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Authors
Mary Beth Flynn Makic is a research nurse scientist at the University of Colorado Hospital and an associate professor at the University of
Colorado, College of Nursing in Aurora.
Sarah A. Martin is a pediatric nurse practitioner and cares for inpatients on the pediatric surgery service at Ann and Robert H. Lurie Childrens
Hospital of Chicago, Illinois. She is the associate editor for the Journal of Pediatric Health Care.
Suzanne Burns is an advanced practice nurse in critical care and a professor of nursing in the acute and specialty care program at the University
of Virginia Health System in Charlottesville.
Dinah Philbrick is a staff nurse on the intravenous team and a member of the Evidence Based Practice Council at Northern Westchester
Hospital, Mt Kisco, New York.
Carol Rauen is an independent clinical nurse specialist and education consultant in Kill Devil Hills, North Carolina.
Corresponding author: Mary Beth Flynn Makic, RN, PhD, CNS, CCNS, 12401 E 17th Ave, Leprino Bldg, Mail Stop 901, Aurora, CO 80045 (e-mail: marybeth.makic@uch.edu).
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)
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Table 1
Study title
Findings
Practice implications
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Current standards for NIBP measurement in children are based on recommendations for identifying
hypertension in ambulatory settings.10,12,15,21 As these
are the only published guidelines, they are used in
acute and critical care settings. The Cincinnati Childrens Hospital Medical Centers Best Evidence Statement15 and the Fourth National High Blood Pressure
Education Program Working Group on High Blood
Pressure in Children and Adolescents21 are the primary
EBP guidelines used to direct standard, accurate measurement of blood pressure in children with NIBP monitoring techniques.
NIBP Methods. The auscultatory method is suggested for NIBP measurement in children more than
1 year of age.10,12,15,21 The practice recommendation is
that the best way to measure a childs blood pressure is
to take the average of 2 measurements obtained 30 seconds apart.10,12,15 Mercury devices previously used for
auscultatory NIBP measurements have been replaced
by hybrid sphygmomanometers. The hybrid device
combines the features of electronic (oscillometric) and
auscultatory devices by using an electronic pressure
gauge that allows a nurse to measure blood pressure
by using a stethoscope to listen for Korotkoff
sounds.10,22 The first Korotkoff sound reflects the systolic blood pressure. The diastolic blood pressure is
Korotkoff sound 4 or when muffling is appreciated.
The disappearance of sound (Korotkoff sound 5) is
thought to reflect the diastolic blood pressure in children
less than 12 years of age.19 Obtaining an auscultatory
blood pressure measurement in children may be challenging because their arms may be too small and contain too much fat to accommodate the cuff and the
position of the stethoscope. Research and practice
standards have found that Korotkoff sounds, specifically sounds 1, 4, 5, are routinely audible and provide a
reliable estimate of systolic and diastolic blood pressure in children 1 to 36 months of age and older.10,15,19
The oscillometric method uses an electronic device
to sense pressure oscillations (vs sound) on the wall of
the artery to determine blood pressure. When the cuff
is inflated, the oscillations begin at approximate systolic
pressure and continue until oscillations of pressure are
no longer sensed (diastolic pressure).10,22 Mean arterial
pressure is the point of maximal oscillation.10,22 Blood
pressure measurements (systolic and diastolic) are
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patient with COPD who has a chronically elevated carbon dioxide level, the provision of oxygen may lead to
an increase in carbon dioxide level, apnea, and other
related adverse outcomes. But the elevation in carbon
dioxide level is not solely due to hypoxic drive. Three
mechanisms are implicated: the Haldane effect, hypoxic
vasoconstriction, and a decrease in minute ventilation.
The Haldane effect: The physiological mechanism
associated with the ability of the hemoglobin to carry
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Table 2
Evidence-based literature
(Authors, year)
Main points
NA
NA
Hypercapnia during oxygen therapy in acute exacerbations of chronic respiratory failure not due to
hypoxic drive but other mechanisms
NA
NA
Yes
NA
Described response of COPD patients to high fractions of inspired oxygen after a period of rest on
mechanical ventilation; provision of oxygen did not
result in hypercarbia or respiratory muscle failure
NA
NA
Pierson,28 2000
NA
Yes
Yes
Yes
West,34 2008
NA
NA
Yes
Yes
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Table 3
Gauge of
intravenous catheter
Description
22-14
24-22
a Based
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Figure 2 Centers for Disease Control and Preventions post about hands of health care workers and spreading of infections.
