid, almost daily, changes in the healthcare environment require immediate access to the myriad resources and databases used by advanced practice nurses. Personal digital assistant technology provides such access.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 09/2003; 14(3):363-70.
• Article: The emerging role of electronic diaries in the management of diabetes mellitus.

  Nicole L Kerkenbush, Caterina E M Lasome
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  ABSTRACT: Diabetes mellitus affects an estimated 17 million people in America. A cornerstone to the treatment of this population is appropriate glycemic control, which has been associated with better patient outcomes and cost savings from lack of diabetes complications needing treatment. The patient diary serves as the primary means used by patients and care providers to monitor and ensure glycemic control among this population and as a key component to effective diabetes management. Diabetic patients are encouraged to track continually, in a systematic way, blood glucose levels, dietary intake, activity level, and insulin dose if applicable for use in guiding appropriate care decisions. Traditionally, the recording of such patient experience data has occurred in paper-based diaries. More recently, with the advent of personal digital assistant (PDA) technology, electronic diaries are demonstrating promising benefits over paper-based diaries. To take advantage of this technology, patients must be able to use PDA devices accurately and providers must be knowledgeable about their capabilities. Advanced practice nurses (APNs) in general, and nurse practitioners in the outpatient setting more specifically play a key role in assessing the appropriateness of PDA technology for individual patients, educating patients in various software applications, and ensuring the documentation and trending of data. This article provides an overview of traditional diabetes management record-keeping techniques followed by a review of current PDA technologies and resources that aim to improve the state of diabetic documentation by patients.
  AACN Clinical Issues Advanced Practice in Acute and Critical Care 09/2003; 14(3):371-8.