Eyecare in the critically ill: Clinical practice guideline

OBJECTIVE: The Intensive Care Collaborative project was established with the specific aim of developing recommendations for clinical practice that are underpinned by the best available evidence to support the objective of improving the standard of care delivered in NSW Intensive Care Units. The eyecare clinical practice guideline for intensive care patients were developed as a result of this initiative. METHODS: Search: The bibliographic databases (PubMed; The Cummulative Index of Nursing and Allied Health Literature (CINAHL); Medline and The Cochrane Library) were searched. The search terms used alone and in combination were: intensive care; prevention; eye; eyecare; and guidelines. In addition, reference lists of relevant papers were assessed to identify additional studies and Google Scholar was searched using the keywords eyecare and intensive care. The search strategy was limited to the English language but was not limited by year of publication. Study selection criteria: All relevant observational and interventional studies were included, regardless of study design. Review process: Each paper was reviewed by at least two Guideline Development Network (GDN) members independently using a data extraction tool. Papers were assessed against the National Health and Medical Research Council (NHMRC) levels of evidence. Recommendations were assigned using a modified Delphi process to ensure consensus. SUMMARY OF RECOMMENDATIONS: We recommend that each patient is assessed for the risk factors of iatrogenic ophthalmologic complications; the ability to maintain eyelid closure; for iatrogenic ophthalmologic complications. It is also recommended that; the rates of iatrogenic ophthalmologic complications are monitored; referral is made in a timely manner for any suspected iatrogenic ophthalmologic complications; eyelid closure is maintained if eyelid closure cannot be maintained passively; all patients who cannot achieve eyelid closure independently should receive eye care every 2h. CONCLUSIONS: The recommendations from this clinical practice guideline were peer-reviewed and examined by ophthalmology experts. Despite the heavy reliance on only a small number of studies and low level of evidence, the recommendations have the potential to positively affect patient outcomes by encouraging clinicians to assess and monitor for ophthalmological complications and to provide appropriate preventative interventions if implemented extensively.     

基于渥太华研究应用模式的妊娠期糖尿病临床护理实践指南应用方案的构建

目的构建妊娠期糖尿病临床护理实践指南应用方案。方法以渥太华研究应用模式为指导,建立指南应用方案构建小组和咨询小组,采用专家咨询法,根据前期确定的障碍因素,从证据、采纳者及实践环境三面面构建指南应用方案。结果在证据方面,制定了针对护理人员的“妊娠期糖尿病护理管理最佳实践手册”;在实践者方面,构建了护理人员培训方案;在患者方面,构建了“妊娠期糖尿病孕妇自我管理手册”、体验门诊、基于微信平台的健康教育;在实践环境方面,构建了护理操作规范和管理流程、患者血糖管理档案、以妊娠期糖尿病专科护士为主导、病区责任护士参与的专科护理团队、多途径、多形式的妊娠期糖尿病健康教育方案、GDM专科护士与医生的双向转诊流程。结论在渥太华研究应用模式的指导下,本研究构建了基于指南的可操作性强的综合干预策略,获取领导力支持、推动干预策略的实施,是下一步研究的重点。     

The effect of implementing adult trauma clinical practice guidelines on outcomes of trauma patients and healthcare providers

ObjectivesThis study aimed to 1) Assess the effects of implementing the initial assessment and management practices of the Adult Trauma Clinical Practice Guidelines (ATCPGs) on the outcomes of multiple trauma patients and healthcare providers in the emergency department (ED) and hospital; 2) Evaluate the effects of implementing the ATCPGs on missed injuries in ED and hospital Length of Stay (LOS); 3) Examine the effect of implementing initial assessment and management on healthcare providers’ compliance with ATCPGs.MethodsA quasi-experimental design with three months before and three month after implementing ATCPGs was used. A total of 464 patient's files were reviewed in the study. However, 66 patients met the inclusion criteria, with 33 patients in each phase. The second sample was composed of 30 nurses and 13 physicians working at the ED.ResultsUsing multiple strategies of implementation of ATCPGs decreased the LOS for multiple trauma patients in the ED. Although the missed injuries did not differ significantly in the study's phases; it was lower in the post-intervention than in the pre-intervention phase. The mean of nurses’ and physicians’ compliance with post intervention was higher than preintervention (p < .001).ConclusionThe results will help the decision-makers to facilitate interdisciplinary ATCPGs training sessions, and establish policies and procedures to introduce ATCPGs in the ED to improve multiple trauma patients' outcomes.     