Table 4
38
on information from Cohen et al,62 The Joint Commission,65 Hugonnet et al,66 and Backman et al.67
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remains the single most effective mechanism to reduce a patient. In that study,68 the use of gloves was found to
HCAIs.52,54,56,60,62,64,65,67 Critical care nurses need to pracprotect the health care workers, but gloves were worn
tice effective and consistent hand hygiene as the first
less often by providers having environment contact
and last step of any interaction with a patient or a
only (eg, touching an infusion pump, monitor, bedside
patients environment so as to prevent and contain
table). Clostridium difficile infections are known to
infections.
spread through environmental sources such as blood
Environmental Considerations. Environmental
pressure cuffs, thermometers, and contaminated hands
considerations encompass several different intervenof health care workers.62,69 Morgan et al70 reported that
20% of interactions between health care workers and
tions to include standard precautions, specific isolapatients in contact precautions for MDROs resulted in
tion precaution interventions based on the organisms
contamination of the providers gloves or gowns. A sysvector of transmission (eg, contact, airborne, droplet),
tematic review by Kramer et al69 reported that organroom and equipment decontamination, and decontaisms live on inanimate surfaces for hours to months if
mination of health care workers clothing and items.
no regular disinfection is performed and that the most
Providers knowledge and compliance with isolation
likely vector in the transfer of organisms from contamprecautions (barrier precautions) are essential in
inated surfaces was health care workers hands. Thus the
reducing the spread of organisms.
expectation to perform rigorous hand hygiene every
Standard precautions (eg, hand hygiene and use of
time a health care worker enters and exits a room; even
gloves, gown, mask, goggles as appropriate) imply a
if the health care worker did not touch the patient, the
routine level of intervention that health care workers
inanimate objects in the room are contaminated as
will engage in during patient care as a standard of
55,58,60,63
Isolation precautions are not a medical
well.59,62,63,69
care.
Health care workers clothing has been found to be
determination, but are based in infection control
contaminated after working in a hospital.71 Connecting
principles to contain infection and should be impleproviders contaminated clothing to a patients infecmented when the risk of pathogen transmission
tion or outbreak, however, is not well supported in the
increases. Critical care nurses can and should impleliterature.71,72 Health care workers nevertheless should
ment isolation precautions on the basis of knowledge
be aware of clothing contamination and take necessary
obtained from the patients chart, specifically any
steps to prevent the spread of organisms. Infrequently
admitting diagnosis suggesting an infection-related
laundered clothing (eg, neckties, lab coats, stethoscope
cause requiring treatment. Collaboration with a precovers) becomes colonized with organisms, including
scribing provider is necessary to determine when isoMDROs.70,72-76 In a few studies of contamination of
lation precautions are no longer needed on the basis
nurses uniforms, researchers have reported that up to
of the treatments effectiveness (eg, the infection
65% of nurses uniforms are contaminated with body
clears). The Centers for Disease Control and Prevenfluids and bacteria/MDROs at the end of the
tion and hospitals provide clear guidelines for differshift.70,72,73,77 Researchers exploring laundering of health
ent types of isolation based on the microorganisms
care workers clothing /uniforms (except for clothing
mode of transmission.
Environmental control reduces
the spread of organisms to inaniTable 5 Recommendations for laundering uniforms
mate objects or surfaces that act as
Wash uniforms separately from other clothing
an infectious source. In a classic
Fully submerge clothing during washing process; dilution is a key component of
study, Hayden and colleagues68
removing microbial contamination
found that health care workers
Use water temperature 60C - 65C
were as likely to contaminate their
Tumble dry uniforms
hands with vancomycin-resistant
Ironing may serve to additionally reduce microbial counts after laundering
enterococcus after environmental
Store clean uniforms in a manner that will ensure cleanliness
contact as after direct contact with
80,81
75
79-81
81
77,78,80,81
79
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Conclusion
Evaluating our practice continually and adopting
EBP interventions as research evolves and new evidence becomes available should be the norm in our
practice. Some traditional practices of critical care
nurses should be replaced with evidence-based practices. As Mick86 recently stated, such practices are ones
where everyone is aware there are no benefits to this
practice and would like to get rid of it. The 4 practices addressed in this article should be replaced with
practice reflective of current best evidence and
research to optimize patients outcomes. Andy Warhol
said it well: They always say time changes things, but
actually you have to change them yourself.87 Critical
care nurses provide an essential contribution to the
translation of best evidence into practice by continually moving nursing practice forward in the care of
the most vulnerable patients. CCN
Financial Disclosures
None reported.
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CNE Test Test ID C1322: Putting Evidence Into Nursing Practice: Four Traditional Practices Not Supported by the Evidence
Learning objectives: 1. Identify key evidence-based components that demonstrate how research can be translated into bedside nursing practice 2. Analyze 4
nursing practice issues to understand how to incorporate evidence-based guidelines into nursing interventions 3. Validate evidence-based guidelines and nursing
research to incorporate practice changes in your own work environment
1. Evidence-based practice (EBP) considers the best evidence from studies, patient
care data, clinical experience, and expertise as well as which of the following?
a. Patients preferences and values
b. Economics of health care agencies
c. National professional organizations
d. Government agencies
4. The evidence shows that noninvasive blood pressure (NIBP) in children older
than 1 year of age should be measured via which of the following methods?
a. Doppler method
b. Oscillometric method
c. Palpation method
d. Auscultation method
Test answers: Mark only one box for your answer to each question. You may photocopy this form.
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Test ID: C1322 Form expires: April 1, 2016 Contact hours: 1.0 Pharma hours: 0.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%)
Synergy CERP Category A Test writer: Lynn M. Simko, PhD, RN, CCRN
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