Which data obtained from the patient would the nurse document under the functional assessment

Nursing role in the recognition of neurologic complications of critical illness

The recognition of new neurologic deficit(s) relies on the ability of the medical team to recognize changes in the neurologic exam which occur in approximately 30% of children during their ICU stay.13 Nurses play a critical role in this process with their frequent physical examinations and attention to bedside monitors. Interventions to treat or attenuate neurologic insults—whether seizures, ischemia, or increasing intracranial pressure (ICP)—are more likely to be successful if initiated early in the process of injury. This means that effective neurologic monitoring in the PICU does not rely solely on the availability of an intensivist, neurologist, electroencephalography (EEG), or neuroimaging. Standardized ICU nursing neurologic assessments using a modification of the Glasgow Coma Scale (GCS) score enables crude but reliable detection of neurologic decline.13

Step 2: Diagnosis

Data from nursing assessments are necessary to identify problems in the order of clinical significance at a specific time and according to the urgent need for nursing interventions. The information may include general and specific data on the presenting problems as defined by the patient and the caregiver, medical diagnoses, prescribed medical treatments, status of physical and mental functions, alternate healthcare resources, patient goals and expectations, safety risks, self-care abilities for recovery, including the ability to perform activities of daily living, and other information that a nurse considers clinically relevant to the case or situation. Identifying nursing diagnoses and prioritizing these problem areas are the major intended process outcomes.

Since 1973, the North American Nursing Diagnosis Association (NANDA) has continued to develop a taxonomy of nursing diagnoses, and currently there are approximately 130 approved classifications of patient care problems in nine categories. In 1987, the Center for Nursing Classification and Clinical Effectiveness at the College of Nursing, University of Iowa (USA) developed taxonomies for classifying and organizing nursing interventions and nursing outcomes through the use of the Nursing Intervention Classification (NIC) (McCloskey Dochterman & Bulacheck, 2004). This was followed by the development of Nursing Outcomes Classification (NOC) coding systems in 1992 (Moorhead et al., 2004). The NIC/NOC codes are linked to the NANDA diagnoses and serve to document the effectiveness of nursing interventions and outcomes. Refinement of the NIC/NOC classification systems has been ongoing. The use of nursing taxonomies facilitates the capture of nursing data useful for evaluation, quality improvement and research activities.

NURSING ASSESSMENT

There are two components to a comprehensive nursing assessment. The first component is a systematic collection of subjective (described by the patient) and objective (observed by the nurse) assessment data. This is done by taking a nursing health history and examining the patient. Detailed guidelines on conducting nursing health assessments are widely available,3 and Box 69.2 provides an abbreviated format of the assessment.

The second component of the nursing assessment is an analysis of the data and its use in a meaningful way to formulate an easily understandable and precise nursing care plan. One way this can be done is by making use of nursing diagnoses to plan and evaluate patient-centred outcomes and associated nursing interventions.

Providers

Before proceeding with the practical aspects of establishing a practice, one must decide who will deliver patient care. Most physicians agree that a physician should perform the sclerotherapy procedure; however, some clinics use nurses to treat spider telangiectasias. A survey of the membership of the North American Society of Phlebology (NASP) (now the American College of Phlebology (ACP)) found that approximately 25% of the members would allow a registered nurse and 20% would allow a nurse practitioner to perform sclerotherapy on spider veins.1 Of NASP members surveyed, 10% would allow a registered nurse to perform sclerotherapy on varicose veins versus 7% who would allow nurse practitioners to perform this procedure. Registered nurses can legally perform intravenous therapeutic injections in most states. Physicians should check with the state licensing board for nursing for the specific requirements.

The arguments for allowing nurses to render such care are both economic and procedural. An economic benefit is realized for both the patient and the physician if a lower-salaried person performs the sclerotherapy procedure, especially in these days of cost containment. Since the injection of spider veins is primarily cosmetic and is rarely fully reimbursable under most insurance plans, cost containment can be translated into economic marketing.

Because the cannulation of a blood vessel is relatively easy to perform and few serious or life-threatening complications can arise from sclerotherapy treatment of spider telangiectasias, an argument can be made for using nonphysicians as sclerotherapists. On the other hand, although rare, serious complications can result from injection of spider telangiectasias. Anaphylactic allergic reactions have occurred with many sclerosing agents; a fatality was reported after a ‘trial’ injection of sodium tetradecyl sulfate.2 Pulmonary emboli also have occurred from the injection of leg telangiectasias (see Chapter 8). Injection into an arteriovenous anastomosis usually produces a cutaneous ulceration, and cutaneous ulceration from sclerotherapy injection (extravasation or arteriolar injection) is the most common reason (in sclerotherapy) for medical malpractice litigation. Injection into a superficial artery, especially around the malleoli, can lead to arterial emboli and pedal gangrene. Duplex-guided injections into deep perforating veins can cause significant muscular necrosis requiring leg amputation. Thus, as with most of medicine, sclerotherapy is not entirely risk-free. The physician is ultimately responsible for ensuring that the nurse is properly trained both in performing sclerotherapy and in recognizing adverse sequelae. The physician, not the nurse, will be the one sued for malpractice.