早期护理干预在预防肿瘤重症病人深静脉血栓中的应用

[目的]探讨早期护理干预对预防肿瘤重症病人深静脉血栓的效果。[方法]将145例肿瘤重症病人分为对照组70例和实验组75例,对照组病人采用重症监护室（ICU）常规护理,实验组在ICU常规护理的基础上行早期评估、行为训练、物理治疗等早期护理干预。每隔14d采用多普勒超声检查有无深静脉血栓的形成,比较两组病人深静脉血栓发生率。[结果]实验组病人中有5例发现深静脉血栓,对照组病人中有13例发现深静脉血栓,差异具有统计学意义（P〈0．05）。[结论]早期护理干预能有效预防肿瘤重症病人深静脉血栓形成。     

急诊科危重患者院内安全转运的护理

目的:了解急诊科危重患者院内安全转运的影响因素和防范对策。方法:对该院急诊科2005年1～8月126例危重症患者转运时意外情况进行统计。结果:126例转运途中发生意外42例。讨论:要做好转运前的评估、准备工作,以及急救药品和器材的准备,加强相关科室的协调,提高护送人员的责任心,以确保危重患者院内转运的安全。     

OEC管理模式在预防重型颅脑损伤患者术后深静脉血栓中的应用

目的 探讨OEC管理模式在预防重型颅脑损伤患者术后深静脉血栓(deep vein thrombosis,DVT)中的应用。 方法 选取2018年1-12月笔者所在医院收治的重型颅脑损伤患者80例,根据患者入院时间将其分为对照组(2018年1-6月)及观察组(2018年7-12月)各40例,2组均采用血栓弹力图进行监测。对照组行常规血栓预防指导,观察组在对照组基础上应用OEC管理模式实施管理,比较2组患者血栓发生率、平均住院时间、患者投诉率及患者满意率。 结果 观察组干预后,血浆D-二聚体(D-D)、凝血酶原时间(PT)、凝血酶时间(TT)、纤维蛋白原(FIB)较对照组明显改善(P＜0.05),观察组患者血栓发生率、患者投诉率均低于对照组(χ²=4.507,P=0.034;χ²=5.165,P=0.023),患者满意率高于对照组(χ²=6.274,P=0.012)。 结论 OEC管理模式能有效改善重型颅脑损伤患者术后血液黏稠度,预防血栓形成,缩短患者治疗时间,提高患者治疗满意率。     

新型约束护理用具在危重患者中的应用

目的：探讨新型约束护理用具在重症监护病房（ICU）危重患者中的应用效果.方法：采用透气性强的棉织品材料改良三种约束工具：双保险约束带、球拍手套和安全背心.随机将100例急性生理和慢性健康评分系统（APACHEⅡ）评分≥10分患者分为观察组（51例）和对照组（49例）,分别应用改良式约束护理工具及传统约束用具,对患者进行防护性约束,比较两组患者并发症的发生率、家属满意率及护士心理压力.结果：观察组患者并发症发生率低于对照组（P＜0.05）;家属满意率方面,观察组明显高于对照组（P＜0.05）;护士的心理压力方面,观察组明显低于对照组（P＜0.05）.结论：改良式约束护理用具能有效降低护理并发症,提高家属对约束用具的满意度.     

影响护理本科生实习质量主要因素的调查分析

目的 探讨影响护理本科生临床实习质量的主要因素,为提高临床带教水平和完善教学体系提供依据.方法 采用问卷调查法,对在我院实习的80名护理本科生从临床科室安排、个人实习时间分配、带教教师及护士长态度以及个人的职业价值观四个影响因素进行调查.结果 四个影响因素得分分别为科室安排(12.59±4.55)分、个人时间分配(21.21±3.83)分、带教教师及护士长态度(16.16±5.96)分、个人职业态度(10.81±4.38)分.结论 个人时间分配是影响护生实习质量最主要的因素.     

