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CONTENTS
Cover
Title page
Copyright page
Contributors
Critical Care Nursing: Monitoring and
Treatment for Advanced Nursing Practice
Introduction
Chapter 1: Philosophy and treatment in US
critical care units
US critical care units
Organization of critical care delivery
Monitoring and surveillance in critical
care
Surveillance
Nursing certification and competency in
critical care units
US national critical care organizations
Acute care advanced practice nursing
Clinical nurse specialists
Acute care nurse practitioners
Critical care and ACNP outcomes
research
Evolution of families in the critical care
unit
2
Progression and development of rapid
response teams
References
Chapter 2: Vital measurements and shock
syndromes in critically ill adults
Monitoring basic vital signs
Respiratory monitoring
Shock conditions in critically ill adults
Other infectious complications in
critically ill adults
Monitoring during transport
Conclusion
References
Chapter 3: Monitoring for respiratory
dysfunction
Acid-base disturbances & anion gap
Metabolic acidosis
Oxygenation
Capnography
Modes of mechanical ventilation
Monitoring for complications during
mechanical ventilation
Weaning from mechanical ventilation
Sleep-disordered breathing in the critical
care unit
Conclusions
References
3
Chapter 4: Electrocardiographic monitoring
for cardiovascular dysfunction
Physiologic guidelines
Goals of monitoring
Acute coronary syndromes
Cardiac arrhythmias
Acute heart failure
Electrolyte abnormalities
Critical illnesses
Drug overdose
Unnecessary arrhythmia monitoring and
underutilization of ischemia and
QT-interval monitoring
References
Chapter 5: Hemodynamic monitoring in
critical care
Hemodynamic monitoring overview
Hemodynamic monitoring systems
Hemodynamic monitoring guidelines
and outcomes
References
Chapter 6: Monitoring for neurologic
dysfunction
Physiological guidelines
Rapid assessment of neurologic
dysfunction in intensive care unit
patients
Intracranial pressure monitoring
4
Measuring brain temperature
Brain tissue O2 monitoring
Microdialysis
Electrophysiological monitoring
The BiSpectral index monitoring
Transcranial Doppler ultrasonograpy
Shunts
Neuromuscular transmission
Management of cervical stabilization
devices
Research-based neurologic protocols
References
Chapter 7: Monitoring for renal dysfunction
Acute kidney injury
Physiological guidelines
Renal replacement therapy
References
Chapter 8: Monitoring for blood glucose
dysfunction in the intensive care unit
Diabetes management in the ICU
Conclusion
References
Chapter 9: Monitoring for hepaticand GI
dysfunction
Physiologic guidelines
Monitoring elements: nasogastric
decompression
5
Endoscopic procedures
Monitoring elements: gastric tonometry
and capnometry
Radiographic diagnostics
Ultrasonography
Treatment of abdominal compartment
syndrome
Diagnostics for liver function
Liver support devices
ICP monitoring in acute liver failure
Nutritional assessment and treatment
Critical monitoring in acute pancreatitis
Summary
References
Chapter 10: Traumatic injuries: Special
considerations
Primary, secondary, and tertiary surveys
Fluid resuscitation
Intracompartmental monitoring
Complications
Thoracic injury management
Abdominal trauma
Musculoskeletal injuries and
management
Burns
Summary
References
6
Chapter 11: Oncologic emergencies in
critical care
Evolution of oncology critical
management
Stem cell transplant
Hematologic complications
Management of electrolyte imbalances
Acute kidney injury
Structural emergencies
References
Chapter 12: End-of-life concerns
Introduction
Assessment and communication issues
Family presence
Advanced directives
Delivering bad news
Palliative care in the ICU
Brain death
References
Chapter 13: Monitoring for overdoses
Introduction
Indexing of drug and toxins seen in
overdoses
Common toxidromes and treatments for
poisoning conditions
Anion and non-anion gap acidosis and
osmolar anion gap
7
References
Index
End User License Agreement
List of Tables
Critical Care Nursing
Table 1 Titling of guidelines within the
National Clearinghouse Guidelines Index
(2012).
Chapter 01
Table 1.1 Family support in the ICU.
