Challenging nursing's sacred cows
Issue Date: April 2008 Vol. 3 Num. 4
Authors: Carol A. Rauen, MS, CCNS, PCCNKathleen Vollman, MS, MSN, CCNSRichard B. Arbour, MSN, CCRN, CNRNMarianne Chulay, PhD, RN, FAAN Until recently, healthcare practitioners have answered questions about clinical practices with their best guesses, intuition, and tradition. But evidence-based practice (EBP) compels us to use solid scientific evidence instead, and to base nursing protocols on this evidence. As defined by the Institute of Medicine, EBP is the integration of the best research, clinical expertise, and patient values when making decisions about patient care. This article discusses three commonly performed acute-care nursing practices that are not based on evidence: • instilling normal saline solution (NSS) into the patient’s endotracheal tube before suctioning • turning critically ill patients manually every 2 hours • relying on the Glasgow Coma Scale (GCS) alone for routine neurologic assessment. When these practices were introduced, no research supported them. Yet many practitioners keep performing them, despite recent research that suggests they should be changed. This article examines these three practices critically.
Instilling NSS before ET suctioning:
Helpful or harmful?
For years, nurses and respiratory therapists have been taught to instill 5 ml of sterile NSS into a patient’s endotracheal (ET) tube before suctioning. According to the traditional theory, this practice decreases mucosal viscosity, eases secretion removal, and improves oxygenation. Although at one time the theory seemed to make sense, research from the past 20 years shows it’s incorrect. Here’s what current research (primarily involving adults) tells us: • Instilling NSS before suctioning decreases oxygen saturation and forced expiratory volume (a sign of bronchospasm). • This practice may increase the risk of hospital-acquired pneumonia (HAP), as bacteria from the nurse’s thumb may contaminate the rim of the NSS vial when the vial top is popped off. • Successful humidification requires small particle size in the form of ultrasonic nebulization, not bolus administration. • No studies show that NSS instillation yields benefits. On the contrary, studies prove that this practice can lower oxygenation levels and increase the risk of HAP. Consequently, the current EBP recommendation is not to instill NSS during routine ET suctioning.
Are we moving critically ill patients enough?
For years, nurses have recognized that proper patient positioning helps prevent skin breakdown, mobilizes secretions, and provides comfort. But many nurses fail to consider the impact of various positioning strategies on pulmonary gas exchange, ventilator weaning outcomes, and prevention of muscle deconditioning in intensive care unit (ICU) patients. A busy healthcare environment can pose a challenge to frequent repositioning—especially with critically ill patients. One prospective longitudinal observational study of a critical care unit found that over an 8-hour period, only 2.7% of observed patients experienced position changes every 2 hours, and more than half were supine for 4 to 8 hours. The solution is to improve nurses’ awareness of the importance of proper positioning on both short- and long-term patient outcomes. If we don’t pay enough attention to this care activity, it’s likely to be neglected. Evidence shows that for many critically ill patients, turning every 2 hours isn’t frequent enough to preserve the lung’s oxygenating ability or prevent HAP. When a patient is at risk for HAP or ventilator-acquired pneumonia (VAP), continuous lateral rotation therapy (CLRT) should be used. Research on the positioning of critically ill patients tells us that: • for patients with consolidated pneumonia in one lung, positioning with the “good” lung down improves oxygenation. The goal is to match alveoli with perfused capillaries....
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