不同方法对危重病人肛周皮肤护理的效果观察

目的:探讨对危重病人肛周皮肤不同护理方法的效果。方法:将2012年1月~2013年6月ICU危重病人500例随机分为3组,空白组166例,给予清水护理;对照组166例,给予造口护肤粉;研究组168例,给予珍珠层粉、双料喉风散、达克宁散混合而成的护肤粉。比较3组病人护理20 d发生肛周皮肤损伤的情况。结果:研究组发生肛周皮肤损伤15例,对照组发生肛周皮肤损伤40例,空白组发生120例,3组比较有统计学意义(P0.05)。结论:珍珠层粉、双料喉风散、达克宁散混合而成的护理粉对预防危重病人发生肛周皮肤损伤的效果和效益最佳。     

Prevention and treatment of deep vein thrombosis and pulmonary embolism in critically ill patients

Deep vein thrombosis and pulmonary embolism remain common problems in the intensive care unit, with limb- and life-threatening complications that are potentially preventable. The intensive care unit clinician is called on to be vigilant with diagnosis and facile with prevention and treatment of thromboembolic disease (venous thromboembolism). This article reviews background, current options, and recommendations regarding the occurrence of deep vein thrombosis and pulmonary embolism in the intensive care unit population.     

Responding to families' questions about the meaning of physical movements in critically ill patients

Background

Families may have questions about the meaning of physical movement in critically ill patients for whom movements are likely involuntary. If unresolved, these questions may contribute to difficult communication around end-of-life care. This study used qualitative methods to describe physicians' responses to families' questions about the meaning of patients' movements in critically ill patients.

Methods

Fifty-one family conferences in which withdrawal of life support or discussion of bad news was addressed were audiotaped and analyzed with a limited application of grounded theory techniques. Patients were identified from intensive care units in 4 Seattle area hospitals. Two hundred twenty-seven family members and 36 physicians participated in the study.

Results

Family members' questions indicating lack of resolution about the meaning of patients' movements that were likely involuntary occurred in 6 (12%) of the 51 conferences. Physicians used 3 approaches to respond to the following questions: (1) providing clinical information, (2) acknowledging families' emotions, and (3) exploring the meaning of families' emotions. Physicians were most likely to provide clinical information in these situations and infrequently explored the meaning of families' emotions.

Conclusions

Physicians' responses to family questions indicating lack of resolution about the meaning of patients' movements that were likely involuntary can be categorized into 3 types. Physicians may be better able to respond to and resolve these questions by using all 3 types of communication approaches. Future studies should determine if such responses can improve families' experiences and other outcomes.     

The development of a clinical practice stroke guideline for physiotherapists in The Netherlands: a systematic review of available evidence

Purpose. To develop a clinical practice guideline for the physiotherapy management of patients with stroke as support for the clinical decision-making process, especially with respect to the selection of appropriate interventions, prognostic factors and outcome measures.

Introduction. Physiotherapists have a high caseload of patients with stroke, so there is a need to identify effective evidence-based physiotherapy procedures. The availability of a guideline that includes information about prognostic factors, interventions, and outcome measures would facilitate clinical decision-making.

Method. A systematic computerized literature search was performed to identify evidence concerning the use of: (i) prognostic factors related to functional recovery; (ii) physiotherapy interventions in patients with stroke; and (iii) outcome measures to assess patients' progress in functional health. Experts, physiotherapists working in the field of stroke rehabilitation, and a multidisciplinary group of health professionals reviewed the clinical applicability and feasibility of the recommendations for clinical practice and their comments were used to compose the definitive guideline.

Results. Of 9482 relevant articles, 322 were selected. These were screened for methodological quality. Seventy-two recommendations for clinical practice were retrieved from these articles and included in the guideline: Six recommendations concerned the prediction of functional recovery of activities of daily living (ADL), including walking ability and hand/arm use; 65 recommendations concerned the choice of physiotherapy interventions; and 1 recommendation concerned the choice of outcome instrument to use. A core set of seven reliable, responsive, and valid outcome measures was established, to determine impairments and activity limitations in patients with stroke.

Conclusions. The guideline provides physiotherapists with an evidence-based instrument to assist them in their clinical decision making regarding patients with stroke. As most of the recommendations included in the guideline came from studies of patients in the post acute and chronic phase of stroke, and in general involved patients with less severe and uncomplicated stroke, more needs to be learned about the more complex cases.     