Chapter 02
Table 2.1 Recommendations for
measuring temperature.
Table 2.2 Beneficial effects of
hypothermia.
Table 2.3 Clinical signs associated with
malignant hyperthermia.
Table 2.4 Published class I ECG
monitoring guidelines for heart rate and
rhythm changes in adults.
Table 2.5 Cuff sizes for appropriate BP
measurement in adults.
Table 2.6 Abnormal respiratory patterns
commonly seen in ICU patients.
Table 2.7 Assessment findings in sepsis.
8
Table 2.8 Risk factors for sepsis.
Table 2.9 Sepsis diagnostic criteria.
Chapter 03
Table 3.1 Causes of metabolic acidosis.
Table 3.2 Parameters for liberating
(weaning) from mechanical ventilation.
Table 3.3 WEANS NOW checklist to
assess failure to wean 48–72 h after
resolution of underlying condition
causing respiratory failure.
Table 3.4 American Association of
Respiratory Care criteria for noninvasive
positive pressure ventilation for
exacerbation of COPD.
Table 3.5 Treatment options for
sleep-disordered breathing in the critical
care unit(assuming data from prior
sleep study is not available).
Chapter 04
Table 4.1 Biomarkers used for diagnosis
of acute MI.
Table 4.2 Monitoring recommendations,
vessels, and selected leads.
Table 4.3 ECG monitoring arrhythmia
classifications.
Chapter 05
9
Table 5.1 Terms associated with
hemodynamic monitoring.
Table 5.2 Principles of hemodynamic
monitoring.
Table 5.3 Factors affecting SvO2. Svo2 is
a sensitive indicator of oxygen supply/
demand balance, If Svo2 decreases to
less than 50%, the patient should be
rapidly assessed for the cause of an
increased oxygen demand, or decrease in
supply. Anemia, hypoxemia, and
decreased CO may result in markedly
reduced oxygen delivery. In the presence
of the high metabolic demands imposed
by critical illness, a reduction in O2
delivery or further increase in O2
demand can produce profound
instability in the patient. Changes in
Svo2 often precede overt changes
reflective of physiologic instability.
Chapter 06
Table 6.1 Intracranial pressure
monitoring options.
Table 6.2 Differences in brain and body
temperatures.
Table 6.3 BIS values and corresponding
levels of sedation
Chapter 07
10
Table 7.1 AKIN Classification/Staging
System for Acute Kidney Injury.
Table 7.2 Etiologies of prerenal injury.
Table 7.3 Common causes of intrarenal
failure.
Table 7.4 Drugs causing acute interstitial
nephritis.
Table 7.5 Physical assessment findings in
prerenal failure.
Table 7.6 Differential laboratory
diagnosis of renal dysfunction.
Table 7.7 Electrolyte imbalances related
to AKI.
Table 7.8 Urinary findings in acute
kidney injury.
Table 7.9 Diagnostic imaging in acute
kidney injury.
Table 7.10 Modalities of CRRT.
Table 7.11 Comparison of renal
replacement therapies.
Chapter 08
Table 8.1 Management options for
insulin coverage of fingerstick glucose
(FSG) testing before meals and at
bedtime (Hospital of Central
Connecticut).
11
Table 8.2 Hypoglycemia protocol:
options based on mental status.
Chapter 09
Table 9.1 Clinical grades of hepatic
encephalopathy.
Table 9.2 Indications for endoscopic and
angiographic therapy in acute upper and
lower GI bleeding.
Table 9.3 Monitoring priorities for intraand postendoscopic therapy.
Table 9.4 FAST guideline summary for
abdominal ultrasonography.
Table 9.5 Management strategies for
ascites.
Chapter 10
Table 10.1 Primary and secondary survey
of the trauma patient.
Table 10.2 Tertiary survey of the trauma
patient.
Table 10.3 Massive transfusion product
(MTP) shipment table.
Table 10.4 Differential diagnosis and
management of gastroparesis, small
bowel ileus, and colonic ileus.
Table 10.5 Organ dysfunction caused by
increased intracompartmental pressure.
12
Table 10.6 Prophylactic antibiotic use in
open fractures.
Table 10.7 Extremity nerve assessment.