In addition to being skilled at sclerotherapy technique, the sclerotherapist must have a thorough knowledge of the anatomy and pathophysiology of venous disease and of the mechanism of action of the procedure, including its potential complications. The ability to appreciate these mechanisms and immediately recognize potential complications and render preventive treatment is critical to maintaining optimal patient care. Furthermore, a thorough understanding of vascular hemodynamics, including the relationship between deep and superficial venous insufficiency, is imperative to those practicing sclerotherapy. For example, venous segments with a certain degree of incompetence are best initially treated with endovenous ablation, which removes the source of venous hypertension, thus reducing or eliminating progression of reflux to other surrounding veins.3,4 Not being trained to recognize when endovenous ablation is a necessary portion of the overall treatment approach results in inadequate improvement following sclerotherapy. Thus, clinical judgment as well as technical skill are both essential attributes in an effective sclerotherapist.

Hallgren et al5 defined basic nursing assessment skills and the requirements for transfer of function of the nurse in a sclerotherapy–phlebology practice. In short, for a nurse to function as a sclerotherapist, the following must be known:

Nature and purpose of the procedure

Specific conditions under which the procedure may be performed

Potential complications of the procedure and methods for notifying the physician and stabilizing the patient with immediate countermeasures

Knowledge of the mechanism of action and potential side effects of sclerosing solutions

Contraindications to sclerotherapy.

This knowledge base should also include instruction so that the nurse can do the following:

Record appropriate physical findings such as size, location, and type of vein and associated cutaneous manifestations of venous hypertension

Recognize and describe the presence and extent of superficial and deep thrombophlebitis and venous ulceration

Perform a noninvasive physical examination to include identifying the presence or absence of reflux from the saphenofemoral or saphenopopliteal junctions and/or perforator veins through venous Doppler and/or duplex ultrasound examination; perform photoplethysmography

Photograph the patient's leg in four general views and specific close-up views to document pre-existing cutaneous irregularities and the specific area of telangiectasia

Complete detailed mapping of the varicose and telangiectatic leg veins

Locate pedal pulses; determine the brachial and ankle blood pressures to determine the degree of arterial insufficiency

Accurately measure and fit the patient with a graduated compression stocking

Apply a graduated compression bandage/stocking.

In conclusion, nurses who practice phlebology must be actively involved in the practice of nursing when delivering care. They should be able to prepare not only the operating room for the procedure, but also the patient for the procedure by answering questions, allaying fears, and documenting pretreatment disease. In addition, follow-up treatments allow the nurse the opportunity to reinforce patient teaching so that preventive measures can be emphasized. For an excellent demonstration of lower extremity superficial venous examination techniques, the reader is encouraged to refer to an educational DVD provided by the American College of Phlebology partnered with the Society of Vascular Ultrasound.6 Various other comprehensive textbooks on sclerotherapy, phlebectomy, and venous ultrasound techniques are available; we have referenced those textbooks that we feel are the most useful at the end of this chapter.7–10

Infection Prevention

Probably because of their impaired immune response, including reduced B- and T-cell responses and phagocytosis, dialysis patients have an increased incidence of and are at increased risk of poor outcomes and complications with bacterial infections. Efforts to reduce dialysis access–associated infections may include the local application of antibiotic creams to access exit sites and intranasal application of antistaphylococcal creams in nasal carriers. Antimicrobial prophylaxis should also be considered a preventive strategy.

Standard I: Assessment—The Hospice and Palliative Nurse Collects Patient and Family Health Data

Whether assessing a newly admitted hospital patient with severe pain, caring for someone who is actively dying, performing intake at home for hospice services, or responding to a palliative care consultation, a nursing assessment is often the initial act of care in the nursing specialty of palliative care. In every circumstance, the patient's evaluation needs to be holistic and should identify current problems that encompass the physical, emotional, social, and spiritual care realms. It is essential that patient and family care goals be identified and communicated to the health care team. Problems need to be responded to according to the patient's identified priorities (or the family's priorities if the patient is unable to communicate). When palliative care is provided by a specialist in a consultative role, it is critical for the palliative care nurse to communicate with the patient's current care team, respond to the initial consultation, elicit their concerns, and provide a model of excellent team work.

Caring for patients with end-stage disease and for those who are actively dying entails the challenge of ensuring that the assessment itself does not pose a burden on patients or significant others. Because a thorough physical assessment may sometimes exacerbate symptoms, determining the cause of a symptom may not be realistically possible. Empirical symptom management, titrated to patient relief, may be the best option, along with intense intervention for immediate physical, emotional, and spiritual needs and immediate needs of the family. For actively dying patients, family support needs related to grieving must be assessed and should particularly identify those at risk for complicated grieving or those with a history of poor coping skills.