预见性护理干预对骨科患者术后深静脉血栓形成的预防作用

目的：探讨预见性护理干预对骨科患者术后深静脉血栓形成的预防作用。方法选择本院收治的骨科手术患者共106例,按照随机数字表法将其随机分为干预组56例、对照组50例,对照组患者采取常规护理,干预组在常规护理基础上加用预见性护理,比较2组患者DVT发生率、住院时间、患者对护理满意度以及术前、术后7 d血浆D-二聚体水平。结果干预组DVT发生率显著低于对照组,差异具有统计学意义（P＜0．05）;干预组患者住院时间显著短于对照组,差异具有统计学意义（P＜0．05）;干预组患者对护理总满意率为94．64％,对照组患者对护理总满意率为82．00％,2组比较差异具有统计学意义（P＜0．05）;术前比较,2组患者血浆D-二聚体水平差异不具有统计学意义（P＞0．05）;术后7 d,2组患者血浆D-二聚体水平均较术前显著升高（P＜0．05）;术后7 d干预组血浆D-二聚体水平显著低于对照组（P＜0．05）。结论采用预见性护理,能够预防患者深静脉血栓的形成,缩短患者的住院时间,提高患者对护理的满意度,值得临床上推广运用。     

急诊科危重症患者院内转运的循证实践

目的 将急诊科危重症患者院内转运的最佳证据应用于临床实践,促进临床护理质量持续改进.方法 本研究以"证据的持续质量改进模式图"为理论框架,运用循证方法检索数据库获取最佳证据并应用于临床,比较最佳证据应用前后系统层面、护士层面及患者层面结局指标的变化.结果 系统层面,完善了急诊科危重症患者院内转运制度流程,修订了院内住院...     

重症患者床旁血糖监测的准确性评价及影响因素分析

目的 评价重症患者床旁快速血糖监测的准确性,探讨其相关的临床影响因素.方法 选择240例重症医学科收治年龄≥18岁的重症患者,血糖调控期间依据血糖检测值将患者分为3组:①低血糖组,血糖值＜4.5 mmol/L,32例;②目标血糖组,血糖值4.5 ～ 8.3 mmol/L,138例;③高血糖组,血糖值＞8.3 mmol/L,70例.试验期间,床旁同步采集患者静脉血、动脉血、指端血,分别采用葡萄糖氧化酶法(GOD法)和葡萄糖脱氧酶法(GDH法)快速检测血糖值,同时以中心实验室己糖激酶法(HK法)测定的血糖值作为标准对照进行准确性评估;对可能影响床旁快速血糖检测准确性的各因素进行logistic回归分析.结果 ①低血糖组患者静脉血、动脉血、指端血快速血糖检测错误率(GDH法:25.00％、40.62％、40.62％,GOD法:59.38％、71.88％、71.88％)显著高于同类受检血样的目标血糖组(GDH法:2.90％、9.42％、7.97％,GOD法:18.12％、27.54％、27.54％)和高血糖组(GDH法:1.43％、8.57％、4.28％,GOD法:11.43％、8.57％、11.43％,均P＜0.01).②低血糖组患者快速血糖检测值与实验室对照值间的差值平均水平为0.41～0.69 mmol/L(GDH法)和0.92～1.18 mmol/L( GOD法);目标血糖组分别为0.16～0.33 mmol/L和0.77～0.90 mmol/L;高血糖组相应降至-0.06～0.18 mmol/L和0.56～0.76 mmol/L.③低血糖组患者快速血糖检测值与实验室对照值间相关系数仅为0.812～0.853(GDH法)及0.723～0.816(GOD法);目标血糖组达0.862～0.890及0.768～0.857;高血糖组患者相应升至0.922～0.957及0.896～0.922(均P＜0.01).④Logistic回归分析显示,患者血糖水平、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、红细胞比容能进入回归方程.结论 重症患者血糖调控期间,血糖、红细胞比容及病情程度等因素影响床旁血糖监测的准确性.低血糖状态下,快速血糖检测的准确性显著降低,更易高估患者的实际血糖水平.     

心胸外科危重患者多管道的护理

目的 分析心胸外科危重患者的多管道护理效果.方法 取本院心胸外科2010～2012年手术收治的多处置管患者108例,随机均分为观察组和对照组.比较两组患者的平均住院时间、护理质量评分、负面情绪评分、护理满意度差异.结果 观察组患者平均住院时间及护理质量评分均优于对照组患者(P＜0.05);负面情绪评分明显低于对照组患者(P＜0.05);护理满意度明显高于对照组患者(P＜0.05).结论 对心胸外科危重患者的多管道进行针对性护理,可以明显缩短患者的住院时间、提高护理质量评分及护理满意度,减少患者抑郁情绪.