Chapter 11
Table 11.1 Laboratory and clinical
findings in tumor lysis syndrome.
Table 11.2 Signs and symptoms of tumor
lysis syndrome.
Table 11.3 Traditional oncologic
emergencies.
Chapter 12
Table 12.1 Strategies for improving
end-of-life communication in the
intensive care units.
Table 12.2 Domains of quality palliative
care and overview of clinical practice
guidelines.
Table 12.3 Core competencies in
palliative care for pulmonary and critical
care clinicians recommended by theAd
Hoc ATS End-of-Life Care Task Force.
Table 12.4 Checklist for declaring brain
death, consistent with these guidelines.
Chapter 13
Table 13.1 Methemoglobin levels and
associated symptoms.
13
Table 13.2 Drug-induced hyperthermia
syndromes.
Table 13.3 MAO/MAOI drug
interactions.
Table 13.4 MAO/MAOI food
interactions.
Table 13.5 Overdose of beta blockers:
effects and treatment.
Table 13.6 Drugs that cause prolonged
QT interval (not all inclusive).
Table 13.7 Common drug or toxin
overdose and antidotes.
List of Illustrations
Chapter 01
Figure 1.1 Knowledge transformation
processes.
Chapter 02
Figure 2.1 Anaphylaxis algorithm.
Chapter 03
Figure 3.1 Diagnostic algorithm for
metabolic acidosis.
Figure 3.2 Diagnostic algorithm for
metabolic alkalosis.
Figure 3.3 Diagnostic algorithm for
respiratory acidosis.
14
Figure 3.4 Diagnostic algorithm for
respiratory alkalosis.
Figure 3.5 Phases of the capnogram.
Figure 3.6 CPAP, PS, and AC patterns.
Figure 3.7 Auto-PEEP effect.
Figure 3.8 Common landmarks and
structures of the chest radiograph. (a)
Projection and the lateral. (b) Projection.
Chapter 04
Figure 4.1 Posterior V7–V9 placement.
Figure 4.2 Electrode placement for right
ventricular and posterior infarction
detection.
Chapter 05
Figure 5.1 Waveforms during insertion of
pulmonary artery catheters.
Figure 5.2 Mechanisms of SVV during
positive pressure ventilation.
Figure 5.3 SVV and fluid responsiveness.
Figure 5.4 Physiologic optimization
program using Stroke Volume Variation
(SVV) and Stroke Index (SI).
Chapter 06
Figure 6.1 Cerebral autoregulation. The
Major physiological system involved in
the complex regulation of blood
pressure. Dotted lines represent local
15
autoregulation, solid lines represents
neural influences, and dashed lines
represents neuroendocrine influence.
SNS, sympathetic nervous system.
Figure 6.2 Glasgow Coma Scale and
application.
Figure 6.3 National Institute of Health
Stroke Scale (NIHSS).
Figure 6.4 Two sections of BRAIN card.
Figure 6.5 The image on the left shows 4
windows of transcranial Doppler
insonation. Clockwise these are orbital,
temporal, submandifular, and foraminal.
The image on the right shows the 3
aspects of the temporal window: 1)
middle; 2)posterior; and 3)anterior.
Adapted with permission from Wiegand,
D.J.L., and the American Association of
Critical-Care Nurses (AACN) (2011).
Figure 6.6 Cervical spine stabilization
from AANA (2007). Cervical Spine
Surgery. A Guide to Preoperative Patient
Care. Used with permission from AANA.
Chapter 07
Figure 7.1 RIFLE classification/staging
system for AKI.
Chapter 08
16
Figure 8.1 Potential pathophysiological
associations between sleep disorders and
diabetes.
Figure 8.2 Critical care insulin infusion
protocol (Hospital of Central
Connecticut).
Figure 8.3 Subcutaneous insulin
correction scales for patients on
tube-feeding diets.
Chapter 09
Figure 9.1 Gastrointestinal tract.
Figure 9.2 Ligament of Treitz.
Figure 9.3 Gastric tonometry.
Figure 9.4 Patient positioning for
intraabdominal pressure measurement.