Postoperative Care and Expected Outcomes

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The patient is placed in a thumb spica splint with the thumb palmarly abducted and the wrist slightly flexed for 2 weeks until the wound is examined and sutures are removed. A monitoring window can be fashioned to allow for nursing assessment of Doppler tones and early detection of vessel thrombosis.

After examining the wound, a short-arm thumb spica cast is placed and left on for 8 to 12 weeks until union is confirmed radiographically.

If an ulnar bone graft has been performed, a bulky, soft dressing is placed and the patient is encouraged to move the elbow to prevent stiffness. Weight restriction, through the elbow, is limited to 1 to 2 pounds until union of the scaphoid is confirmed.

If an MFC flap has been performed, the knee and medial thigh are protected with a soft, bulky dressing. The knee may be immobilized in the immediate postoperative period for patient comfort.

The patient is allowed to ambulate immediately following the procedure but should be informed that pain may persist for several weeks.

E-Fig. 25.14 shows an MRI at 3 months following an MFC flap.

Fig. 25.20A and B shows 5-month postoperative x-rays following an MFC flap.

E-Figs. 25.15–25.18 demonstrate range of motion and healing at 8 months following ulnar bone graft for scaphoid nonunion.

Postoperative Pearls

An MRI can be obtained to confirm proximal pole vascularity, although this is not necessary.

See Video 25.1, Treatment of Scaphoid Nonunion Using an Ulna Bone Graft; and 25.2, Treatment of Scaphoid Nonunion Using a Free Vascularized Medial Femoral Condyle Flap, on ExpertConsult.com.

Summary of Bispectral Index Related Studies in Critical Care

After the clinical introduction of BIS into operating rooms, this technology naturally found its way into the ICU. Numerous studies in both adults and children have been published. Initial reports in both populations suggested good correlation between objective sedation scores and BIS.89, 90 One such study in children showed that the BIS and COMFORT scale measurements were highly correlated (R2 = 0.89).91 Others demonstrated a strong correlation between the Ramsay Sedation Score and BIS in nonparalyzed children for sedation monitoring.92 They also noted the inadequacy of the Ramsay Sedation Score and bedside nursing assessment in the presence of chemical paralysis in their ability to recognize adequate or inadequate sedation states accurately. Others found the correlation between sedation scores and BIS was suboptimal and inconsistent in the heterogeneous ICU population.93, 94 Reliance on the BIS as the sole monitor of sedation may result in excessive sedation, primarily because of high levels of muscular activity.95

Although BIS monitoring is a well-established clinical parameter in the adult surgical population, its use and application in the critical care and pediatric arenas is still under investigation. Unfortunately, validation studies are very unlikely to ever be attempted in children. Several preliminary clinical studies of BIS monitoring in both the operating room and the ICU have demonstrated possible clinical utility and efficacy for improved sedation titration, decreased drug usage, strong sedation score correlation, and greater accuracy and reliability in sedation assessment for paralyzed children.

Assessment of Postoperative Pain in Children

For pediatric pain, measurement tools include the Beyer’s Oucher Scoring System, the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS), the Children and Infants Postoperative Pain Scale (CHIPPS), and the Crying Requires oxygen for saturation < 95%, Increased vital signs, Expression, Sleepless Score (CRIES) Scale. Some of the tests observe the emotional and vital signs to assess the patient’s degree of pain. These involve several characteristics of the child, including alertness, crying, facial expression, restlessness, body movement, posturing of the trunks and legs, and vital signs. For children with cognitive impairment, the revised Face, Legs, Activity, Cry, and Consolability (r-FLACC) tool and the Nursing Assessment of Pain Intensity (NAPI) may have higher utility than the Non-Communicating Children’s Pain Checklist-Postop Version (NCCPC-PV).61

The IMMPACT group recommended the following self-report measures for acute pain intensity: (1) poker chip tool for patients 3 to 4 years of age, (2) Faces Pain Scale Revised for patients 4 to 12 years of age, and (3) visual analog scale for patients 8 years of age or older.43 For observational pain scales, the IMMPACT group recommended the FLACC, CHEOPS, Parents Postoperative Pain Measure (PPPM), and the COMFORT Scale for patients 1 year and older and the Toddler-Preschooler Postoperative Pain Scale for patients 1 to 5 years. For the cognitively impaired children, the Non-Communicating Children’s Pain Checklist–Postop Version (NCCPC-PV)62 may be useful. The COMFORTneo Scale appears to be a promising tool for the assessment of pain in neonates.63

For emotional assessment in pediatric patients, the IMMPACT group recommended the Adolescent Pediatric Pain Tool for use in children 8 years of age or older and the Facial Affective Scale as the single-item scale of the affective component of pain.43 For observational measures of the assessment of behavioral distress during procedures, the Procedure Behavior Checklist (PBCL) and Procedure Behavioral Rating Scale Revised (PBRS-R) was recommended. Both measurement tools can be used for patients 1 year of age or older. The VAS Anxiety Scale in children aged 7 to 16 years compares favorably with other measures of preoperative anxiety in children.64