Chapter 10
Figure 10.1 Traumatic brain injury
management algorithm, Carle
Foundation Hospital. *Unless ICP rises
>20. **Stop if PbtO2 falls 60.
Inotropes to increase CI. ****If CPP <
60, consider inotropes. If CPP < 60,
consider vasopressors. NOTE: This
protocol provides for all factors that
should be considered.
Figure 10.2 Stages of damage control
surgery.
17
Figure 10.3 Burn evaluation and Lund/
Browder chart.
Chapter 11
Figure 11.1 Suggested adjustments to the
empirical antibiotic regimen after 3–5
days treatment.
Figure 11.2 Electrical alternans in
malignant cardiac tamponade.
Twelve-lead electrocardiogram shows
electrical alternans. Note the alternating
amplitude and vector of the P waves,
QRS complexes, and T waves.
Figure 11.3 Carotid blow-out syndrome
algorithm.
18
Critical Care Nursing
Monitoring and Treatment for
Advanced Nursing Practice
EDITED BY
Kathy J. Booker, PhD, RN, CNE
Professor, School of Nursing Millikin University
Decatur, Illinois, USA
19
This edition first published 2015 © 2015 by
John Wiley & Sons, Inc.
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ISBN-13: 978-0-4709-5856-8 / 2015.
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All brand names and product names used in
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Library of Congress Cataloging-in-Publication
Data
Critical care nursing (Booker)
Critical care nursing : monitoring and
treatment for advanced nursing practice /
[edited by] Kathy J. Booker.
p. ; cm.
Includes bibliographical references and
index.
ISBN 978-0-470-95856-8 (pbk.)I.
Booker, Kathy J., editor. II. Title.
[DNLM: 1. Critical
Care–methods–Handbooks. 2. Nursing
Care–methods–Handbooks. WY 49]
RC86.8
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2014030769
A catalogue record for this book is available
from the British Library.
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Wiley also publishes its books in a variety of
electronic formats. Some content that appears
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Cover image: © iStockphoto / agentry / File #
2205780
Cover design by Modern Alchemy LLC
23
Contributors
Jennifer Abraham, RN, BS
Staff Nurse Medical/Oncology
Advocate BroMenn Medical Center
Normal, IL., USA
Laura Kierol Andrews, PhD, APRN,
ACNP-BC
Associate Professor
Yale School of Nursing
Orange, CT., USA and Senior ACNP,
Department of Critical
Care Medicine
Hospital of Central Connecticut, New Britain,
CT., USA
Lisa M. Barbarotta, RN, MSN, AOCNS,
APRN-BC
Nurse
Practitioner,
Hematology-Oncology
Service
Smilow Cancer Hospital at Yale-New Haven
New Haven, CT., USA
Catherine L. Bond, MS, MSED, ACNP-BC,
TNS
Nurse Practitioner
Critical Care Team
Carle Foundation Hospital
Urbana, IL., USA
24
Kathy J. Booker, PhD, RN, CNE
Professor, School of Nursing,
Millikin University
Decatur, IL., USA
Dawn Cooper, MS, RN, CCRN, CCNS
Service Line Educator
Medical Intensive Care Unit
Yale New Haven Hospital York Street Campus
New Haven, CT., USA
Linda M. Dalessio MSN, ACNP-BC, CCRN
Assistant
Professor,
Nursing
Western
Connecticut State University
Danbury, CT., USA
Eleanor R. Fitzpatrick, RN, MSN, CCRN
Clinical Nurse Specialist for Surgical Intensive
Care & Intermediate Care Units
Thomas Jefferson University Hospital
Philadelphia, PA., USA
Carey Heck, MS, MSN, ACNP-BC, CCRN,
CNRN
Instructor
Jefferson School of Nursing
Philadelphia, PA, USA
Janice L. Hinkle, RN, PhD, CNRN
Nurse Author and Editor
Washington, DC, USA
Alexander P. Johnson, MSN, RN, CCNS,
ACNP-BC, CCRN
Critical Care Clinical Nurse Specialist
25
Cadence Health, Central DuPage Hospital
Winfield, IL., USA
Mary Beth Voights, MS, RN, CNS
Trauma Services Coordinator
Carle Foundation Hospital
Urbana, IL., USA
Catherine Winkler, PhD, MPH, RN
Professor
Fairfield University
Fairfield, CT., USA
26
Critical Care Nursing:
Monitoring and Treatment for
Advanced Nursing Practice
Kathy J. Booker
Introduction
The many contributions to patient care and
safety made by critical care nurses have been
substantial since the inception of critical care
units. As advanced nursing practice has
expanded into high-risk and complex
environments, the role of careful monitoring
and surveillance to care management has
become exponentially important to patient
safety. However, wide variation in practice and
outcomes across the nations’ critical care units
continues. Monitoring the condition and
progress of critically ill adults remains vital to
good patient outcomes but many treatment and
monitoring protocols are still grounded in
descriptive and observational studies and
expert practitioner experience. Although a
substantial number of evidence-based protocols
have been refined over the past decade, many
monitoring practices have not been sufficiently
studied. This book is designed to guide critical
care nurses and advanced practitioners by
examining guidelines and evidence-based
27
treatment recommendations associated with
assessment and monitoring of patient
conditions commonly treated in critical care
units. It embraces recent advancements in the
concept of surveillance as a mainstay of clinical
quality.
There is considerable variation in levels of
evidence and practice guidelines. Within the
National Clearinghouse Guidelines alone, vastly
varied titles of guidelines can be found among
the over 2500 guidelines housed in 2012 (Table
1). These title variations, while selected by
authors and organizations, reflect the difficulty
clinicians face in locating clinical practice
guidelines and standards of care. As sources of
published guidelines expand, clinicians may
find multiple care practice patterns unique to
customary practices by country, region, or
clinical organization, further compounding the
difficulty enacting practice changes.
Table 1 Titling of guidelines within the
National Clearinghouse Guidelines Index
(2012).
Medical guidelines Consensus
statements
Clinical practice
guidelines
Practice parameters
Guidelines of care
Guidelines for
monitoring and
management
28
Medical guidelines Consensus
statements
Guidelines for practice Assessment guidelines
Evidence reports
Evidence-based
guidelines
Clinical guidelines
Clinical policy: critical
issues
Medical guidelines for Quality indicators
clinical practice
Evidence-based
interventions
Standards of medical
care
Medical position
statements
Practice advisories
Evidence-based
patient safety
advisories
Evidence review and
treatment
recommendations
Best practice
Care of patient
guidelines and policies guidelines
Guidelines for
management
Clinical expert
consensus
Recommendations for Recommendations for
standardization and
delivery of care and
interpretation
ensuring access
Despite titling confusion, clinicians have more
data to guide practice than in prior decades.
Within this text, chapter editors have sought to
examine the evidence base of practices in
critical care monitoring and care delivery in
29
critical care systems. While no single evidence
system has been applied, strong evidence is
acknowledged in systematic reviews of
phenomena amenable to randomized controlled
studies. Moderate levels of evidence advocated
by most sources are supported in published
guidelines from well-designed qualitative and
quantitative studies. However, many of the
practices currently used to monitor critically ill
patients remain at the level of weak evidence or
expert opinion. Protocols, even those based on
strong evidence, do not always apply to every
unique patient condition. Patient choice and
philosophy should guide implementation of any
monitoring and treatment practice. In addition,
in many practices that are not widespread or
targeted by review organizations due to high
risk for poor outcomes, weak evidence
continues because of a lack of practice
guidelines. Study funding remains a barrier to
advancing best practice for the nation’s
critically ill. As systems improve for organizing
and applying research findings, improvements
in patient outcomes will continue to be
advanced. Always, critical care nursing practice
remains grounded in human ethics and respect
for individualized care.
30
Chapter 1
Philosophy and treatment in
US critical care units
Kathy J. Booker
School of Nursing,
Decatur, IL., USA
Millikin
University,
In this chapter, the evolution of critical care
practice and advanced nursing roles are
explored. An examination of factors that
contribute to safe monitoring and treatment in
critical care units includes certification
processes and national support for critical care
nursing practice, perspectives on patient and
family-focused care, and the evolution of rapid
response team (RRT) roles in hospital settings.
US critical care units
Critical care units were formally developed in
the United States in the years following World
War II. Common elements driving the origin of
critical care units remain important even today,
including close patient monitoring, application
of
sophisticated
equipment,
and
surveillance-based interventions to prevent
clinical deterioration or health complications.
Today’s critical care units are often diverse,
specialized areas of care for patients at high risk
31
or those undergoing critical health events
requiring nursing attention. The critical care
team is generally quite complex, including
medical management increasingly supported by
intensivists, residents, acute care nurse
practitioners (ACNPs), clinical nurse specialists
(CNSs), and other nursing personnel.
Additional
vital
practitioners
include
respiratory therapists, dietitians, pharmacists,
social workers, and physical/occupational
therapists. Over the last 50 years, sophisticated
treatment modalities, technology, and care
philosophies have evolved to promote a strong
patient-centered care ethic coupled with
technological complexity.
The cost of delivering care to the critically ill
continues to rise. The Society of Critical Care
Medicine (2013a) identified increasing costs of
critical care medicine in the United States, with
current projections of $81.7 billion (13.4% of
hospital costs) in the care delivery of over 5
million patients annually in the nation’s critical
care units.
Organization of critical care
delivery
Haupt et al. (2003) published guidelines for
delivering
critical
care
based
on
a
multidisciplinary review of the literature and
writing panelists with representation from
important critical care providers including
32
physicians, nurses, pharmacists, respiratory
therapists, and other key critical care team
representatives. A three-level system of
intensive care unit (ICU) care was promoted in
these guidelines, acknowledging various ICU
care systems based on the availability of key
personnel,
educational
preparation,
certification,
and
fundamental
skill
requirements. These general guidelines for
hospitals in establishing and maintaining
critical care services assigned levels of care as
follows:
Level I care: units that provide medical
directorships with continual availability of
board-certified intensivist care and
appropriate minimal preparation
recommendations for all key and support
personnel.
Level II care: comprehensive care for
critically ill but unavailability of selected
specialty care, requiring that hospitals with
units at this level have transfer agreements
in place.
Level III care: units that have the ability to
provide initial stabilization and/or care of
relatively stable, routine patient conditions.
Level III units must clearly assess
limitations of care provision with
established transfer protocols (Haupt et al.,
2003, p. 2677).
33
Emphasis on intensivist medical management,
diagnostic testing availability, and specialty
interventional availability guides hospitals to
provide optimal care to the critically ill. This
has also been supported by the Society of
Critical Care Medicine (SCCM, 2013a). Haupt et
al. (2003) also made recommendations for
graduate education and/or certification by
critical care nursing managers within the
leadership structure. Transfer protocols for
higher levels of care were recommended if
selected life-saving services were unavailable,
suggesting that protocols be incorporated into
patient management systems in all hospitals
without the full range of service based upon
these guidelines. Despite the fact that these
guidelines were advanced over 10 years ago,
critical care practice remains diverse across the
nation due in part to the availability of key
personnel,
state
emergency
system
organization, system restrictions due to
population and area coverage, and cost
constraints. Emergency management and
trauma support guidelines have been advanced
by the American College of Surgeons (ACS)
though the Advanced Trauma Life Support
courses and guidelines for the transfer of
patients in rural settings are also published on
the ACS web site (Peterson and the Ad Hoc
Committee on Rural Trauma, ACS Committee
on Trauma, 2002).
34
Monitoring and surveillance in
critical care
In the care of critically ill patients, the use of
monitoring technology to support care is
central to evidence-based practice. Research on
the frequency and types of monitoring that
affect the best patient outcomes is growing.
Selected technologies, such as the use of
pulmonary artery catheters in the critically ill,
have been studied extensively. But the rapid
growth of new technologies for monitoring at
the bedside are often labor-intensive, requiring
considerable nursing time to set up and manage
to ensure good outcomes. In addition, ethical,
humane application of technology must be
continually considered so that the effect of
intrusive or invasive technology is continually
monitored in individualized care (Funk, 2011).
Effective monitoring requires familiarity with
the patient’s condition and preferences, the
equipment, the processes inherent in obtaining
the data, and the interpretation of monitored
data, all affected by potential error in
acquisition and management. Monitoring
allows for the calculation of critically ill
patients’ physiological reserve and effectiveness
of interventions but also carries the caveat that
practitioners must be familiar with the pitfalls
associated with data interpretation commonly
found in all areas of acute and critical care
practice (Andrews and Nolan, 2006).
35
Young and Griffiths (2006) reviewed clinical
trials monitoring acutely ill patients and
observed that “to display data which cannot
influence the patient’s outcome might increase
our knowledge of disease processes but does
not directly benefit the monitored patient. Nor
is it harmless, more information brings with it
more ways to misunderstand and mistreat” (p.
39). More monitoring may not be the answer to
improving the treatment of critically ill persons
but individualized monitoring of the right
parameters to guide therapy and improve
patient outcomes is the goal of the critical care
team. Revolutionary changes in patient
outcomes have been obtained with the
development of selected technology, including
pulse oximetry, bispectral index for depth of
anesthesia, and noninvasive measurement of
cardiac output and stroke volume (Young and
Griffiths, 2006). Despite the expansiveness of
monitoring, many have noted the paucity of
evidence of its effectiveness. Particularly in the
arena of hemodynamic monitoring, studies
have been equivocal regarding the effectiveness
of monitoring data to influence patient
outcomes (see Chapter 5).
Surveillance
Kelly (2009) studied nursing surveillance and
distinguished monitoring from surveillance by
noting that surveillance informs decision
making and involves action steps that stem
36
from more passive monitoring. Kelly (2009)
defined surveillance as “a process to identify
threats to patients’ health and safety through
purposeful
and
ongoing
acquisition,
interpretation, and synthesis of patient data for
clinical decision making in the acute care
setting” (p. 28). Surveillance is a core role of
critical care; while not unique to nursing,
surveillance is applied continuously in critical
care units worldwide. Henneman, Gawlinski,
and Giuliano (2012) identified surveillance as a
nursing intervention critical to patient safety. In
a review of practices recently studied in acute
and critical care nursing, Henneman,
Gawlinski, and Giuliano (2012) examined the
use of checklists, interdisciplinary rounds, and
other
clinical
decisional
support
and
monitoring systems important to surveillance
and prevention of errors.
The need for monitoring systems that produce
reliable and accurate data has never been more
urgent. Monitoring systems should be designed
to foster action and supportive care to improve
patient and family experience and physiological
outcomes for patients. Practices that do not
improve
patient
outcomes
should
be
eliminated. In addition, clinicians need to help
patients and family members understand
monitoring systems. Continual assessment of
changing conditions, critical reflection, critical
reasoning, and clinical judgment are all
supported with the use of appropriate
37
technology (Benner, Hughes, and Sutphen,
2008). Safe care practices depend on these
habits of the mind as well as reliable and
accurate technology. The potential for error is
evident at many junctures in today’s complex
hospital systems and the critical care unit is the
hub of such concentrated complexity, making
surveillance essential for safe patient care.
Research on monitoring and surveillance is
increasing. Schmidt (2010) studied the
concepts of surveillance and vigilance, and
identified the basic social process of nursing
support for patients in a critical care
environment, ensuring continual vigilance and
protective action to ensure safety. Yousef et al.
(2012) examined continuous monitoring data in
326 surgical trauma patients to determine
parameters associated with cardiorespiratory
instability. These were defined as heart rate less
than 40/min or greater than 140/min;
respirations less than 8/min or greater than 36/
min; SpO2 less than 85%; and blood pressure
less than 80 mmHg, greater than 200 mmHg
systolic, or greater than 110 mmHg diastolic.
Patients who remained clinically stable versus
those who had even one period of instability
were more likely to have more comorbidities, as
measured by the Charlson Comorbidity Index.
In earlier work, these authors found that 6.3 h
ensued between periods of cardiorespiratory
instability and activation of a rapid response
team (RRT) (Hravnak et al., 2008). In these
38
studies, automated, continuous monitoring
recorded and validated in the clinical
monitoring system strengthened the data
validity, including automated blood pressure
measurements measured at least every 2 h.
Clear
consideration
for
technology
advancement and the effects on both nursing
practice and patient outcomes is need
